28.11.2024
Continuing the decline
After 14 years of Tory austerity the health service has been left broken. But can Wes Streeting fix things? James Linney lambasts his idea that league tables are part of the solution
On November 12 health secretary Wes Streeting spoke at a gathering of health service leaders - the NHS Providers conference in Liverpool - where he unveiled his vision for how Labour plans to ‘fix’ the NHS, which he rightly pointed out has been left broken by 14 years of Tory mishandling.
The Tories launched their attacks on the NHS with Andrew Lansley’s ‘reforms’ in 2012, which supercharged private health’s access, by making it a requirement that NHS service contracts be periodically offered to “any qualified provider”. This launched a ‘race to the bottom’ - multinational health investors could offer cut-price patient care, resulting in a predictable drop in quality. Over the next decade things went from bad to catastrophic - bureaucracy steadily increased, staff had been haemorrhaging with no attempt to train more; meanwhile wages had been frozen, leaving workers demoralised and burnt out. Running parallel to this, there was a wilful defunding and undermining of the NHS, whilst more and more private health companies were encouraged to cherry-pick the more profitable elements.
Left in the hands of the Tories, the NHS was clearly heading towards collapse, so it is understandable that many felt some sense of hope when Labour won the general election in July. And there have been some promising signs; in the autumn budget chancellor Rachel Reeves announced an extra £22.6 billion for the NHS over a two-year period - not enough to reverse its decline, but perhaps the beginning of a turnaround? Unfortunately the reality is rather bleaker: despite the headlines generated by the budget, the NHS is facing a deficit of at least £4.8 billion this financial year; according to the Nuffield Trust, this means it needs at least a 3.6% increase in its budget just to meet its day-to-day running costs,1 but is only being offered a 3% increase, adjusting for inflation, between 2023-24 and 2025-26.2 This means the health service is still facing the need for some eye-watering savings just to stay still.
So the future of the NHS is still in the balance and going to need some major TLC just to resuscitate it, so it was with some trepidation that we awaited Labour’s first major announcement regarding plans for reforming the NHS.
Sadly any hopes that it was going to be treated better by Labour took a major blow in the conference in Liverpool, where Wes Streeting focussed on his “no-holds-barred, sweeping review” - his plan to introduce hospital league tables. These, we were told, would use a range of performance criteria such waiting times in accident and emergency departments, etc, and financial deficits, in order to rank hospitals and ‘name and shame’ those performing most poorly. The hospitals at the bottom of the league will have their managers replaced and face “turnaround teams”, made up of “expert leaders”, to try to correct things.
Leading doctors, unions and patient groups have rightly been highly critical of these league tables, that Streeting aims to start publishing in April next year - they are likely to further demoralise staff and undermine patient trust for hospitals. Beyond this though, a more fundamental concern is that to aim simply to improve a few arbitrary targets and force overspent hospitals to make cuts is to completely misunderstand both the causes and extent of the current NHS crisis, and is essentially a continuation of the harmful policy of previous Tory governments. Don’t get me wrong: I won’t lose sleep over the sacking of a few NHS bosses, but there is nothing to celebrate if they are immediately replaced by others who are equally inept - and who will presumably be parachuted in from the private sector to offer their own complete lack of any experience on how to run a health service.
Past failures
If this all sounds familiar, then it is probably because you are old enough to remember Labour’s last attempts to introduce NHS league tables back in 2001 - when Alan Milburn had the same idea. Milburn’s league tables lasted a few years and then were abandoned due to justified criticism that a few arbitrary performance markers are not an accurate way to reflect quality of care or how well the staff are performing.
To put it mildly, things are more nuanced than this. A&E waiting times, for example, are more a reflection of how much a hospital is under pressure rather than what kind of care patients are getting when they do get treated. Enforcing arbitrary targets with threats as well just leads to staff being forced to play the system to make the numbers look better without improving the service. In the past, for example, if patients are about to breach their four-hour waiting time limits in A&E, managers simply pressured staff to move patients to holding wards, so that they could be marked as having been ‘seen’ and the performance numbers looked better.
Despite league tables previously failing, this attempt to resurrect them is a continuation of Sir Keir Starmer’s infatuation with Tony Blair’s ‘New Labour’. Hence we have seen Streeting recently appointing Milburn as one of his top advisors. Milburn also just happens to be a strong believer in incorporating more private health companies to tackle NHS backlogs and is a consultant to Bridgepoint Capital (which owns Care UK) and the Price Waterhouse Coopers health practice.3 With the likes of Milburn helping to steer the ship, Streeting’s statement that the NHS must “reform or die” sounds more like an ominous threat of continuing privatisation than a genuine attempt at improving standards.4
So league tables for hospitals already struggling will likely just equate to undermining staff morale and patient confidence. Meanwhile those hospitals at the top of the league will be rewarded, by allowing them to keep budget surpluses and choose how they reinvest that money. Wes Streeting claims that these league tables will create an environment of accountability and supposedly ‘competition between hospitals’ that he hopes will raise standards. More likely, as seen with another league table - eg, that of football’s Premier League - punishing those at the bottom and rewarding those at the top will result in exacerbating the difference in performance.
The belief that competition has an inherent tendency to raise standards is, of course, a myth central to capitalism - one that figures particularly strongly in the narrative of explaining scientific and technological advances of the past two centuries. The reality is the opposite: advances in science are hindered by having to be made within the framework of capitalist competition - which preferences profit and the protection of intellectual property over the sharing of information and cooperation.
That is not to say that all competition is bad: it clearly makes football more entertaining, for example, but this does not automatically mean that it is the best way to raise the standard of all teams equally. And sport is one thing - when it comes to something like providing a state-of-the-art health care system, competition between hospitals will have a negative impact: it will lead to an environment of fear and discourage cooperation.
We do not need to wait for the publication of the first NHS league tables to confidently predict that they will demonstrate that - barring a few possible outliers, hospital trusts in the more deprived areas will fare less well. This tells us nothing about the staff who work in these hospitals or how they are run: it is simply a reflection of the fact that deprivation is the primary driver for poorer health - in these areas people have more complex mental and physical health needs, yet there the NHS gets proportionally less funding. People in these areas tend to be more vulnerable to rising costs of living, can less easily afford healthy food, have access to less recreational time or less green spaces.
Utopian
Here perhaps we have stumbled on a possible positive reason for league tables - not in an exercise of naming and shaming, but to determine which communities should be prioritised for providing more access to parks, healthy and affordable, high-quality food, more direct control in their workplaces, more recreational time, better-quality housing and so on. Sadly in the current climate under this Labour government such minimal demands sound utopian.
If these league tables signal the future direction of travel for the NHS under Labour’s stewardship, then the final destination will likely be the same as when it was in the hands of the Tories - namely, heading downhill towards a crash. Streeting could instead have used his first big NHS reforms to commit to undoing the harms done to it during the Tory years, to start the process of extracting the private health profiteers, introducing a scheme to pay NHS trainee students and committing to a fully funded NHS that allows the staff to properly perform the job they were trained for.
As communists, we also would further point out that accountability will not come through the imposition of arbitrary league tables, but through the introduction of democracy into the NHS, where the leaders are directly appointed or removed by the staff. If this was the case, the likes of Wes Streeting would not last very long, of course.