Background briefing notes –  The current state of the NHS, public health and social care

1. Privatisation

1.1 Private companies now have contracts to provide almost every area of NHS healthcare from urgent care and ambulances, to GP practices, to support activities (cleaners, porters, maintenance staff, laboratories). Privately contracted services account for between 18-26%  of all NHSE spending. (CHPI, 2023)

1.2 The transaction costs of devising, awarding and monitoring such contracts reduce the proportion of NHS budgets available for actual patient care. ‘Marketisation’ has cost the NHS anywhere between £4.5bn and £10bn per year in extra administrative costs alone, while the services provided have deteriorated. Hence administrative costs of the NHS have increased from 6% to 15% per year, between the 1990s and 2012-13.

1.3 Private companies, through PFI contracts, provide maintenance of NHS assets including both hospitals and community health centres and provide essential services (though usually referred to as ‘ancillary’) of cleaning, laundry and catering. These are provided at huge cost to the NHS in the form of debts owed to investment companies mostly based in tax havens;

1.4 Private hospitals and other health services provided through private insurance companies undermine publicly provided healthcare by limiting the NHS access to trained professionals, and propagandising for private provision.

1.5 The NHS procurement system (buying equipment and drugs) has itself been part privatised creating a deeply flawed system. Rather than controlling and scrutinising contracts to private manufacturers, the system has attempted to legitimise private sector profiteering and minimum standards have become the norm. Drug companies especially have made huge profits during the pandemic.

1.6 Patient data is being set up for use by corporations. The General Practice Data for Planning and Research launched this year promises merely to ‘scrape’ details from patient records, but the data is open to identification of named patients, and private companies could be given access. NHS Digital has awarded the controversial surveillance firm, Palantir, a contract for storing (and potentially mining) the Covid datastore.

2. Cuts and overall capacity

2.1 Ten years of cuts have had a devastating impact on the ability of the NHS to respond to patient needs. Together with privatisation, and therefore private profit eating up ever larger slices of financial resources, the last 30 to 40 years have resulted in a crisis of capacity.

2.2 There are severe staff shortages. Overall Britain has one of the highest ratio of doctors per 100,000 inhabitants in the OECD. On average 1 in 10 FTE medical posts are unfilled. As of September 2021 there were over 38,000 nursing vacancies, or 10.5% of the total target, and a vacancy rate of nearly 7.6% of hospital medical staff. (A vacancy is a post unfilled by qualified permanent or fixed-term staff). : 79% of nurses in an RCN survey felt that staffing levels at their workplace were insufficient to meet patient needs There is a 17% shortfall of emergency medicine consultants. There are 0.45 fully qualified GPs per 1,000 patients in England – down from 0.52 in 2015. Thus the average number of patients each GP is responsible for has increased by around 300 – or 16% – since.

2.3 Beds – European comparison The number of available hospital beds has almost halved over the past 30 years. The UK in 2019 had 2.3 beds available per 1,000 population compared with Germany’s 7.9 and Italy’s 3.2. Moreover there has been a decrease in the proportion of these which are for acute and mental health patients and an increase in the proportion which are day beds only. The Royal College of Psychiatry estimates that an additional 1,000 mental health beds are needed to cope with Britain’s mental health crisis.

2.4 The real pay of NHS staff has declined by 5% since 2010

3. Sectors

3.1 Dentistry has been substantially privatised in a process stretching back to 1951, until today access to free dental care is severely limited. Small, local practices are finding it increasingly difficult to bid for the highly complex NHS dental contracts, with the concern that the area will become dominated by corporate interests. Patients who cannot afford to go private may wait two years or more for checkups on the NHS. Emergency NHS dentistry has severe staff shortages.

3.2 Midwifery suffers very severe staffing shortages with eight out of ten midwives reporting unsafe staffing levels on their shifts. The RCM calculated in 2017 that an additional 3,500 midwives were needed (rising to 5,000 is EU nurses leave). A further danger is that one thirs of midwives are over 50 and the nukbers entering profession may be insufficient to close the gap, especially as staff leave and retuire due to work pressures. Meanwhile The num,ber of births has risen (100,000 more births in Ebgland in 2016 than in 2001) and births have become more complex for instance as the average age of women giving birth has risen and when 20% are obese.

Privatisation of community maternity care has already been attempted but more concerning are the plans to provide women with a ‘personal budget’ allowing them to choose private provision threatens to fvragment the service. The policy is further developed in the Health and Care Bill which encourages midwives to set up their independent companies.

3.3 Long term care, especially the care of the elderly has already been extensively privatised. For-profit companies own 83.6% of England’s care home beds. (13% are run by the voluntary sector and 3% by local councils.) Social care cannot be integrated with health care, nor can different elements of the healthcare system be integrated when the system is fragmented by of a tangle of providers.

3.4 Public health (Covering health visitors, school nurses, addiction and obesity treatment, sexual health and health education). In 2013 these functions eere made the responsibility of local authorities together with the 0-19 healthy child programme. Between 2015 and 2020 and there was a 22% cut to the local public health system and local authorities saw a decline in.  Since then all these areas have been extensively outsourced. – smoking, drugs andPublic Health England suffered a 16% funding cut. It was reorganised, during the pandemic for which it has key responsibilities and against professional advice. The work on infection control passed to a new UK Health Security Agency, with responsibility for inequality and the most significant preventable diseases such as obesity. There is a shortage of qualified Environmental Health Officers (covering eg food safety, housing standards, pest control and health and safety at work) with just 10 per local authority the number made up by staff without the professional qualification. Functions such as pest control and dog wardens have been widely outsourced and other areas part-outsourced.

3.5 Community healthcare.  In addition, swingeing cuts to local authority budgets have decimated a range of social and mental health support in the community. Together with outsourcing this has affected the provision of women’s health clinics, school nurses, health visitors, sexual health counselling, youth clubs, luncheon clubs, libraries, creche provision, balanced school meals and of course, housing.

3.6 Mental health There is a severe crisis of capacity, while recent decades have seen a steady growth in the numbers seeking mental health services, and during the pandemic in 2020 the number of children and young people needing emergency mental health care rose 20%.

On average 1 in 10 mental health posts in the NHS were unfilled in 2018. Today the vacancy rate for mental health professionals in the NHS ranges from 6.6% in the East of England to 17% in the midlands and the North West. There is a 10% vacancy rate overall for consultant psychiatrists. The Child and Adolescent Mental Health Service (covering children aged 5-16) is particularly struggling. It receives 6% of the total mental health funding, while children make up 20% of the population, and while 1 in 10 or 3 children in every classroom has a diagnosable mental health condition. There is a 13% vacancy rate for CAMHS consultant psychiatrists. As a result waiting times to see a mental health specialist have increased – sometimes up to 18 months – the criteria for provision of services have been tightened leading people to seek private provision. In 2018-2019 26% of referrals to specialist children’s mental health services were rejected.  Between 2009 and 2018 the number of mental health beds fell by 30%.

Privatisation of mental health services had produced well-publicised scandals in care. Between 2013 and 2018 private health companies won 58% of all mental health contracts awarded.

In contrast a mental health crisis grips the country, in part arising from the pandemic. However, the longer-term roots of the crisis lie in general social and economic conditions including poor housing, low income and financial instability. In the longer term the issue therefore requires a range of solutions which lie outside the ability of the health service or a local authority to deliver but require government action and trade union agitation to create a more equal society.

4. Administration, training, science

4.1 Training of clinical and care professionals has been neglected and even discouraged, for instance through the withdrawal of student nurse bursaries, the introduction of student fees and the general pressure on hospital and GP budgets which limits their ability to provide training places.

4.2 Diagnostics, pathology and NHS laboratories have been subject to commissioning and privatised such as the PET-scan. The number of hospitals with their own pathology (testing) processes has been reduced under a new model of shared labs. In turn these are open to privatisation. During the pandemic, existing NHS labs with experienced staff have been increasingly marginalised and underused as contracts are awarded to privately owned ‘super-labs’. Concerns have been expressed about the level of training and expertise in these new labs.

5. How the charter can be funded.

5.1 We know that when governments see a need for decisive massive injections of public money, that money can be found. Hence defence and banks which are ‘too big to fail’ are provided with funds instantly, with no detailed prior publication and discussion of the costs and benefits. We note also the privatisation has been carried through with scant scrutiny of the costs nor any assessment of the proclaimed benefits.

5.2 Therefore, we do not accept that these policies promoting the public provision of healthcare should be subjected to detailed costings and scrutiny while policies promoting privatisation and fragmentation are untested and have been steamrollered through against professional advice.

5.3 Many of the policies will pay for themselves. Ending private contracts could release up to 15% of the NHS budget currently spent on transaction costs. Public manufacture of basic equipment and drugs will remove the costs of patents and profits on the prices charged to the NHS.

5.4 Given the profiteering that has occurred in the course of the pandemic, compensation where outright nationalisation occurs should reflect the extent of social  responsibility shown by such companies during the pandemic as evidenced through rates of profit, excess charging etc.

5.5 To the extent that many services central to public health and well-being are provided through local authorities, funding to local government requires major increases.

6. Conclusion

6.1 Privatisation is being extended not reversed. The extension of private provision will inevitably involve cuts to staffing levels and rates of pay. The current trajectory of government policy is for further extension of a system of private provision, private insurance, and the milking of public assets.

6.2 The effects of all these policies has been to reduce overall capacity, fragment the provision of health and social care, to starve it of funding, to enforce rationing and limiting access to care. It is leading to poorly qualified staff with all staff under immense time pressure. Ultimately, this leads to unnecessary and avoidable deaths, as was demonstrated during the UK’s response to the pandemic.