Monday 22 May 2023

Patients and Profits

In his famous address to the Albanian people, Enver Hoxha said "This year will be harder than last year. However, it will be easier than next year." Stirring words and ones Keir Starmer might have quoted while discussing the recurring winter crises in his much-trailed NHS speech earlier on Monday. As health is one of his "five missions", what was said here is almost guaranteed to go into Labour's next manifesto.

Starmer spoke about the scourge of health inequalities and the reversal of life expectancy under the Tories. He identified the "three big killers" and what Labour wants to do about them: reduce cardiovascular disease by a quarter, diagnose 75% of cancers while they're still stage one, and drive down the incidence of suicide among younger people. Also repeated was what he called the biggest expansion of NHS training in the organisation's history, funded by the removal of the non dom tax status. And the latest idea got an airing: the sharing of waiting lists so patients could opt to be treated at hospitals with shorter waiting lists. This would be underpinned by a more collaborative culture across the NHS, which was coming into being before Matt Hancock kyboshed it. This might help manage he backlog crisis around the edges, but is hardly a major policy announcement.

Indeed, that was not the point of the speech. Starmer wanted to hammer home the message that what the NHS needs more than money is reform. He identified the "three shifts" that would structure the remodelling of the NHS. The first would be moving care out of hospitals and into the community. What he called the 'neighbourhood health service'. This would entail improving GP access and make it more sustainable. This means moving away from the practice model and its gradual replacement by salaried GPs who would be deployed to serve all communities. In other words, a possible end to the GP shortages that particularly afflict inner city working class areas. Appointments would be "modernised" with an end to the 8am rush, and a pledge to bring back the family doctor. Clearing hospital backlogs by integrating health and social care would be a priority with joined up care in the community and a commitment to reverse the crisis in the care industry with a foundational fair pay agreement.

The second shift is movement away from treating sickness to prevention. This is a return to one of the objectives of the New Labour years with its keen emphasis on public health strategies. Starmer argued this had cost, or rather savings implications by taking weight off the NHS as well as heading problems off at the pass. He promised a revolution in mental health treatment, which would include 8,500 new community-based mental health professionals, dedicated support in schools, and four week maximum wait guarantee. The other new announcement, which was the placing of vaping, junk food, sugary snack advertising after the watershed and banning their marketing at children was lumped in here.

The third shift was technology, and specifically the rolling out of a digital service on a par with all the other digital services we take for granted. He condemned the wasted opportunity of the NHS Covid app and suggested he would like to see similar apps developed further to transform our relation to the NHS. Looking forward to using them to book appointments and making appropriate self-referrals, while ensuring patients had control over their data. This would enable us to make better choices and access faster care. He also spoke breathlessly of using Artificial Intelligence for the scanning of results, which are quicker and more accurate than doctors sifting through x-rays by hand. He wanted an agile NHS, one that had incentives to innovate but greater planning about the introduction of technologies.

In all, taken at face value this is the sort of thing you might expect a would-be Labour Prime Minister to be saying about the NHS. The main thing is a public service that works, and one crucial to Starmer's programme of repairing the popular legitimacy of the state. But there were a couple of questions for which there were no satisfactory answers. One got aired four or five times by reporters: what about the money? We know the Tories' refusal to pay the market rate for medical staff has the happy consequence of pushing the NHS toward becoming residualised. Strikes disrupt the service, people leave, everything gets worse and more opt for private treatment, leaving the queues and the exhausted, demoralised staff to those who are unable to pay. A boon for private health, certainly. Starmer said very little about pay, except for an approving aside on the New Labour years and how much nurses pay improved then. It's not that the Labour leader, Wes Streeting and the rest don't know pay need addressing, it's that they prefer a politically easy life. By being non-committal, the implacable Tory press can't use whatever figure to tie Labour up in knots over its spending plans and add to the narrative that the NHS is an unfillable money pit. Instead, that can is kicked down the road nearer to the election and all we hear between now and then are the new targets, the sexy technologies, and the overall direction of change.

The second issue is privatisation, which didn't get an airing today (apart from a vague gesture toward partnerships). That probably has something to do with how ill-received it was last time. And the small matter that using private providers to treat NHS patients is not really spare capacity as such. As is well known the likes of Streeting have received plenty of cash from for-profit health interests, but that doesn't mean the continued residualisation of the NHS is on the cards. During the Blair and Brown years, Labour became the preferred party of some sections of British capital because parts of the state were put out to tender and profits made from delivering government contracts. In line with Starmer's technocratic bent, these firms, in all likelihood, will be invited, or "partnered" into a reformed NHS providing some of the services the ambitious renovation demands. All under the likely guise of offering their "expertise". There is more than one way to skin a cat, and there is more than one way of making sure state money ends up in private coffers. Outright privatisation won't happen, but a new set of contracting-out relationships that provide firms guaranteed incomes and guaranteed profits will.

In all, Starmer will be happy with the reception his speech received. It is Labour-enough sounding to settle activist jitters of those worried his moves to the right include abandoning traditional Labour ground. It will have frustrated the Tories and their press because there are few angles from which this can be attacked from the right. Reading between the lines health unions can cut through the Starmerist cypher and glimpse the prospect of better pay deals, an end to the recruitment crisis, and less pressure, and those ever-so-philanthropic private health interests can see where they fit into the picture.

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1 comment:

Anonymous said...

«the message that what the NHS needs more than money is reform.»

Ah the usual hypochrisy: "reform" actually means "efficiency savings", and "efficiency savings" means "lower pay".

«the Tories' refusal to pay the market rate for medical staff has the happy consequence of pushing the NHS toward becoming residualised.»

It works very simply; privatise a bit of the NHS means eventually cutting wages by 20-40%, and that means 10-20% got to profits, 10-20% to lower taxes. It is a win-win!

That 20-40% wage cut is usually done by hiring cheaper immigrants, by hiring less qualified people, or simply "cramming down" existing employees.

The defining moment of New Labour was when Blair sacked 500 NHS staff nurses because they were too expensive, to replace them with lower paid temp nurses, when to see how would that play with public opinion, and there was no protest, business as usual ("don't make waves" as long as property prices and rents keep booming). Another defining moment was when the Work Minister John Hutteon said that immigration was essential to reduce the costs of the NHS and thus keep taxes from rising.
“Last year 59% of new registrations in England had been trained by other countries, writes Prof Rachel Jenkins [...] The number of medical student training places in the UK needs to double. This should not be as expensive to Treasury as feared”

The ultimate goal is to have different types of "plans": a residualised "bronze plan" for losers (the lower classes), a "silver plan" partially paid for by employers or property profits for the upper-middle classes, and a self-paid, or generously paid by employers, for the upper classes like investors, directors, CEOs.

As final bonus, here is Norma Tebbit of all people pointing out how privatised service screw the NHS:
Lord Tebbit said Health Secretary Andrew Lansley’s plans could bring “unfair” competition, enabling private firms to cherry pick. He said: “It’s fine for the private sector, which doesn’t have responsibility for teaching and bringing on young surgeons, to take the straightforward and easy stuff. But that means the public sector is then left without the base of work to subsidise the more difficult surgery and the teaching of surgeons.”
Lord Tebbit, whose wife Margaret was left in a wheelchair after the IRA Brighton bomb attack in 1984, spoke of his experience as chairman of a charitable fund which helped the Nuffield Orthopaedic Centre NHS Trust. He told how a local private hospital was contracted by the NHS to help shorten waiting lists.
“But the damage it did to the finances of Nuffield and its ability to carry out training...was quite considerable,” he said. “The private sector hospital had neither any obligation, nor wish, to take on the more difficult and complex surgery. It had no obligation to teach the next generation of surgeons the skills they would need to deal with such work. That was all left to be done by the NHS hospital. But the NHS hospital lost income from that bread-and-butter work. It no longer had enough of the routine work for young surgeons to gain the experience needed to take on difficult and complex work and it ran into real financial difficulties.”»