Health campaigner Gill George analyses the crisis facing the NHS, both nationally and in Shropshire, where she lives. The challenges are huge – but local campaigners continue to fight, and the wave of strikes kicked off by the RMT holds out renewed hope.
Photo: Steve Eason, flickr – Licence: Creative Commons
The NHS is in crisis. I’ve been saying to people for a few years now that the NHS is ‘on the edge of a cliff’ – well, now it’s fallen off the cliff and it’s plummeting downwards. This isn’t primarily to do with Covid, though Covid hasn’t helped. It’s about twelve years of underfunding and understaffing – which in turn are a consequence of deliberate government policy. I don’t know if the NHS will survive in a recognisable form.
A shortage of GPs means people have to wait an average of ten days for an appointment. In February 2020, the government pledged to recruit 6,000 GPs – but since then the numbers in post have continued to fall. Over 6 million people were on hospital waiting lists in April. Almost 100,000 people with serious heart conditions are on those lists, almost 5,000 of them for over a year – the British Heart Foundation say that “some people will die as a direct result of their long wait for care.”
Destroying the NHS by sleath
The government’s agenda has been to destroy the NHS by stealth. NHS dentistry is in crisis, so many people feel pressured to go private – MPs have even talked about constituents pulling out their own teeth with pliers – and that’s the way more services will go. Many people needing a hearing aid already go to Boots or SpecSavers instead of depending on diminishing NHS provision. As hip and knee replacement surgery is increasingly rationed, people who can scrabble together the money will go private. The same will be true for cataract surgery and other elective treatments. We’re also starting to see the growth of private sector A&E units – although currently useless for life-threatening conditions as they don’t have the back-up of ICU, specialist doctors and so on. At this rate, we’ll be left with little islands of world-class care dotted around in highly specialist units – but bread and butter care is being smashed to bits.
Traditionally the left has seen threats to the NHS in terms of large-scale privatisation – big corporate takeovers. I reckon piecemeal privatisation is probably going to be a bigger slice of the story than corporate takeovers, but the threat from handing out contracts to the private sector is real. The potential for cronyism and corruption is clear from how Covid contracts were awarded. Going forward, the NHS at a local level will hand out contracts to the private sector using a ‘flexible, proportionate decision-making regime’ that is currently entirely opaque. Around half a million patients are now registered with GP surgeries run by US corporate Centene/Operose – a BBC investigation in January found that the company ‘lets less qualified staff see patients without adequate supervision.’
The funding crisis
Privatisation comes on top of huge problems with funding and staffing. The King’s Fund summarised the funding situation in a recent article:
In the decade following the global financial crisis in 2008, the health service faced the most prolonged spending squeeze in its history: between 2009/10 and 2018/19 health spending increased by an average of just 1.5 per cent per year in real terms, compared to a long-term average increase of 3.6 per cent per year.
Funding has not remotely kept pace with the health needs of an increased population, and has drifted well below health spend in comparable European countries such as Germany, France and the Netherlands. The government has made all sorts of wild and inaccurate claims of record spending on the NHS – but at a local level the NHS faces a financial gap of more than £1bn in 2022-23.
Health spending per person, 2017, Source: Office for National Statistics
The 2019 Tory manifesto claimed they would build 40 new hospitals by 2030 – in fact, there are five new hospitals at the most. NHS buildings are crumbling and increasingly not fit for purpose. There is now a maintenance backlog of over £9 billion.
The staffing crisis
There are also issues with staffing levels. Staff numbers have been squeezed at individual trusts, and there have been endless reorganisations that are about driving down the pay bill. What’s worse is that there has been no workforce planning in the NHS for at least twelve years. The number of doctors, nurses, therapists and healthcare scientists being trained has simply been left to chance. Then add in Brexit and a ‘hostile environment’ for migrant NHS workers, and include the rising number of existing NHS workers who want out because the pressures are just so great.
Over the last couple of years a kind of ‘phoney war’ has gone on, though I think that period is crashing to an end now. Health bosses were focused on Covid, and were given extra funding to deal with it. They also started to hold their board meetings ‘virtually’ – which suits them very well, as members of the public can’t pitch up and challenge. And from our side, the pandemic meant a long period without traditional campaign activities of petitioning, leafleting, public meetings and the like. All this means the government has been getting away with things.
Now, instead of more funding and staff, there’s another reorganisation. The irrational split between ‘purchasers’ and ‘providers’ remains, albeit in a different form. From April 2013, the purchasers were ‘Clinical Commissioning Groups’ (CCGs), bodies that decided what health care to buy for their area. Now, from 1 July, the statutory responsibilities of CCGs have passed to regional ‘Integrated Care Boards’ (ICBs). These, if Shropshire is anything to go by, are remote and unaccountable bodies, with minimal clinical involvement and dominated by extremely senior NHS bureaucrats. And behind them, NHS England controls the purse strings and tells the Boards when their cuts are not deep enough.
The ICBs sit within Integrated Care Systems, with 42 of these across England. The rhetoric is about collaboration and integration, but at the core of Integrated Care Systems is a drive to control costs. NHS England has made a ‘generous’ offer to Integrated Care Systems. Historic deficits will be written off – but only for ICSs that operate within budget this financial year, 2022/23. Every ICS is likely to be managing a significant real terms cut in NHS funding, with inflation running at nine or ten per cent. This means massive pressure on the Integrated Care Boards to implement cuts.
Shropshire – ambulance service on the brink
And in Shropshire? Currently we’re fighting for an emergency ambulance service that gets to you on time. That’s very hit-and-miss now, particularly in rural areas. After ten minutes without oxygen getting to the brain, the probable outcome is death. The national response time target for a Category 1 ambulance is therefore seven minutes. I put in a Freedom of Information request a couple of months ago. In January this year, the average response time for my postcode was 28 minutes. One in ten people waited over 40 minutes.
We have local examples of people waiting five hours for an ambulance after a stroke or heart attack. An elderly person who has fallen and has a suspected hip fracture can now wait now five hours, ten hours on the floor, unable to be moved, in pain. And then they wait again when they get to the hospital. People are dying, completely avoidably, and sometimes just because they’re so exhausted and battered by the time they get the medical care they need.
How the hell did this crisis happen? For one thing, ambulance service bosses closed ambulance stations. Up until 2018, there were seven community ambulance stations serving rural Shropshire. Now ambulances are based only in Shrewsbury and Telford. It means much, much longer waits for people in rural Shropshire. That’s what ‘efficiency’ savings mean – people lose their lives.
Health systems grinding to a halt
But this is only part of a bigger problem. It’s happening across the whole of the NHS, but Shropshire, Telford and Wrekin is one of the worst affected areas. Rural areas have been underfunded historically, and we’ve had the disadvantage of very complacent Conservative MPs who have not fought against cuts and closures. The problem is known as ‘exit block’. Ambulances bring patients to A&E, but the A&Es are already stuffed full of patients. The ambulances, with patients in the back, have to queue up outside. Waits of several hours are the new normal. We’ve had a recent ‘handover’ time of 25 hours at the Royal Shrewsbury, my nearest District General Hospital. Of course this put patients at risk.
The A&Es, in their turn, are full because there aren’t enough hospital beds – so sick patients needing hospital admission are stuck in A&E waiting for a bed to become available. This leads to overcrowded A&Es, long waits for treatment, and worse patient outcomes. There aren’t enough beds because bed numbers have gone down and down in the UK and are way lower than comparable wealthy countries. Germany has 8 hospital beds per 1000 people, France is on 5.9, but the UK has just 2.5.
On top of that, when people are medically fit for discharge, there’s often nowhere for them to go if they need a bit of extra care. Community NHS services have been run down for years, despite lots of rhetoric about out-of-hospital care closer to home. District nurse numbers nationally are down by about 40 per cent in the last decade. Meanwhile, social care has a funding and staffing crisis all of its own. Care homes are already closing, with government funding changes predicted to lead to a rapid escalation of this. And domiciliary care – people coming into your home to look after you – is in tatters. Pay is bad, any career structure is non-existent, Brexit has slashed the available workforce, and in a tightening labour market, workers have more choices and are going elsewhere.
Ambulances are the bit of this iceberg which becomes visible. The leaders of the West Midlands Ambulance Service describe the situation as ‘catastrophic’ – they recently reported 100 patient deaths being treated as serious incidents because ambulances were unable to respond in a timely way. They speak very openly of the growing risk that the ambulance service will just ‘fall over’, that it will fail completely. They’ve even given us a date. Don’t go visiting the West Midlands on or around 17 August.
Bosses threaten more cuts
Over the coming months, we’re also expecting an attempt to take out community hospital beds – currently much in demand and with sky high occupancy rates of around 97 per cent. Community hospital closure would also mean trips of 30 miles each way for an X-ray, to get kidney dialysis, or to get a minor injury checked out.
Shropshire’s health bosses are still trying to implement A&E closure and the downgrading of the Princess Royal Hospital in Telford – but with a lot less capital available than they thought they’d have. There are plans to centralise GP services in Shrewsbury, sharply reducing access to primary care. Also we know hip and knee replacement surgery is a major target for cost savings. People are being forced to jump through more and more hoops before they are eligible for cheap and effective treatment that can transform the quality of life. Emerging information shows a scattergun approach to cuts, with ‘unglamorous’ services like podiatry and continence support to be slashed. Think of the impact on quality of life, though, as access to support is taken away. And services for children with special needs are already shockingly poor here – but are in the firing line for further cuts.
Years of campaigning – and some victories
The local campaign, Shropshire, Telford and Wrekin Defend Our NHS, has existed for some years. When there’s been a sharp focus – an immediate threat to the A&E in Telford, for example, or a threat to Ludlow Community Hospital – we’ve been able to mobilise large numbers of people. We’ve organised demos of several thousand people, for example, and quite often mobilised fifty to a hundred people to pitch up to Board meetings and give health bosses a hard time. Despite local NHS managers attempting to play off Shrewsbury and Telford people against one another in a fight over which town loses its A&E, we’ve kept both open for eight years now.
One of the things I’m proud of is the work Defend Our NHS did around the local maternity scandal. Bereaved parents fought from 2009 right through to 2022 for justice for the babies who had died or been harmed avoidably. Their courage was extraordinary. It was their fight, not ours. What we were able to do was stand in solidarity with them, share information, do some research and pull together obscure strands from different meetings and different documents. More than anything else, I think it was just straightforward, unquestioning, heartfelt solidarity.
With the crisis the NHS in in now, it has to mean the gloves are off. The NHS is falling apart in plain view. The new Integrated Care Systems are remote and unaccountable. People’s lives depend on us doing this, especially in a rural area like Shropshire. The scale of the NHS crisis is so great that in the end it’s only fixable through major political change. But in the short term, getting victories, however small and partial they might be, builds confidence and therefore makes future victories more likely – and they do slow things down and they will save lives.
Here in Shropshire, four of our five MPs are Conservative and most voters are Tories. We have no choice but to build a broad campaign. That doesn’t mean we drop politics. The NHS is falling apart as a direct consequence of political decisions, and part of the job of health campaigners is to keep pointing this out – and to seek to hold to account the MPs who like to pretend that the only problem with the NHS is a slight ‘wobble’ because of Covid. We also reckon campaigners need to do detail. Read Board papers. Watch online Board meetings. Ask awkward questions. Remember always that they make shit up. Some of it’s easy enough to understand. When they talk about ‘efficiencies’ or use the word ‘sustainability’, just think ‘cuts’.
Allies are important. Round here, we’ve worked at different times with town and parish councils, with the two unitary authorities, with GPs, and with a range of community groups and faith groups. And remember that people fight on things that they know about through personal experience. My own emotional connections with the NHS include infinite respect for the hospital that helped my Dad die peacefully and deep anger over the hopeless care that meant my partner died in pain. The ambulance campaign is the most exciting thing happening in Shropshire just now. We didn’t start that. It was set up by a Ludlow Dad whose baby daughter almost died when she stopped breathing and the nearest ambulance was 25 miles away in Hereford.
The gloves are off
I expect that some of these arguments will be easier for us after the ‘partygate’ revelations, and in the context of the truly shocking cost of living increases we are seeing now. This is a government that is causing hardship for millions of people. Poor people are more likely to get sick. Poor people live shorter lives than rich people.
The final part of the fightback has to be the unions. NHS unions are not particularly strong in Shropshire, Telford and Wrekin, so if you’d asked me about that a month ago I wouldn’t have been too optimistic. But I think the size of TUC march on 18 June shifted the mood in the trade union movement – and the first week of the RMT strike has shown the potential for unions to get huge public support. It’s not just the rail workers – there are strike ballots in the post and telecoms, and cabin crew at Heathrow just won a big pay rise. The NHS Pay Review Body should announce its recommendations shortly, and they will be nowhere near inflation. There’s potential for a coordinated fight on pay, including NHS pay, and that can really put the government on the back foot. So the attacks on the NHS are very serious, but the potential for a fightback is huge as well.