Save NHS bursaries march, Jan 2016 (Photo: Steve Eason)

What do we need to do to defend the NHS?

Pete Gillard assesses the limitations of Labour’s manifesto promises on health and argues that enthusiasm for the NHS can be used to build unions among health workers.

Three days before the election, the Financial Times ran a headline “Health service campaigners struggle to be heard in UK election”. A Director of the King’s Fund, a leading health think-tank, was quoted as saying: “I think the NHS has [been] somewhat underplayed in the election so far, particularly compared with the level of public concern about the NHS as an issue.”

That did not stop passion to protect the NHS being a major component of Corbyn’s campaign. At every rally, when Corbyn talked about saving the NHS, he was met with tremendous enthusiasm – frequently at an even higher level than other important issues. Many of the people who decided to vote Labour during the campaign will have been motivated by Labour’s NHS promises.

The opinion polls before the General Election, and the exit polls after, almost unanimously found that the NHS was the most important issue for voters. Surprisingly, though, there was very little debate about the proposals the various parties put forward in their manifestos.

There was a reason for this. There were no “big ideas”. The parties promised a minimal set of concrete proposals.

NHS funding 

Let’s look at the current state of the NHS. Underfunding leading to massive cuts in services, to longer waiting times for routine surgery – and raising the bar before you can get it,  to a crisis in A&E with not enough ambulances, staff, or beds. GPs are overstretched and retiring as soon as they can. Staff are leaving the NHS to work in supermarkets because of the pay freeze, and leaving the country because of Brexit.

The Tories want a privatised health service. But at the moment this is being driven less by selling off bits of the NHS and more by reducing the service so much people “go private” if they can possibly afford it. The NHS is designed, under Tory plans, to become little more than a safety net for the poorest, not a universal service.

In 2000, Tony Blair came up with his “big idea” for the NHS. He promised that Labour would increase NHS spending to the average percentage of GDP spending in the EU. At the time, spending was 6.3% of GDP in Britain, and the promise was to raise it to 8.5%. Over the period of the Blair/Brown Governments, the EU average went to over 10%, and Britain was close to matching that figure by 2009 and the crash.

It can be argued, rightly, that much of this extra cash was wasted. The private sector took a big chunk through things like PFI. But on the ground there were visible improvements to services. Importantly, waiting lists for high volume elective surgery were almost eliminated. That changed the quality of many people’s lives. Even less visible services – e.g. services for disabled children – were significantly expanded.

A magazine for NHS managers, Health Service Journal (HSJ), analysed the 2017 manifestos using work from the Nuffield Trust think tank. They reported their estimates of how the promises would affect health spending.

Unsurprisingly, the Tories were the worst. With their proposals, spending would fall “on a generous interpretation” from 7.3% of GDP to 7.04%. The Lib Dems proposals would lead to a fall to 7.07% – only marginally better.

Labour’s manifesto

Labour’s proposals, the HSJ said, would have led to a fall to 7.23%. Labour represented the best option but still promised a cut in the percentage of GDP spent on health. Labour said “Labour will commit to over £30 billion in extra funding over the next Parliament. That works out to £6 billion extra per year. To match Blair’s promise of 2000, the King’s Fund estimated it would take an extra £43 billion per year, an increase of over 30%.

Labour’s financial proposals would have papered over some cracks, but not reversed the Tories cuts of the last seven years. Labour’s proposals would mean that cuts continued, albeit at a slower rate.

How much finance does the NHS need? There is no easy measure. Historically, people have always reckoned it needed to rise, in real terms, about 4% a year simply to meet the extra demands of population growth and advances in medicine. The result of not getting that money for the last seven years means – in stark terms – people are dying prematurely, or are being left in unnecessary pain and disability. The ongoing “efficiency savings” are not about saving money on paperclips. Health bosses are now doing cost-benefit analyses on every type of treatment patients might receive.

The measure of percentage of GDP was a simple one that demonstrated the UK was not falling behind other countries. Labour consciously dropped that target in its 2017 manifesto.

There were other promises in Labour’s manifesto: “Labour will halt and review the NHS ‘Sustainability and Transformation Plans’ (STPs), which are looking at closing health services across England…” That halt would have been welcome. The promise to involve local people in drawing up revised plans was also welcome. But what was not addressed in the manifesto was the reason for the plans in the first place. The STPs come from NHS England’s plan to implement £22 billion savings. This is what the so-called “Five Year Forward View” is all about. If public involvement were to be limited just to how the cuts should be made, not whether, then it would just be another recipe for divide and rule.

There are fine words in the manifesto, but the question of how they will be implemented is dodged. Labour promised “Labour will protect patients and legislate to ensure safe staffing levels in the NHS.” We all want safe staffing levels. One of the crimes of the Tories was to prevent the National Institute for Clinical Excellence’s (NICE) recommendations on safe staffing from being enforced.

But the problem is that without funding for sufficient staff, safe staffing can only be managed by eliminating some services to move staff elsewhere. The Tories solved the dilemma by removing the requirement for safe staffing. Labour legislating for safe staffing would not solve the problem. Who would be prosecuted? The local health managers trying to work within grotesquely inadequate budgets?

Great play was made by Labour of removing the 1% pay cap for NHS workers. The proposal was that decisions on pay should revert to the existing NHS Pay Review Body. What was not spelled out is what this would actually mean for NHS workers’ pay. The Pay Review Body’s terms of reference require them to consider the financial position of the employers (but not that of workers). Again, it comes down to a question of funding.

Labour costed this proposal. They said there would be an extra £4 billion over five years to implement the removal of the pay cap for all public sector workers. The GMB estimated that the total annual pay bill for public sector workers in 2014/15 was £193.8 billion. So the Labour proposal represents an extra 2% in the pay packet as a one off in the five years of a Parliament. And that is assuming no extra staff to shore up services that are being run down or closed. The GMB estimated removing the pay cap would take an extra £8.5 billion per year. That is over ten times the amount promised in Labour’s Manifesto.

Jon Ashworth, the Shadow Secretary of State for Health, took the credit for writing the health section of the Manifesto during a post-election interview on the Sunday Politics show. Ashworth’s political career might make one wary. He was a special advisor to Gordon Brown when he was Chancellor, and in 2015 he nominated Yvette Cooper in the Labour Leadership election.

But this section of the manifesto was not his alone. It was moulded by John McDonnell’s instance on a balanced budget. McDonnell’s fear of Labour being accused of “tax and spend” ran through the manifesto. All the proposals would have been mainstream social democracy two or three decades ago. There is no fundamental challenge here to capital. Everything is to be done slowly.

The Labour manifesto concedes that the market will continue in the NHS – the NHS will be merely a “preferred provider”. It was the introduction of the market, first by the Tories and then developed by Blair, that destroyed any meaningful concept of integrated care. Capitalist competition between different hospitals is set to remain under Labour proposals. An initial promise to repeal the Health and Social Care Act became a promise to repeal some (unspecified) sections of the Act.

There was no real challenge in Labour’s manifesto to privatisation. There is no proposal to say that big business has made enough profits under PFI deals already, and that we’ll take the buildings back under NHS control without compensation. Given how much PFI is generally hated that would have been a popular demand. But it would have gone against the economic moderation that permeated the manifesto.

Most people did not look at the manifestos in any detail before deciding how to vote. The enthusiasm to vote Labour came simply from the belief that Labour would be much better at defending the NHS and public sector workers.

Not waiting until the next election 

But socialists need to go a bit further than that. If Labour had formed the Government, the implementation of these proposals would not have solved the crisis in the NHS. The crisis would have deepened. And disillusion with Labour would have followed.

What we cannot afford, though, is to simply wait until the next election to solve the NHS crisis, whether that is this year, or whether the Tories manage to hang on for a much longer period.
We need to act now. Many NHS workers have been enthused by Corbyn. Many will have joined the Labour Party or helped in the election effort. We need to build on that enthusiasm.

Union organisation in the NHS has been substantially weakened since the aborted dispute over pensions in 2011-12. Can Corbyn-supporting NHS workers get together in every area to organise to rebuild union structures? If people are willing to join the Labour Party, why not also build on that enthusiasm to recruit to our unions.

Strong union organisation can stop the STP cuts being implemented locally. Health workers and communities together can halt the health bosses and their Tory overlords. And on the pay cap, there is a traditional way to remove it. It’s one that doesn’t require a new Government. Rejuvenated union organisation can lead to a real fight on pay, and, in the process, ensure May cannot implement her programme – no matter how long she lasts.