WHEN the Prime Minister announced her much vaunted 70th birthday present for the NHS of an extra £20.5bn a year, she controversially suggested it would be funded, in part, from the Brexit dividend.
The subsequent wrangling about this point rather obscured the fact that what was presented as a generous deal falls some way short of the annual four per cent increase the NHS had received to meet increased levels of need until the election of the Cameron government in 2010, and which the Office for Budget Responsibility believes is the minimum required.
Alongside the anniversary, the background to this announcement is the very obvious consequence of a period of restricting health spending, evidenced by the worrying failure currently to meet a whole series of key targets in the delivery of patient care.
The recent Nuffield Trust and Health Foundation report showing, since 2010-11, a near 20 per cent increase in patients readmitted to hospital as emergency cases within days of being discharged, is another indicator of a service under immense pressure. The fact that, in English hospitals alone, there are almost 36,000 nursing posts and 10,000 doctors’ posts unfilled will undoubtedly contribute to these failures.
Nevertheless, it is nothing less than remarkable that our NHS is about to enter the 70th year since its establishment in 1948.
Although successive governments of various political persuasions have all proclaimed genuine belief in its basic principle of care free at point of need, their fluctuating approaches to the resourcing and structure of the service, and its relationship with social care and public health, have meant that for most of its existence it has not had the opportunity to deliver the outcomes envisaged by its founders.
Just as important as a new deal on resourcing is the need to unravel some of the structural barriers to a coherent and cohesive health and care system. During my time in the Commons, I saw numerous organisational changes by governments of both the major parties which made absolutely no sense.
The essential contradiction between the Conservatives’ belief in free market capitalism and governing a system of socialised medicine such as the NHS manifested itself in the Thatcher administration’s introduction of an alien market philosophy. During the 1980s, the purchaser/provider split meant health authorities and some GPs doing the buying and the hospitals selling their services.
The ‘thinking’ behind this so-called ‘internal market’ was that hospitals and community services would be competitive, resulting in efficiencies and savings in the cost of care. But the huge bureaucratic expense of contract negotiation, monitoring and enforcement, as well as billing for all the individual treatments, simply hadn’t been thought through.
If this marketisation of health was radical, alongside it were the even more revolutionary changes taking place in social care where what had been, in the main, public sector provision of residential and domiciliary care was being rapidly privatised, and placed largely in the hands of commercial enterprises. Any notion of a joined-up health and care system was long gone by then and is impossible now with as many as 7,000 different providers in the home care sector alone.
Margaret Thatcher is on record as saying that the creation of New Labour was her greatest achievement and, after Tony Blair’s election as Labour leader, it was soon apparent when he became Prime Minister in 1997 that her marketisation of health and care would go largely unchallenged.
During the lifetime of his later governments, the NHS would receive unprecedented levels of increased funding but the failure to challenge the market philosophy and address its separation from the social care system meant that the impact was limited.
Their different organisation and funding is at the heart of so many of the problems we have faced throughout the service’s 70 years and slashing social care funding by £7bn since 2010 has had a huge effect on the NHS.
The ambulance queues outside A&E departments in recent times are often down to their inability to move patients onto wards where beds are occupied by the elderly – fit for discharge – awaiting the arrangement of social care.
Formal integration has been recommended by the Health Select Committee on several occasions and it has to be the way forward. Determining exactly where the care of, say, a dementia patient splits between free NHS provision and means-tested social care is utterly nonsensical but a costly industry of health and care managers are doing this on a daily basis. The Treasury rejects combining health and care on cost grounds, but not doing so is wasting billions in terms of delayed hospital discharges.
The Private Finance Initiative introduced by the Conservatives, and embraced by New Labour, has been a scandalously costly method of funding new hospitals, leaving the Trusts concerned facing near-impossible annual payments to the companies involved. PFI is a key factor in English hospitals being over £1bn in the red.
I hope that during the three decades before the NHS centenary we might see the service change from its traditional focus on hospital-based treatment models towards a community based preventive approach.
Alongside the merging of health and care provision should be the gradual return of social care to properly planned public provision. If this is accompanied by phasing out the NHS internal market, I believe that by its 100th birthday it could be restored to excellent health.
David Hinchliffe is the former Labour MP for Wakefield. A former Chair of Parliament’s Health Select Committee, he has served, more recently, on a NHS Board and still contributes on a regular basis to NHS staff development courses in various parts of the country.