The General Election and Our NHS: Have the politicians any clue as to how to deal with it?
First off, a health warning to readers: I am a fervent supporter of the NHS, so cannot claim to be unbiassed. I’ve worked for the NHS since the late 1970s, in England and in Wales. And of course I’ve been a patient too.
The NHS is unique in being 100% publicly funded. It is also unique in the way in which it is politically managed.But listening to our politicians’ pronouncements in the run up to this election is worrying. Both Cameron and Miliband continue speaking in vague generalities, when they can be pushed beyond platitudes. Both parties box and shuffle around their proposed spending commitments. Jeremy Hunt spouts dogma-driven drivel while Andy Burnham talks of integration as though it will solve everything. I know that we haven’t had formal manifestos yet, but here are some of the issues we need to hear more about from each party before entrusting them with our votes.
Money: The talk, so far, is all about the mythical magical figure of £8billion and who will/won’t commit to this level of funding. This figure comes from estimates produced by the new “NHS Czar”for England, Chief Executive…Stevens, who predicts that the NHS needs £8bn over inflation by the end of the next Parliament (2020/2021) to maintain its present level of services.
Reports from leading health experts and think tanks suggest this figure is inadequate because:
- it relies on achieving efficiency savings of 2-3% per year
- The proportion of elderly people in the population will continue to grow during that period
- Elderly people, with growing rates of chronic disease, use more health and social care services than the rest of the population.
Efficiency savings in the NHS currently run at 1.5%, so expecting these to increase to 2% is a big ask, let alone expecting 3% per year.
Historically, costs in the NHS tend to rise faster than inflation because of the steadily increasing number of elderly people and because the costs of new medical technologies tend to rise faster than inflation. Now we have an added factor, as cuts to Social Services budgets begin to hit the NHS. Therefore the supply of places providing rehabilitation facilities is falling. This leads to back up in NHS acute hospitals and we have all seen the knock on effects of that this winter.
Resources No place to discharge vulnerable patients to, means that beds in acute hospitals are full; so, no room for new patients, whether from A&E or scheduled admissions. The whole system grinds to a halt, waiting times increase, staff are over-worked and pressured. They get sick and are off work, so agency nurses and locum doctors are needed, adding increased and unanticipated spending on hiring short term staff. And then the hospital emerges over-spent at the end of the financial year.
Performance By this time with waiting times targets have been missed frequently, staff become stressed and demoralised while politicians wring their hands…
So is there a way out of this vicious cycle?
Funding: The Health Foundation estimates that, expecting more realistic efficiency savings of 1.5% a year (the rate at which they are currently being achieved), the NHS still needs some £65 billion over and above inflation by 2030. That means annual funding needs to increase to 2.9% a year, slightly higher than the predicted rise in GDP of 2.3% a year.
So far, spending on the NHS in England has risen by an average of 0.7% per year in real terms over this parliament (2009/10 to 2013/14). This is lower than the average rate of increase for the UK of 3.7% a year in real terms since the NHS was created in 1948. But it has enabled Coalition politicians to claim, rightly, that they have increased spending on the NHS: from 2010-2013/14, spending on the NHS rose to £112, the highest amount since 1948. Spending increased by 1.1% in real terms in 2013/14. And planned spending is set to increase by 1.3% in real terms in 2015/16. But the statement above still holds: this is less than at any time since 1948. And here are some effects:
- Spending by hospitals increased by 2% a year during this parliament (2010-15). Now, 4 out of 5 hospitals are expected to be reporting deficits as this financial year ends.
- Meanwhile spending on general practice has fallen by 1.3% a year. This is unfortunate because primary care is the bedrock of health systems, providing 80% of care. Care provided at primary care level can prevent more expensive care needing to be given at acute hospital level. And so. stresses on this part of the system have the sorts of knock-on effects we’ve all bemoaned this winter: increased waiting times for GP appointments, A&E attendances up, bed shortages in hospitals and round we go again.
At the same time, NHS spending on care supplied by non-NHS providers (private, voluntary and local authority organisations) has risen by an average of 6.2% a year in real terms between 2009/10 and 2013/14. Services purchased by NHS commissioners (primary care trusts, NHS England and clinical commissioning groups) from non-NHS providers rose from £8.2bn in 2009/10 to £10.4bn in 2013/14 in real terms (see figure 5).www.health.org.uk/ fundingbriefing.
Spending on private providers is meant to bring in a more diverse range of services. Introducing an element of competition can stimulate quality improvements. But what it also does, much more inexorably and inevitably, is to increase transaction (administration) costs. It may increase patient choice but, in my experience, this is a two-edged sword. The patient also gets the burden of choice: s/he has to take on finding and selecting a provider, despite usually being in a vulnerable position (ill and anxious) when undertaking those roles. And it makes it very hard to make judgements on relative quality because indicators are different in different systems, and commercial confidentiality concerns limit the information available to would-be service users. Our system using GPs as gate-keepers provides both advocacy and monitoring of quality.
Miliband’s proposals, announced today, to cap profits made by private providers would ensure that some of the £18 million a day profit currently being made by private providers from the NHS budget (Patrick Wintour, http://www.theguardian.com/electionlive27.03.15) gets ploughed back into the NHS. This would help to pay back the NHS for its investment in training, developing and employing those who may also work for the private sector…). In addition his proposals to repeal the Health & Social Care Act, more aptly tagged as Lawnsley’s Disaster, perhaps, and remove the requirement on Commissioners to include private tenders, may also help the NHS to refocus on its core functions. But more funding and more funding for social care have also got to be part of any package to ensure the NHS remains a viable free-at-the-point-of-access service, regardless of a patient’s locality, age,gender, or means!
Health of the Nation: 49 Days left…
Oh dear, still no coherent or compelling narrative emerging to challenge the endless repetition of the Tory mantra: it has to be this way, this is the only way, it was Labour’s fault anyway. OK, I get that we don’t do Revolution. It’s a bit cold and damp here for any of this Tahir Square-type stuff, too. I understand that. And when I first came to Britain all those years ago, it was the all pervading tolerance was one of the things that grabbed me. That and the general sense of communal responsibility. Well we all know where that went, with the abrupt dismissal of the concept of “society” from the public discourse by Our Maggie.
But even so, we could oppose more forcefully, more coherently? Especially now, as the evidence of the harm and pain created by so many of the current policies grows daily. This government doesn’t do evidence, it’s true, dogma-driven as it is. “Mr Cobber’s” message discipline is so strong that even when the Mental Health Minister, ostensibly bringing the failings of mental health services to the fore, based on his family’s personal experiences, he manages to blame the NHS for “letting us down”, rather than recognising that the inevitable consequences of decades of under-investment is a stressed out, over-stretched, patchy service. When I first went to work for the NHS, back in the 70s, I was taught that Mental Health was a Cinderella service along with Mental Handicap. It was managed then within Community Services, along with, I think – though the memory is a bit dim- the Aids (as in Incopads, not AIDS) Service. But what else could it be, when even to have a mental health problem has long been considered weak and shameful? But to so cynically twist this “coming out” to blaming the service itself in order to promote a root and branch reorganisation with more private provision….Enough!
What have we gained, as a society, on balance through the policies of this Tory-led government?
- Inflation is lower
- House prices are back to pre-crisis levels
- Unemployment has fallen to 5.7%
- Youth unemployment is down from 19% to 16% (compared to 22%in the Eurozone)
- Waiting times for hospital appointments (ie Specialist medical Consultant opinion) are up
- Three quarters of Hospitals are over-spent at the end of this financial year
- Targets for A&E waiting times and Ambulances have been overshot more often than they have been met this winter
- Waiting times for GP appointments are up to a week (in a good week)
- Cuts to Social Services budgets mean that more people are ‘stuck’ in hospital beds awaiting discharge to more appropriate places for their needs.
The Resolution Foundation (www.guardian.com/society) reports that the majority of new jobs created under this government have been either part time or low paid self employed. The implication of this is that few of the much vaunted tax benefits will even reach people in these categories, further exacerbating the divide between well off and poor.
So, are we better off than before the election? Are we a healthier happier society now?
Going Home
Funny thing, going home. For a long-ago immigrant, where is home, anyway? Back to Oxford, where I first met and fell in love with Britain – and the man who became my husband. Chance encounters – this time walking into a photo being taken by a couple from Washington DC. We two had been talking about how very priivileged Oxford students are. Did they know it? Had we? Then the interrupted man remarked about how “exclusive” the US college in DC was, that I had attended, and how beautiful the campus was. Another jolt: was it? Had I known that then? Or simply taken it for granted, as perfectly normal and as expected, certainly nothing special to me then, hemmed in as it was by streets full of crowded multi-occupancy housing.
And yet we thought we were thinking radically then, questioning everything around us.And maybe it is only during those college-age years, when we really start to become who we want to be? Home, as in family – and place – of-origin form us unthinkingly, clothing us with sets of assumptions and expectations, which then seem to take a lifetime to unpick, examine and decide whether to keep or trash.
And then something happens, to re-start that process, after thinking it was all over and done with, it starts again, ferociously, insistently and can’t be ignored. Deaths of parents, of course, and now the death of a much younger brother. Coming to terms with losing him, just as I was getting to know him better. The shock and horror of dying, being there and then so suddenly not there. And even though it was sort of expected, the speed and inexorability of the last weeks, collapsing into days. Finally getting into the rhythm of the hospice day, visiting and returning, becoming familiar and then, in a minute, gone. Prayers said, belongings gathered; the room cleared, ready for the next patient.
Straight into funeral arrangements: in Connecticut funerals usually take place within 3 days of the death, so no time to lose. We work long days and manage to get everything done, just in time. A Monday morning funeral : then nothing. It’s all over; too quickly perhaps? We are exhausted and wrung out but not “done”. Too much to take in so quickly. We have done our best for our brother. And we have all dispersed, thankfully able to get back into our own lives again.
But still. Not really ready to be the same, to do the same things. Forced to confront how little time is left, for me especially, as the oldest, well out in the front of the queue now. How to use every minute of the time that is left? How to pick up some of the dropped threads of ambition spun in those college years? The contributions not yet made. The need to live more fully, eyes and ears more open to everything and everyone around me.
Trinity College, with its ethos of giving back. A lifetime of “public service” working for the NHS doesn’t feel like enough now. Another birthday days away, no time to lose.
Inspection Day at The Allotment
Hurrying up to the allotment, after yet another more-prolonged-than-hoped-absence, and full of good intentions to clear things up a bit, I was somewhat horrified to see a group of people gathered in a loose cluster but obviously not doing anything. Uh oh. I was right to be concerned: it was The Allotment Committee. Our allotment is Local Authority-owned, administered by the Parish Council. In the past the allotments have flourished under a system of benign neglect. The Clerk to the Council very properly allocates plots, organises the lawn mowing, and collects rents, all from the Parish Office. There is no communal seed buying or manure collecting or compost heap. Latterly, with the neighbouring cemetery space under increasing pressure, one or two plots have been confiscated to make more room for long term residents. But even those changes were effected without much evidence of officialdom on-site. Consequently a spirit of quiet independence reigned over the patch. Everyone was very happy to offer advice – if asked. No one seemed to take any interest in their fellow diggers, and a live-and-let-live philosophy seemed to prevail. Despite all the head-down, minding-your-own-business air, when probed, an awful lot of information could be unearthed, and not all of it to do with growing things. Occupations of fellow plot-holders, gardening styles – or lack thereof – were noted and passed on judiciously. “Oh you can rely on the soil in that plot. Jim digs it over every year, that’s good stuff there, that is!” “Well, we don’t see much of her; she doesn’t actually grow anything, just brings chairs up and leaves them scattered about.” Such an atmosphere suited my sporadic and laissez faire approach just fine. But this Spring I noticed a sea change. Suddenly, a lot of plots were being landscaped. There’s no other word for it. They were being carefully designed and planned. Hard standings were sprouting along with manicured stone paths between beds. New sheds were being erected – and painted! Some people spent a whole season without planting anything at all except infrastructure. This was serious – and a little intimidating. And then the Allotment Committee arrived. Plot holders’ numbers were checked and state of the plot noted. If no one was on a plot, questions were asked of neighbouring plot holders: “Have you ever seen anyone working this plot? How long ago?” etc. Fortunately, the Committee members were shepherded round by the local prize winner, a lovely man who made nice comments about each plot. Sometimes – particularly in the case of mine – this was challenging: last year’s bean poles were still up and adorned with the remains of what had been a poor crop even then. Couch grass and bindweed was evident in most beds, all of which needed re-digging. Both compost bins -and wheelbarrow – were already overflowing with weeds and brambles waiting to be composted or removed. But Mr Prize Winner managed: “Look at those beautiful artichokes” he said. “They are wonderful for bees and butterflies”. Cheered, I made some serious resolutions to up my game. But, yet again, life had other plans. A confirmed skin cancer needed excising from one leg – well that took out 8 weeks. Then a long-planned holiday. Returning, having cleared the beds – not soon enough for potato-planting, but still – I carefully sowed trays of beans in the greenhouse before going away, then proudly brought up my tray of plants. Then a necessary trip to visit family abroad-including a brother with terminal cancer. Back home 10 days later the beans were decimated: they might as well never have been planted. So I tried direct sowing, but no joy: no beans appeared. Finally I sowed the last of the packet of seeds, helped considerably by the gift of an assortment of left over seeds from a fellow plotholder. Presto, we had seedlings at last! A £1 packet of purple podded peas, bought at Chelsea, and sown direct also flourished, despite a determined attempt to die back almost immediately after appearing. Courgette plants also refused to grow: and thanks to some predator or other, whole plants simply disappeared soon after planting out. The corn seemed to stop at 2 feet high and the pumpkins never amounted to anything. The only thing that thrived were the golden beetroot, though I thought I’d sown chard (that never appeared either). And by August my much vaunted artichokes were long finished. So the Allotment Committee inspection was not welcome. Each member of the inspectorate held a clipboard and plot numbers and conditions were again duly noted. After all, we had had notice that Prizes Were To Be Awarded at the Village Show the following week. However I needn’t have worried. Keeping my head down, and weeding away, various snippets could be heard: “Oh do you know them? Isn’t he the Head of XXX? I heard she went off with the neighbour…”. “Oh those, I like growing them too”; “How do you cook those?” “Oh look at the little bunny rabbits, aren’t they just darling” (this from the PC Chair). Phew! Survived to fight again for another year…fingers crossed, there’s still some beans to harvest from that late sowing!
Politics and Storytelling
So, the Tories are now The ‘Defenders of the NHS’ and prepared to fight the next election on that promise. Where oh where has the truth gone from politics? Do we really have the politicians we deserve? How on earth could we ever, collectively, have been that bad?
We now have a government run by Frat Boys, because they think ‘they’re worth it!’ Cameron’s famous admission that he ran for Prime Minister because he “thought he’d be good at it” rings awfully hollowly now, as austerity measures fall ever more heavily on the Have Nots. And yesterday Cameron announced £7bn of tax cuts by 2020 targeted largely on those earning above average incomes.
So, then, where is the Opposition? Out to lunch? Gone fishing? At any rate, not home speaking to the voters, in the sense of connecting to real concerns. What’s more, there is still no coherent narrative to unite progressives and centre – or any non-Torybody, really. Despite this gift of a government, the alternatives lie silently sleeping.
If I ruled the world what would my rallying cry be? How would I help people to see my view of what’s really going on ‘round here these days? And how might such an alternative story be told? Or, is it just too complex and nuanced, compared with the overly-simplified, seemingly straightforward Tory Story?
Here’s my starter for 10:
TORY STORY
- Government should be as small as possible
- Poor people are lazy, dirty scroungers, out to get all the benefits/state aid they can get their hands on
- Too much State help will entrench existing couch-potato behaviours amongst the undeserving
- Rich people are rich because they are virtuous hard-workers, deserving higher rewards and incomes
- Benefits (tax breaks) for rich people drive the economy upwards and forwards
- Taxes are bad for the economy, taking funds out of the hands of individuals and putting them in the hands of the bloated State
- The Public Sector drains the economy, slowing growth
- Public services should be the fall-back option, not the mainstay of society
- Immigrants are only here for the beer
PROGRESSIVES’ STORY
- Government exists to support society
- All people are created equal but not all have access to the same chances
- Everyone deserves equal chances
- Ill health and disability are accidents, of birth or life events, not life choices
- A civilised society tries to care for those who need it when/while they need it
- Most people actually need to and like to work and contribute to their society/communities
- Taxes are the monetary tool with which the State pays for public services
- Public spending stimulates the economy and contributes to improved infrastructure (e.g.roads, rail networks)
- Immigrants contribute to diversity and richness of society (and sometimes do the jobs nationals don’t want to do)
So, why can’t the Opposition say so? Simply. Clearly. Loudly. Any views on how this story could be improved and told? Answers, please?
Thank you for your response. ✨
References:
The Guardian 1.10.14 p1 PM tries to plant Tory flag on NHS with spending vow, Patrick Wintour.
The Guardian 2.10.14 p1 The election starts here, Patrick Wintour
Welsh language
The Welsh Assembly Government is working hard to promote Welsh language learning among all age groups of the population. Welsh language classes are running locally, under a special initiative and in tandem with Cardiff University. This promotion means that classes are free of the usual restrictions on LEA-run adult education and community learning programs. So even if class numbers are small, the subsidy means that tutors and groups can keep running. What’s more, terms are longer than other LEA-run language courses and there are more levels and conversation classes/learning opportunities too. All this is meant to promote appreciation of Welsh history and culture and so, of course, is A Good Thing.
But is it appreciated? Do Welsh people want it? The 3 generations of a family sitting behind me on the train to London yesterday didn’t. They were unanimously against it. The Gran told her son and daughter-in-law about a school she knew of in Cardiff, where they were ‘trying out’ teaching Spanish instead of Welsh and that, if it worked, the scheme would be spread out across Wales and would reach their schools, too, in the south Wales Valleys. The son-in-law commented that “if people want to learn Welsh they can go to the Welsh schools”.
This unbidden and unprompted exchange surprised me. What about you? What do you think? Should the WAG keep spending upwards of £30,000,000 a year
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