The NHS in Scotland and England
Oh the irony. Labour’s killer argument to win the next election –that the Tories are destroying the NHS – has become Alex Salmond’s killer argument to win independence and lose Labour some safe seats. Salmond argues that the privatization of the NHS in England will shrink the health budget and have a knock-on effect in Scotland, and that independence will protect the budget and also allow protection from future privatization to be (hastily) written into the Scottish constitution.
Yet the NHS in Scotland is already devolved and has the power to resist private providers. In Scotland, personal care, prescriptions, dental check-ups and eye-tests are all free. Scotland has more GPs, medical hospital staff, nursing, midwifery and health visiting staff per person. It has no ‘market’ in healthcare; there are no Foundation Trusts, just a few PFI hospitals and none of the extra bureaucracy and regulation needed to manage the market. It has comparatively little private provision either outside or within its NHS. Scotland’s spend on public health is highly focused and it was first to introduce the public smoking ban. And yet despite this publically funded, controlled and provided NHS, life expectancies in Scotland are 2.7 years lower for men and 2.2 for women. If Scotland votes for independence, the life expectancy in what’s left of the UK will increase.
Life expectancy – and the number of years lived in good health – are far more strongly determined by poverty than how much money goes into the NHS. By far biggest risk for Scotland’s NHS is if independence makes the country poorer, which would cause a double whammy of greater demand on the NHS and less tax to fund it. There’s already nothing to stop the Scottish parliament increasing NHS spending, but it has to be paid for. Meanwhile, the flat-line funding of the English NHS makes it harder for NHS trusts to balance their books, private companies to make money and for patients to get care. Both the Nuffield Trust and NHS England calculate that by 2021, the shortfall in NHS funding will be £28-30 billion.
And yet the demands on the NHS are rising year on year as we live longer. The majority of patients using GP and other community services are already over 75. The average age of hospital patients is over 80, and 10 per cent of the patients over 90. The average age of patients admitted with hip fracture is 84, of whom one in three has dementia, one in three suffer delirium and one in three never return to their former residence. Most patients over 85 go to hospital because of an emergency, and stay on average for about 12 days. The majority of people nursed at home and who get help with activities of daily living such as washing, dressing and eating are 75 or older. Older patients account for more than half the caseload of district nurses, half a million people receive home care from social services and 84 per cent of them are over 75. Around 2.5 million people over 75 also have some kind of informal care at home from close family members, neighbours and friends. A quarter of carers are themselves 65 or older. Andy Burnham has warned that five more years of austerity will “push the NHS off the cliff-edge” but will Labour and the SNP commit to raising taxes to prevent its decline?
The Tory solution is to hope that enough people who can afford to get fed up with the waiting and pay to go private, particularly in NHS hospitals. The number of patients in England waiting for routine hospital treatment on the NHS has reached a six-year high with 3.2 million awaiting surgery, scans or other treatments, a rise of 700,000 from April 2010. By lifting the cap on the amount of private work NHS hospitals are allowed to do, the coalition has encouraged NHS hospitals to tout for private business and many are undercutting private hospitals. Meanwhile private hospitals are having to take on state-funded patients from the NHS to balance the books. Care is not driven by need, but by a business plan that searches for customers. The profit motive has gone viral in the English NHS
The argument for NHS expansion of private work is that some of the profits get ploughed back into the NHS, the argument for allowing private companies to take on NHS services is that they deserve a chance to do better. The Circle takeover of Hinchingbrook hospital has not yet made a penny in profit, and its support payments from the NHS to stay afloat are nearly £5 million. Circle won the 10 year contract based on the assumption that it could deliver £300 million savings, but without being able to cherry pick, it simply can’t. It’s ‘friends and family’ scores are high but the true test of a well performing trust is the staff survey. Out of 28 Key Findings, it came out worse than the NHS average on two thirds (19), and is in the lowest 20% in half. Like many trusts, Hinchingbrook can only balance its books by expanding its private business, an option the Scots are avoiding. For now.
Gordon Brown may promise Scotland that its NHS it will never be privatised but in England he endorsed market competition and the handover of large chunks of public money – and the power and control that brings – to private corporations and their shareholders, to run NHS services. When they can’t make a profit, they will up sticks and leave – or have to be bailed out by the NHS. The Scots should be very wary of Brown’s bluster, but all four home nations will struggle to deliver high quality healthcare for an ageing population, whatever the outcome of tomorrow’s vote.