John Lister, Director of Health Emergency
The pace and scale of the cuts is inexorably rising across England as primary care trust and trust boards resort to desperate measures to slash back spending and deliver huge savings targets this year, next year, and up to 2014.
The real-terms cuts that have now been confirmed by last month’s comprehensive spending review have piled on more pressure – and with the prospect of shrinking actual resources for health services for the next three years or more have come policies and practices which hark back to the grim days of Margaret Thatcher.
For three years in the mid-1980s NHS spending was static or fell in real terms – forcing cuts, closures and lengthening queues for care.
In the early 1990s another financial squeeze brought proposals by some local health authorities to ration care by excluding a list of “low-priority” or “less effective” treatments from the NHS.
Primary care trust and trust bosses are turning again to these policies, with cynical trust bosses reviving tricks such as the deliberate demoralisation of staff in threatened units and the non-replacement of those they persuade to leave, to the point where they can claim that the closure of the A&E, maternity or other unit is both necessary and urgent for the sake of patient safety.
Vacancy freezes have become more or less the norm across most NHS trusts, even though this is the most random and chaotic way of imposing cuts, and of course dumps extra stress and workload onto the staff who remain behind.
The Royal College of Nursing has estimated that up to 100,000 jobs could be set to go from the NHS workforce of around one million.
This more or less equates to the 10 per cent cut in workforce which last year’s controversial McKinsey proposals suggested across the NHS to generate the massive £20 billion of so-called “efficiency savings” which Health Secretary Andrew Lansley is now committed to impose by 2014.
The knock-on impact of this on the staff who remain is underlined by a recent Unison survey of 8,000 front-line staff, which showed that half were already facing staff shortages.
As the inquiry continues into the disastrous failings at Mid Staffordshire Hospitals Trust, where £10m of cost-cutting reduced staffing levels below the bare minimum, it’s clear that dozens of trusts are now being forced to contemplate cuts as big or bigger in their own budgets.
Lansley’s scrapping of the waiting time targets which, alongside investment in staff and buildings had been the key to Labour’s success in improving the NHS, has predictably been followed by an immediate increase in waiting times in A&E.
But primary care trusts are also looking for savings by deliberately increasing waiting times for operations. NHS South West Essex so far seems to have the most ambitious plan to impose a four-week pause in non-urgent operations and outpatient appointments in all its provider trusts, effectively pushing a whole month’s worth of work into the next financial year to “save” £8.4m (while hospital trusts such as Basildon carry the cost).
Decisions vary. NHS Warwickshire has decided to halt all elective orthopaedic operations for six months. East Kent has also resorted to longer waiting times as a way to save money – more will certainly follow.
In each case the unspoken hope of primary care trust bureaucrats is that patients will decide not to wait but to find the money to go private.
This is also the implicit logic behind the decision by more and more primary care trusts to draw up lists of treatments and operations that will no longer be funded by the NHS.
While IVF treatment has been widely picked on as a relatively “soft” target by many, the lists can be very extensive.
The £52m cuts package adopted by NHS South West Essex, for example, includes adding a further 113 treatments and procedures to a pre-existing list of 94, bringing a total of 207 which are no longer to be funded by the local NHS, including hip and knee replacements.
East Kent has included cataract operations on its excluded list. NHS Warwickshire will no longer fund injections to relieve chronic back pain. All of these will of course still be available for those with the money to pay privately.
And while some primary care trusts have continued to provide them, others have arbitrarily decided not to – creating a postcode lottery for patients.
South West Essex also decided to cut £1m from its £6.5m spending on HIV/Aids, despite warnings from a leading clinician in the public board meeting that such cuts would inevitably mean cutting off drugs to patients who would die without them.
This inequality in access to treatment will become even more random as a result of Lansley’s decision to neuter the body that Labour set up to combat the postcode lottery – the National Institute of Clinical Excellence.
NICE will now lose its power to decide whether drugs and treatments offer value for money. Instead decisions will be made by local GPs, to the delight of the big drug companies.
While big pharma profits seem set to increase, the primary care trust cuts are spreading to trust level.
In Stoke on Trent the University Hospital of North Staffordshire (UHNS), which hit national headlines back in 2006 when it was one of the first to announce big job losses as it wrestled with a huge deficit, is facing a £22m deficit by March. It is staring down the barrel of drastic new cuts which trust bosses warn will “distress” local people.
UHNS’s plight is similar to many front-line trusts hung out to dry by primary care trusts attempting to solve their financial problems by simply refusing to pay for hospital treatment of local people, even where no alternative community-based services to reduce the pressure on A&E have been put in place.
Trusts are left treating thousands of patients more than they are paid for.
UHNS bosses are warning this can’t go on, especially since the trust must also find another £12m in “efficiency savings” to pay for the refurbishment of wards and departments in preparation for the opening of a new PFI-funded £400m hospital in 2012, which will immediately soak up 10 per cent of its budget.
Around the country acute and mental health trusts are facing the same problems.
NHS Lincolnshire is seeking to cut £54m over three years, Doncaster £51m, Bradford £50m, Sheffield £100m. Plymouth’s Derriford Hospital Trust is £7m behind target in its quest for £27m savings this year – and slashing pay for temporary nursing staff.
Add to this the massive financial blow that has just been struck against specialist children’s hospitals, which face a massive cut in the premium they are paid above the standard paediatric tariff – from 75 per cent extra to just 25 per cent – slashing £70m from these hospitals.
What is it that Lansley and the Tories have got against children?
Couple these cuts with the dynamic towards privatisation at the centre of Lansley’s white paper, which is being speeded up regardless of all the criticism and opposition, and it’s clear we are set for more than a miserable winter. The very fabric of the NHS and its values are being undermined.
And while NHS managers revive some of the cynical manoeuvres and techniques of the 1980s and the Con-Dem government drives through a reactionary programme that makes Thatcher look like a social worker, there is sadly no sign yet that either the Labour leadership or the health unions have revived the tradition of militant resistance that challenged Thatcher and fought each NHS cutback.
Labour has been near-invisible in opposition to cuts and the white paper, while the unions have yet to crank up the national campaign that is so desperately needed to defend jobs, pay and the country’s most popular public service. Time is short. Let’s press for serious action.
From the Morning Star