The NHS We Could Have Had
LOOK BACK
By George Williams, Biomedical Sciences student at New College All of us who spent long hours trudging through marginal seats in miserable weather this winter believed in the 2019 manifesto – and believed in it enough to spend our free time convincing voters to believe in it too. It was bold, uncompromising, and above all necessary. That we could see so clearly just how people needed a radical Labour government made it all the more bitter when they expressed their disagreement. Few would have predicted after the disappointment of election night how quickly we would be proven right, and no-one could have predicted how it would happen. Yet somehow, a microscopic virus has done what busloads of canvassers failed to do. The 2019 manifesto looks ever more prescient as governments cast around for novel solutions. Ideas which were the butt of jokes when proposed by Labour have been rolled out without fanfare, buried in the daily tide of emergency schemes and dire statistics. Of all the policies proposed in It’s Time for Real Change, many of those which have already been enacted – and those which may yet prove to be visionary – concern the NHS and social care.
The tone of the election was unsubtle: nuanced policy proposals were figuratively (and occasionally literally) bulldozed aside by vacuous slogans. When the discussion could be wrested away from Brexit, the NHS appeared frequently, but only in broad strokes or else factually questionable proposals. Would it be sold to Donald Trump? Who was responsible for the images of children sleeping on piles of coats? Would there be 50,000 new nurses - and what constitutes a ‘new’ nurse anyway? Despite the lack of discussion, Labour’s manifesto contained six pages of detailed proposals for both health and social care. These varied from increasing funding and structural reforms to more ambitious plans to integrate health and social care, and even a national drug manufacturer. On the 12th of December, it seemed that these policies would be shelved. COVID-19 would not only make them once again relevant but actively necessary to help re-orient the NHS to deal with an unprecedented emergency.
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To the public, the NHS may seem like one organisation – all the workers who we clap assiduously every week have the same three blue and white letters on their ID badges – but this disguises a great deal of organisational com-
plexity. The NHS is made up of 211 clinical commissioning groups. These CCGs are the buyers in the NHS’ internal marketplace, run by GPs and purchasing services for the local area they cover. The sellers supplying them can be hospital trusts, GP practices, charities, or even private healthcare providers. Marketplaces are supposed to increase competition and improve services – instead, they add an extra layer of bureaucracy and cost. By forcing services put ‘out for tender’, those which could easily and cheaply be provided by the NHS itself must instead be offered for a lengthy bidding process. This opens them up to legal action when private companies are unhappy with the results. Labour promised to abolish the Health and Social Care Act 2012, which created the CCGs, to ‘end and reverse privatisation’, and ‘end the requirement … to put services out to competitive tender’. The economic and administrative savings brought by these policies may well have been ignored were it not for the outbreak of a major disease. Faced with a global crisis in health procurement, and with GPs suddenly too busy to oversee lengthy commissioning processes, the government ordered NHS England to take over the functions of the CCGs – centralising the commissioning of services for at least the rest of the year. While this is not as far as Labour envisioned, it is a tacit acknowledgement that the market structures created in 2012 and further back are dangerously inefficient. Another body created by the Health and Social Care Act, now familiar to us all from daily briefings, is Public Health England. This was a streamlined organisation: under the Act, most public health services (from smoking cessation and sexual health to environmental hazards) were handed to local councils. Just as they gained new responsibilities, councils lost millions to funding cuts. Despite saving the NHS significant sums by improving health before it got bad enough to need treatment, many council budgets simply could not support this extra expense. The most deprived areas –already struggling with poor population health – suffered cuts 6 times more severe than the richest. Over the course of a decade, this neglect began showing in increased rates of STIs, rising drug-related deaths and falling life expectancy. A country so unhealthy would always have struggled to fight a disease which disproportionately affects those with existing conditions. At the election, the manifesto promised a £1billion increase in public health funding, alongside improved funding for sexual health (including rolling out PrEP, a drug which prevents people from contracting HIV), smoking-cessation, and anti-obesity measures. These measures were sensible precautions before the pandemic; now they are necessities.
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