25.11.2021

Onslaught continues

With the busiest winter period fast approaching, James Linney savages the government’s NHS ‘rescue plan’

Remember the recent duplicitous media and government campaign for more face-to-face appointments with GPs?¹ We were told that they were being denied to long-suffering patients, so that ‘lazy’ GPs could improve their work-life balance. Apparently the lack of appointments has nothing to do with the government’s diabolic mismanagement of the pandemic, on top of its long-term, veiled scheme to underfund and outsource the NHS.

Since then, the government has published its ‘rescue plan’ for improving access to GP surgeries and like a hostage being handed a plan for escape by their captor we should be highly sceptical. As though to reinforce this point, in the introduction of the plan we are told:

… patients’ ability to access primary care is often not as good as it should be. Some patients are experiencing unacceptably poor access to general practice, including an inability to contact practices - as witnessed by their stories and those reported in the media.²

Here we are given a peek at the real motivation behind this worse than inadequate plan: to placate and give credence to the rightwing media and the campaigns to undermine the NHS. When it comes to the detail, it appears to have been written by someone who has absolutely no experience or concern about the desperate state of primary care. We are told that the government has a grand plan to increase the number of GPs, despite the total continuing to fall and a recent GP poll revealing that more than half (54%) of respondents are thinking about “leaving the NHS altogether”.³ Undeterred by a little thing like reality, the authors of the ‘rescue plan’ go on to claim that the “government’s manifesto has commitments to improve general practice capacity by increasing the size of the primary care workforce and delivering 50 million more appointments”.

Empty promises aside, we eventually get to the hub of the plan, which boils down to a meagre pledge of a £250 million ‘winter access fund’ for GP surgeries. Even if this money was divided out and given to GP surgeries to spend on what they feel is most important, it would have very little impact on the enormous, unsustainable pressures currently being faced. But this is not the deal. This pledge comes with a list of prescriptions and hoops to be jumped - arbitrarily the money will only be available till March and any funds not spent during this time will be lost. GP surgeries are told they must submit a detailed business plan justifying how they plan to spend the money, and they were only given 13 days to submit it - or else the offer would be withdrawn. This is a substantial extra burden to administrative and clinical staff already trying to juggle their ever more demanding routine clinics, extended hours and the running and staffing of Covid vaccination centres. Even if by some miracle GP surgeries manage to secure some extra funding this winter, we are told, “funding could be reduced or discontinued if demonstrable progress has not been made by mid-December”.

Pathetic

By any standard this so-called ‘rescue plan’ is pathetic. Demand for GP appointments has never been greater, whilst the number of available clinical staff is falling, not increasing. GPs are still not seeing as many patients face-to-face (currently about 60% of consultations vs 80% pre-pandemic), but we are still in the midst of Covid-19, which is by its nature very unpredictable. But it would be surprising if a government that showed little remorse for its own role in the mass deaths during the pandemic should start caring now.

As I write (November 22), there were 44,917 new cases of Covid and 292,417 in the last seven days - an increase of 10% on the previous week. The high number of circulating viruses means an increased risk of new variants developing. Despite this risk GP surgeries are still trying to keep face-to-face consultations, when clinically indicated. Yet the ‘rescue plan’ aims to punish GPs for their justified caution by monitoring the number of face-to-face appointments offered by each surgery - the lowest 20% will be named and shamed, and these practices “are likely to be required to resolve the issues: for example, to increase resilience; smaller practices offering unacceptable access may be expected to partner with other practices, federations or [primary care networks].”

GPs are having more clinic contacts each day than ever: there have been 196.8 million so far in 2021 - up 10% on the previous years.⁴ The argument about face-to-face appointments is for the government a useful distraction and an attempt to deflect blame from the real causes and depth of the current crisis - a crisis which has nothing to do with face-to-face consultations and was not caused by Covid-19. It is actually the continuation of a trend resulting from over a decade of Tory government mismanagement of the NHS. From its inception until 2008 the health service received an average annual uplift in funding of 3.7%, but since 2008 this has been reduced to 1.4%⁵ and, compared to other G7 countries, the UK’s healthcare spending per person has fallen to the second lowest.⁶

The consequences of this defunding are being seen not just in the difficulties in getting to see a GP, but in the equally disastrous state of hospital care. NHS England’s most recent monthly data paints a bleak picture of a service already beyond capacity - and not yet in the busiest winter period. The overall number of people waiting for routine operations was at a record high of 5.83 million at the end of September, with more than 10,000 people having to wait more than two years. In October, more than 30% of people attending accident and emergency departments had to wait more than four hours for a bed or to get treatment after the decision was made to admit them - more than 7,000 people had to wait more than 12 hours! These figures are likely to represent an underestimation of the problem, because many people attending A&E choose to go home when they are told how long they may have to wait: ironically, they feel too unwell to cope with such a long wait.

Ambulance and paramedic services are in just as dire a situation. A recent report published by the Association of Ambulance Chief Executives⁷ estimated that up to 160,000 people in the past year have been harmed due to having their handover to emergency departments delayed - approximately 12,000 of these patients could have experienced severe harm or even died as a result. Across the country the average ambulance response time for those with life-threatening illnesses is significantly below the target: the average waiting time for an ambulance is now 1 hour and 17 minutes! That represents an increase of 88% on 2020 and more than double the wait in 2019.⁸

What of the reaction to the government’s ‘rescue plan’? To their credit, the British Medical Association (BMA) and General Practice Committee England (GPCE) were quick in unequivocally rejecting it and called on GPs not to engage with the process of trying to apply for the funds offered. Going further, the BMA is balloting GPs as to whether they would be prepared to engage in protest action, the most significant of which would be to resign from their primary care networks (PCNs). In 2019 NHS England forced GP surgeries to create these new organisations, grouping several GP surgeries in a given area, which were each responsible for managing care for tens of thousands of patients. The extra clinical staff they employed (such as pharmacists, dieticians, social prescribers, etc) were spread very thinly despite increased numbers of patients. PCNs are just the latest in a long line of bodies created since the Andrew Lansley-inspired Health and Social Care Act of 2012, along with clinical commissioning groups, GP federations and the newest manifestation: ‘integrated care systems’ (ICS). These bodies have been vehicles for privatisation and implementing Tory cuts, whilst shouldering the bureaucratic burden of micromanaging the ever deepening primary care crisis.

Timid

What the BMA and GPCE are threatening then is not a GP strike, but merely a withdrawal from PCNs - a rather tame threat, even by the standards of the BMA, which is a very conservative union historically.

Yes, leaving the PCNs would reduce some of the administrative burden on GP surgeries and would be a token show of dissatisfaction at the current underfunding, but it is hardly going to have the government shaking in its boots. It would also have negative consequences: it would mean that the clinical staff employed by PCNs would likely be out of a job and surgeries would lose that part of their funding which is currently routed through PCNs. However, even this rather timid proposal already has the rightwing media outraged. Hence the Daily Mail’s headline: “Fury over ‘absurd’ GP plans to ‘STRIKE’: Campaigners urge Sajid Javid to crack down on family doctors who’ve threatened industrial action in protest over ‘being asked to do their job’.”

The government can always rely on the media to spew their anti-union bile and it is easy for them to paint any protest action involving doctors or medical staff as self-serving and dangerous to the public. This is exactly what happened with the 2016 strike action involving junior doctors against the government’s implementation of their contract. Then the BMA did propose strikes and, although public opinion and support was clearly behind the junior doctors, the BMA mismanaged the episode so badly that momentum was lost and ultimately the leadership does what it knows best: it capitulated to the government for the absolute minimum of gains.

We must not fool ourselves that a GP strike would be guaranteed to have any lasting impact, but it has more chance than the current BMA’s proposed ballot; it would get significant media coverage and be an excellent opportunity to voice opposition to the government’s covert campaign against the NHS.

The most recent manifestation of this campaign has been the creation of the Integrated Care Systems (ICSs), which threaten to open the door to even more privatisation. Already it has been estimated that as much as 26% of NHS funding goes to private healthcare providers.⁹ The creation of ICSs will be cemented by the proposed Health and Care Bill 2021, which is currently going through parliament. ICSs will be controlled by ‘integrated care boards’, constituting a group of interested parties responsible for care provision in 42 geographic regions of the UK - a model that looks suspiciously like the one used to provide care by insurance companies in the US. Not surprisingly then, there are already examples of private health companies securing seats on these boards, like Virgin Care’s local managing director, Julia Clarke, being listed on the board which currently runs the ICS covering parts of Somerset and Wiltshire.¹⁰

Here lies the real and imminent threat to the NHS. It is not that it costs too much, it is not because of an aging population and it is not Covid-19: it is the fact that it offers an opportunity to access an untapped source for profit.