24.11.2016

Defend founding principles

Ensure the enthusiasm for Corbyn is not wasted, urges medical archaeologist Robert Arnott

The national health service, created in 1948 out of the optimism following the defeat of fascism in Europe, is facing a major crisis - a crisis that is not related entirely to financial, social or clinical pressures. It is a crisis prompted by the actions of those who want it to fail, so that the Tories and their friends can dismantle it in the interests of those who favour new funding based on insurance companies or delivery based on private suppliers - both making huge profits.

One of the major influences on Clement Attlee’s Labour government, which introduced the NHS, was the Socialist Medical Association (SMA). When the question of how the NHS was to be managed was first discussed, the question of what model to use arose. The idea of a US-type system of private insurance and medical inequality was not even considered, so it was an argument between the Bismarckian and Soviet systems. The first, which originated in Germany in the 19th century, was a mixture of social insurance and free treatment, but with differing providers - some public and some private. The alternative was a state-funded and state-provided service, like the one that existed in the Soviet Union.

It was communists within the SMA that pressed for the Soviet model. Several SMA doctors, who were members of the Communist Party of Great Britain, visited the Soviet Union pre-war and some worked as volunteers alongside Soviet doctors in the Spanish civil war. Even within the Labour Party, leading figures such as Harold Laski and Sidney Webb had visited the Soviet Union in the 1930s and were impressed by Soviet healthcare.

There was also the British Sigerist Society, named in honour of Dr Henry E Sigerist, the leading Swiss medical historian who worked at Johns Hopkins University and was a member of the Communist Party of the USA. The society was established by Marxist (mostly CPGB) doctors in 1947 and met several times a year until 1955 to discuss the theoretical and social aspects of medicine from a Marxist point of view. Most of them were also members of the SMA and influential within it. They discussed the relationship between science and social responsibility and the significance of social class. They advocated salaried and group practice for primary care.

Sigerist was a great advocate of socialised medicine in the 1930s and influenced its introduction in Canada. He also wrote for the Left Book Club Socialized medicine in the Soviet Union, which was widely read in the UK and would have had a major influence on the CPGB, the Sigerist Society and the SMA.

The NHS has never experienced stability. No other organisation that is publicly funded has ever gone through so many organisational changes in the years of its existence and been the subject of so much debate on how it is funded. The most significant in recent years resulted from the Health and Social Care Act 2012, which established the statutory basis for the imposition of privatisation and created clinical commissioning groups (CCGs), many of which are now run by global firms of accountants and management consultants - whose interests, to put it mildly, do not lie in patient care.

A further £10 billion has been promised for the NHS before the 2020 election. But that is an illusion - the government is also looking in the same period to make so-called “efficiency savings” of £22 billion: in other words, a net cut of £12 billion. Most have said these savings are unachievable. Nearing its 70th birthday, the NHS is witnessing its lowest ever funding increase and worse is to come.

The latest attempt by the government to undermine the NHS is through what are called ‘sustainability and transformation plans’ (STPs). Any suggestion that they are there to rationalise the service is an illusion. Without legislation or publicity, the government has divided all English NHS trusts, CCGs and local authorities into 44 ‘footprints’, each of which has been ordered to develop an STP. These plans are mostly being kept secret from the public, despite a department of health proposal to consult patients.

These new, unaccountable bodies are supposed to plan future NHS and social care funding across England along with local authorities, but with massively reduced budgets. The core component of STPs is a financial one, where local authorities and NHS trusts are being compelled to tailor provision to meet the demand for cuts and for budget deficits to be reduced to zero. The STPs aim to shift core elements of health provision from hospitals to ‘the community’.

With local authority cuts, this will result in lower healthcare standards, for many core NHS functions are to be handed over to ‘accountable care partnerships’, which may lead to further privatisation in the NHS and over which local authorities will have no control. The role of community hospitals is being questioned and the number of mental health inpatient sites could be reduced. NHS England prefers to call it “transformation” and claims it will provide for consultation with local communities. But when? The truth is, it is all about finding the treasury £22 billion, not about healthcare improvement or ‘rationalisation’.

Social care

Singling out cuts in domiciliary care is a good example of a deteriorating service and how it has a knock-on effect on the NHS. Just over £3.5 billion has been cut from local council care budgets. A quarter of a million fewer older and disabled people are not now getting vital services like home care visits, which help them get up, washed, dressed and fed. Over 5,000 fewer people are benefitting from home adaptations like handrails, ramps and stair lifts - a lifeline for older and disabled people, helping them to live independently at home. Fewer home adaptations, alongside the lack of other services in the community, means increasing numbers of frail, elderly people are ending up in accident and emergency departments - and having to be kept in hospital when they do not need to be there. This causes huge distress for them and their families, but it is also a false economy, because taxpayers end up paying more in the shape of expensive hospital care. The answer lies in the integration of properly funded health and social care.

At a time when any number of areas in the public sector could argue that they deserve more funds, there is compelling evidence that this is particularly the case for social care. While the NHS has seen its budget rise in real terms, once inflation is considered, the opposite has happened for local authority-run social care. What makes this particularly frustrating is that the two sectors are often referred to as two sides of the same coin. Cuts to social care have a knock-on effect on NHS funding - as the rising number of hospital admissions and increasing delays in discharging patients show.

The government had claimed that some of these issues would be resolved through the Better Care Fund, launched to ‘encourage more efficient working’ between the two sectors. A total of £3.8 billion for 2015-16 has been set aside; but it is not new money, having been taken out of current NHS budgets. This is being topped up to a total of £5.3 billion from local authority budgets, already under huge strain. There is, however, real doubt in the social care sector about how effective this spending will be. It is not the answer. Where the answer lies is in the merging of social and health care, and funding it properly.

Challenges

We have no illusions that the NHS faces some very real challenges. They include the increased cost of drugs and new technology; a continued growth in the ageing population; larger real incomes and a much better educated population, which have rightly created greater expectations. To this can be added a huge increase in dementia and lifestyle issues, such as sedentary activity and obesity - creating, for example, a big rise in type-2 diabetes, even in adolescents. There is no indication from the government that resources will be made available to address these challenges.

Today some major cities lack sufficient general practitioners, hospital beds and community care services, and face a huge shortfall in their finances. Regardless of the government’s alleged ring-fencing of NHS expenditure, the amount of cash available has not grown and many departments are being forced to make what are euphemistically called “efficiency savings”. The resolution to the financial crises lies in the abandonment of the totally counterproductive austerity measures involving the NHS. In fact, expenditure must rise - there is no alternative.

Everyone involved in the NHS - patient or staff - knows what needs to be done, and it is not cutting services. Some measures are very urgent, including the need to significantly reform general practice; the need to end the increasing pressures on Accident and Emergency services; the need to expand work in the field of promoting healthy living and accident prevention; the need to re-examine hospital ‘rationalisation’ and centralisation; and the need to counteract deprofessionalisation in healthcare before it seriously undermines staff morale and patient care.

Of course, we must also understand that the challenges of the 21st century are largely different to those of 1948 and recognise that changes must be made to reflect this. But such changes must not compromise the founding principles of the NHS, which are:

1. Services are provided free at the point of delivery.

2. Services are paid for out of central taxation, not national insurance.

3. Everyone is eligible for treatment.

For the NHS to survive in its present form and not to be privatised piecemeal, it requires the application of some specific policies, many which are a response to the dangers inherent in the Health and Social Care Act 2012.

The NHS was established as the climax of a plan to set up the welfare state after World War II, tackling what was called at the time the ‘five giants’: disease, ignorance, squalor, idleness and want. Whilst 68 years later these five factors have changed, the need for the NHS and its basic principles has not. We must always be reminded of what Nye Bevan said in 1948: Britain could “take pride in the fact that, despite our financial and economic anxieties, we are still able to do the most civilised thing in the world - put the welfare of the sick in front of every other consideration”. Again, that has not changed.

Since 1948, the NHS has grown into the world’s most respected free healthcare system and one of the world’s largest employers, along with the Chinese People’s Liberation Army, Indian Railways and the Wal-Mart supermarket chain. We are also reminded that NHS staff are in daily contact with more than 1.5 million patients and their families. Men and women now live an average of 10 years longer than they did before the NHS was established.

Health and welfare must come first, not profit. Without a healthy population, nothing else matters. The NHS is a part of all our lives from the very moment that we are born to the time we die, and often many times in between. But the NHS is even more than this. It is an important expression of our basic values; a belief in the power of collective action to change people’s lives for the better, by ensuring proper care is available to each of us according to our needs, not our ability to pay. Nothing will be allowed to take it away from us.

It would be a disaster for the NHS if we simply waited for the Labour Party to form a government to implement change. The NHS is at breaking point today and by 2020 it will be too late. We need to act today to reverse the damage done by the closure of A and E departments, outsourced or pared-down services, ward and hospital closures, reduced access for patients and further privatisation.

It is only through the creation of real grassroots movements, present in towns and cities everywhere, that we can protect our NHS. We are reminded that a campaign to save a local A and E department win more hearts and minds than anything else. The fight to save our NHS must become a visible reality on every high street. Only such a fight might give our health service a chance of survival.

Campaigning to save the NHS must be a first priority. We must ensure that the enthusiasm, within trade unions and the left as a whole, which the election and re-election of Jeremy Corbyn as leader of the Labour Party has generated, is directed to practical ends.