The creation of the National Health Service marked a decisive moment in the UK’s adoption of elements of the north European social market, and a modern, accountable and properly funded NHS is central to the Radical Party’s programme for a better Britain. Since Mrs Thatcher came to power, great efforts have been made to push it in the direction of a US-style profit-driven system by contracting services out to private sector providers. But this drive has run up against the fact that the integrated, taxpayer-funded, NHS model provides some of the best care in the World at a lower cost than any alternative.
This achievement will be threatened if Brexit leads to trade agreements negotiated from a position of weakness with a Washington administration seeking to chisel out opportunities for US healthcare corporations. Freeing health provision from the destructive consequences of neo-conservative dogma will require increased public funding, a strong commitment to accountability and public service, and a sustained support for a holistic approach to healthy living with the integration, where appropriate, of health and social care.
The public service model and the relationship of trust it encourages between health professionals and patients should not be traded away. Rather, it should be used to provide the public with the best healthcare in the World by protecting the integrity of the service and increasing spending progressively towards the average for comparable advanced economy countries. According to the World Bank, the UK spent 9.1% of GDP on health in 2013, compared to 11.3% in Germany, 11.7% in France, 12.1% in the Netherlands and 17.1% in the USA. At the same time, people in Britain live longer than people in the US or Germany.
The fundamental problem for the NHS is not structure but rising costs resulting from increasing life expectancy and new technologies and pharmaceuticals. Improvements in waiting lists and service quality were achieved between 1999 and 2010, largely because of a 94% rise in spending by the then Labour Government. But, according to the Institute for Fiscal Studies, growth slowed from an average of 4.1% between 1955 and 2016 to 1.3% between 2009 and 2016. Demographic trends mean that funding must increase in real terms if the NHS is to continue to deliver a high quality of service and improve the quality of care, particularly for mentally ill and elderly people.
Radical Reform Proposes:
- A Properly Funded Health Service
- Structure and Management
- Protecting the Integrity of the NHS
- Human Resources
- A Holistic Approach to Health
A Properly Funded Health Service
To address this need, the Government should be required by law to adjust public spending on the NHS annually in real terms on the basis of Office of Budget Responsibility supervised assessments of such factors as the ageing of the population and the cost of new pharmaceuticals, taking account of any efficiencies that can be achieved.
While it is right that efficiency should always be a high priority, this must not distract from the fact that the Service urgently needs more money. This is underlined by a recent analysis of OECD data by the King’s Fund, which shows that in terms of nurses, hospital beds and doctors per head, the UK ranked 16th, 18th and 19th respectively out of the 21 countries surveyed. The Government’s announcement in June 2018 that it intended to increase funding over the following three years is welcome, but the Prime Minister’s admission that she intended this to be largely funded out of savings she hoped would result from Britain’s departure from the EU does not inspire confidence.
Structure and Management
Despite strong opposition from health care professionals, Governments since 1979 have sought to sidestep the funding issue by restructuring and marketisation. Overall, the predicted benefits have not materialised as savings from staff cuts have failed to offset the added costs of duplication, tendering and profit margins. The failure of marketisation came to a head in 2016 with the abandonment, three years into a ten-year contract, of a flagship commercialisation project, which had transferred management of Hinchinbrooke Hospital in Cambridgeshire to Circle Holdings Plc. This highlighted the difficulty of attracting private sector bidders for major contracts without paying over the odds.
Splitting the buyer and provider functions and creating management units small enough to be put out to tender has also led to a jumble of decision-taking bodies. For example, Foundation Trusts enjoy greater control over resources and spending than other parts of the service, which encourages sub-optimal allocation of resources.
Meanwhile, according to the OECD, the Scottish Government has achieved results comparable to those of the NHS in England – without much of the disruption and demoralisation afflicting the Service south of the border. An evolutionary approach should be adopted to consolidate the public service ethos and accountability of the Service, while helping it respond more effectively to new demands and ensuring continuing cost effectiveness.
A national bipartisan Oversight Board should be created with responsibility for protecting the foundations and integrity of the Service. Strategic management responsibility, within broad parameters set by the Board, should be transferred to the proposed elected regional authorities with powers comparable to those of the relevant departments of the Scottish and Welsh Governments. At the hospital level, changes should be introduced to slim down management and ensure that health professionals have a central role in all decisions relating to clinical issues. As part of improving quality and efficiency, resources should be provided to help the UK establish a leading role in the use of artificial intelligence in medical diagnosis and procedures.
Protecting the Integrity of the Service
Private sector and not-for-profit providers, including GPs, dentists and pharmacists, have always played an important role in health care in Britain and will continue to do so. But increasing marketisation leads to conflicts between profit maximisation and the interests of patients, and to reduced transparency – denying patients information they need to make informed choices. This undermines public confidence and, by replacing collaborative relationships with internal competition, threatens the integrity and quality of the Service.
An example of this is the loss of relationships and collective memory when in-house teams of health professionals are replaced by short-term agency staff. To protect the integrity of the relationship with patients and the long-term viability of core services, the proportion of NHS services put out to tender should be reduced by 50% from the 2018 level over an agreed timescale.
Strict rules should be enforced within the NHS and general practice to prevent conflicts of interest, which may undermine patients’ trust in the professionals they depend upon. Private sector providers should be required to operate on a level playing field with the NHS in terms of transparency, to ensure quality of service and value for money and enable the public to choose on a basis of proper information. As part of this, gagging clauses should be banned in employment and medical liability disputes.
Statistics show a sharp rise in the proportion of community care contracts awarded over the last ten years to tenderers from outside the NHS, both profit-seeking and not-for-profit. While profit-seeking contractors still represent a relatively small proportion of the total, there is a risk that community-based providers will be progressively squeezed out. The Government claims to have created a level playing field for private and non-private tenderers but, in fact, local organisations committed to maintaining good employment conditions and a stable workforce face a handicap in competing with for-profit organisations, which operate over several sites and can draw on external financial reserves. To address this issue, the minimum employment standards demanded of all tenderers should be raised and the requirement for mutual providers, which have spun out from the NHS or local authorities, to re-tender every three years should be removed.
The motivation and commitment of the people who work in the NHS are essential to delivering a high quality of service. Any policy for the Service should embed and build upon this precious resource. We believe that legislation should be introduced to require the Government to ensure that sufficient medical professionals are available to meet national needs, subject to an annual review by the proposed Oversight Board.
A third of GP practices in England are currently unable to fill vacancies and, according to the British Medical Association, 84% of them report that excessive workloads are affecting patient care. The Government is now very unlikely to meet its timescale for increasing the number of GPs by 5,000, with NHS Digital reporting that the number of full-time equivalent GPs fell by 523 between March and June 2018.
More resources are needed for training future GPs but, with a 2018 King’s Fund survey finding that 47% of GP trainees now intend to work part-time, training places in themselves will not be enough. Measures are urgently needed to address this problem, encompassing workloads, stress, development opportunities and stronger incentives for GPs who have gone part-time to raise children to return to full-time work. In addition, hospitals and GP practices should continue to be able to recruit staff from EU countries on terms at least as good as at present.
A determined effort must be made to increase the number of doctors and nurses educated in the UK to bolster NHS staffing and reduce the number of health professionals drawn away from lower-income countries, which often face critical shortages of trained personnel themselves. This will create a more stable workforce and help end the scandal whereby clinics and hospitals waste precious resources on agency staff, while talented candidates are denied the opportunity to qualify because of a lack of study places.
At the same time, to optimise the use of human resources and improve quality of care, a determined effort should be made to ensure that the UK plays a leading role in the development and application of artificial intelligence in medical diagnosis and procedures
A Holistic Approach to Health
The priority in the reform of the NHS has now moved to integrating social and health care, which has broad political support and is set to be the focus for a fresh round of experiments over the coming years. The fact that, according to the Institute of Fiscal Studies, spending in real terms on adult social care fell by 8% between 2009 and 2017 suggests that unless additional resources are found integration will only be achieved at the cost a significant reduction in the quality of the care provided.
One of the greatest strengths of the NHS is its mission to promote health care in a holistic sense and not just to treat disease. But achieving the goal of optimum health for all requires recognising the close relationship between poor health outcomes and deprivation, poverty and unemployment.
For example, Office of National Statistics figures show that rising inequality between different parts of the country over the last 20 years has led to a situation where a boy born in Blackpool, one of the poorest cities in the UK, can now expect to live 8.6 years less than a boy born in Chelsea and a girl born in Middlesbrough, 6.9 years less than a girl born in Chiltern District.
The second factor is the need to overcome political obstacles to achieving better health for all. While big steps have been made, in the face of stubborn opposition, in tackling smoking, progress in addressing alcohol and pollution-related illness and obesity has been impeded by the continued ability of powerful lobbies to block urgently needed measures. An integrated approach is needed involving education, hard-headed negotiations with the industries concerned and fiscal measures to reduce the use of fossil fuels, alcohol and sugar, which can clearly be shown to cause illness.
SUMMARY OF PROPOSALS
A Properly Funded NHS
- increase spending on the NHS and social care and adjust it annually on the basis of assessments by the Office of Budget Responsibility, to reflect rising demands and costs and improved efficiency.
Structure and Management
- create a national bipartisan Oversight Board responsible for protecting the foundations and integrity of the Service;
- transfer strategic management responsibility, within broad parameters set by the proposed Oversight Board, to elected regional health authorities;
- slim down hospital-level management and ensure health professionals have a central role in all decisions relating to clinical issues.
Protecting the Integrity of the Service
- reduce the share of NHS services put out to tender by 50% to tackle conflicts of interest and protect the long-term viability of core services;
- require all providers within the NHS, general practice and the private sector to meet the same high standards of transparency;
- raise the minimum employment standards demanded from tenderers and remove the requirement for mutual providers spun out from the NHS to re-tender every three years.
- require the Government to ensure that sufficient medical professionals are available to meet national needs;
- increase the number of health professionals educated in the UK to create a stable workforce and reduce the need to hire expensive agency staff;
- increase resources for training future GPs and provide stronger incentives for GPs who have gone part-time to return to full-time employment;
- ensure that hospitals and GP practices can continue to recruit staff from EU countries on terms as good as at present.
A Holistic Approach to Health and Care
- support initiatives to improve the integration of health and social services provision for vulnerable patients;
- promote healthy living by increasing the cost of fossil fuels, sugar and alcohol;
- improve services for mental health and elderly people;
- support the development of a leading UK role in the use of artificial intelligence in medical diagnosis and procedures.