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The publication of the Tories' white paper plans for the NHS was met with headlines about the government 'taking back control' of the NHS and reversing past privatisation policies.
As reported in last week's Socialist, the headlines were wrong. This does not signify a reversal of privatisation in the health service, nor an increase in democratic accountability. In fact, it signals an intention for further privatisation.
The Covid pandemic has revealed huge problems in the NHS due to past policies of underfunding and privatisation.
The lack of available beds, including intensive care; the unequal impact of the virus reflecting wider inequality in society; the huge staff shortages meaning that even when 'Nightingale hospitals' are built, they cannot be staffed properly; the growing waiting lists for treatment which were high even before the pandemic resulted in further, sometimes fatal, delays.
The Tories have effectively admitted the failings of the last top-down reorganisation of the NHS, the 2012 Health and Social Care Act brought in by the Tory-Libdem coalition government. Tory MP Dan Poulter, who was a health secretary during that coalition government, spelt it out: "The current structures are not fit for purpose as they focus on competition and not enough on the integrated approach to health and social care that is so badly needed by patients."
Before its introduction, the act had been criticised by campaigners as further introduction of privatisation in the NHS. It created new layers of bureaucracy including around 200 'Clinical Commissioning Groups' (CCGs), which buy health services from competing providers both public and private. It also created a complex web of other quangos to run the NHS including NHS England as well as structures in other parts of the UK. It reduced some of the powers of the health secretary to direct the NHS.
In fact, governments and the NHS nationally have been trying to overcome some of the problems it created ever since its introduction!
But the NHS did not start being turned into a marketplace in 2012. The Thatcher Tory government began a process in the 1980s, continued under Tory prime minister Major and New Labour's Blair, which developed the 'internal market'. There was a split created between 'purchasers' and 'providers' and the NHS trusts were established along with a system of 'payment by results'.
The ideology behind it was that a competitive market would give patients the ability to choose the best hospitals and that they would prosper. For the neoliberal right it was a step towards the sell-off of the NHS. The reality was quite different, it could never work like this idealised 'free market', and there was a huge increase in the cost of administering NHS bureaucracy.
The 2012 Act made the situation worse. For example, its section 75 enforced competitive tendering for services.
NHS England has recently developed a long-term plan to replace the CCGs with a smaller number of 'Integrated Care Systems' (ICS). The idea of integrating services, including social care with health care, is of course an attractive one. But the devil is in the detail and the proposals do not really do that. As set up, they are likely to increase private sector involvement in the NHS while doing nothing to solve the problems of integration.
The white paper proposes a legal framework for the establishment of these bodies, although splitting them between commissioning bodies and 'Health and Care Partnership' boards, making clear that these can include private companies. They will also rely on new digital and data systems provided by the private sector.
Real integration would necessitate, as a first step, bringing all health services back into public ownership, including the largely privatised social care sector and nationalising the pharmaceutical and medical supply companies.
Much has been made of the white paper's proposal to abolish compulsory competitive tendering for clinical services. However, the handing out of big contracts to private companies will still continue - NHS bodies can still put services out to tender if they wish, and competitive tendering will continue for all non-clinical services in any case. Nor will contracts already handed out be revoked.
The NHS has been developing 'framework agreements' which are lists of pre-approved companies that can be handed contracts for NHS work. This can make it easier for commissioning groups or trusts to fast-track the process.
Since the beginning of the pandemic, the Tories have handed out billions to private companies for a range of things including test and trace, PPE, and private laboratories. These contracts were given out without a competitive tendering process and lacked any transparency. They have allocated £10 billion to give to private hospitals after the pandemic to help reduce the waiting lists that have been inflated over the last year.
Privatisation in the NHS has taken different forms, one of those being Private Finance Initiative (PFI). This was a policy again initiated by the Tories, but massively ramped up under New Labour. New hospital buildings were paid for by expensive private finance and the NHS pays these profiteers to use them for decades into the future. A staggering £55 billion is still owed by parts of the NHS to these companies.
If left to the Tories, privatisation in the NHS will go unchecked.
At the time of the 2012 act, campaigners opposed the abolition of some of the powers of the heath secretary because they saw it as further fragmentation of the idea of a National Health Service, publicly owned and ultimately accountable to an elected government. It also gave the government a certain amount of 'plausible deniability'. The government could tell bodies like NHS England to make billions of pounds in 'efficiency savings' but try to distance themselves from the cuts as they impact local people.
But of course, the return of some of these direct powers to the secretary of state, in a very imperfect democracy - especially when there is no working-class political representation does not mean genuine democratic accountability.
The bodies that already exist and the ones proposed in the white paper are not elected. Even where there is representation for doctors, nurses, and the public, they are appointed. There are limited powers for local authorities, but even those are often not used, and the actions of local NHS bureaucrats not properly scrutinised.
At the moment, local authorities can 'call in' decisions of the local NHS such as closures of hospitals or services if they feel it has a detrimental effect, forcing the health secretary to look again at these decisions. The new proposals mean that the government could intervene directly at any point during the decision-making process. Either way, cuts and closures will only be stopped by building campaigns that involve the workforce, unions, and large numbers of local people, as has been done on a number of occasions over the last few years.
Real democratic control over the NHS would need the creation of bodies that had elected representatives of the workforce and also service users ie, the public. But it would also need the abolition of private companies' involvement in health care and the proper funding of services.
The NHS has far fewer doctors, nurses, and beds per patient than similar countries like France and Germany. Germany has twice the number of nurses per capita than the UK, for example.
Under the Tory and Tory/Liberal governments of the last few years spending on the NHS has drastically slowed. Even though the current government has promised an increase in spending by 2023, it does not restore NHS spending back to the levels that existed in the previous periods.
In fact, both the NHS and social care need a massive increase in funding, not least because we have an ageing population.
NHS staff have had their pay cut for a decade in real terms, in itself a factor in the 100,000 staff shortage nationally. Buildings are falling apart because of inadequate funding of maintenance. Government representatives are still claiming they are going to build 40 new hospitals, yet the funding they announced at that time has gone to only six trusts and the reorganisation that investment involves is actually closing hospitals, like in Leicester.
Tory claims they are strengthening and greater integrating the NHS are empty promises. We need to fight for a fully funded, publicly owned and genuinely democratic NHS as part of a wider socialist society to improve the health and lives of millions of people.
Matt Hancock describes the proposals set out in the white paper as helping to integrate the NHS, social care and local government while getting support "closer to the front line".
This does not address the issue of adequate funding, or the previous Tory reforms and the years of privatisation.
It allows greater private sector involvement and the reorganisation simply speeds privatisation up.
We don't doubt that outsourcing will continue despite its failures and that contracts will continue to be handed out to Tory mates.
The Department of Health and Social Care has said that the reform will help to deliver on the Tories' manifesto commitments including 50,000 more nurses and 40 new hospitals. However, this will not happen unless staffing is addressed properly, which means bringing the NHS back into democratic control and funding it adequately.
The restructuring doesn't address the disparity in pay for healthcare workers, and doesn't address the core issues of retention and recruitment and better working conditions.
The Tories are making it look like the reforms will make things less bureaucratic but they will just take more power away from the NHS.
When I heard rumours that the Tory government was going to reverse Andrew Lansley's disastrous 'reforms' of the NHS, I thought it sounded too good to be true. Turns out it is.
They say they want to force local authorities and the NHS to work together on social care. But the new ICS bodies that they want to set up to bring those two groups together and plan services also have shadow ICS boards in every region where the private sector will be invited in.
These shadow boards are the cuckoo in the nest, aiming to compete for power and shoulder the public boards aside. The private sector has no place in a publicly run health service. Their priority is profit.
Look at the disaster when Circle, a private company, tried to run Hinchinbrooke Hospital. Look at the PPE scandal last year. Allowing the private sector any say in how NHS services are run would be a disaster.
Another 'reversal' is to reduce competition rules when private companies bid for contracts, and to give these contracts for longer periods. The contracts given out already are too long for people forced to work for private company after private company, with all the disruption, chaos and problems these companies bring.
What the NHS needs is a plan to bring all services back in house, not give the private profiteers even more access to NHS money than before.
The marketisation introduced by Lansley has been destroying the NHS, forcing hospitals to compete against each other instead of cooperating, with horrible effects on patient care. Reversal of that would be a major step forwards. But leading Tories like Jeremy Hunt are calling for more "Ofsted style ratings" to pit the ICS boards against each other.
The Tories scratching their heads over what to do with the NHS is priceless. You couldn't print most of the comments from staff, but the main theme is 'invest in your bloody staff'. The Tories showed themselves totally out of touch when they built the Nightingale hospitals and then couldn't run them. Did no one tell them about the massive shortage of staff in the NHS? We desperately need to retain the staff we still have but so many are thinking of leaving after the year we've been through.
Our experience of reorganisation is always moving the same money around but in a different way. The announcement we need is a massive increase in spending, particularly for staff retention and for fully funded training at all levels.
We'll never get that from the Tories without a hell of a fight, but then we've been battling the odds throughout the pandemic. Give us a lead and health workers will respond.
Globalisation Anticapitalism keywords:
Article dated 17 February 2021
The Socialist, weekly newspaper of the Socialist Party
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