"The NHS is being hollowed out from within; that's not efficiency." Photo: Getty
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NHS reform and the hollow marketisation myth

A metamorphosis is taking place; a mutation of the NHS from a public service into a lucrative marketplace.

When the chief executive of NHS England produces a 39-page, 15,000-word rescue plan for the health service that, a senior doctor later told me, “doesn’t even mention the real problem in the system”, you know something is up.

Not that it’s any great surprise. Simon Stevens isn’t likely to agree with my source that the real problem in the NHS is a prevailing ideological dogma that “private is good and public is bad” among top brass, nor that the aggressive marketisation programme currently underway is all based on a myth. The private healthcare man turned NHS-saviour has only been in his post for seven months after 10 years at global giant United Health Group, and old habits die hard.

But the real paradox at the heart of Stevens’ five-year plan is that he calls for ruthless efficiencies and then turns a blind eye to the sort of “grotesque financial waste” that consultant clinical oncologist and National Health Action Party (NHAP) co-leader Clive Peedell says is crippling the system.

Peedell says: “Wasteful internal markets, commissioning support units, management consultancy fees, the cost of procurement of clinical services, profit-taking by private providers, the cost of fragmenting pathways due to outsourcing components to private contractors, and PFI deals bankrupting our hospitals; they are draining billions from frontline care in our NHS”.

A metamorphosis is taking place; a mutation of the NHS from a public service into a lucrative marketplace. None of this is particularly new – but since the Health and Social Care Act kicked in two years ago, trusts have been legally obliged to compete with private providers over contracts, and take on the extra administrative costs of doing so. Allyson Pollock, professor of public health research at Queen Mary University of London, says: “It’s quite clear that the government wants to contract out as much as it can before the general election, but there’s no data about the costs for trusts such as lawyers and management consultants in doing this”.

And after a slow start, the scrum has really kicked in now. Campaign group NHS Support Federation has recorded five times more contracts coming onto the market between July and September this year, a cool £2bn’s worth, than in the first three months of life under the Health and Social Care Act when only £266m was up for grabs. Bound by competition laws, NHS trusts find themselves in the position of having to spend tens, maybe hundreds of thousands bidding to carry on running services they already deliver, or, even worse, to then lose out to private providers that have cherry-picked the contracts and put all of their corporate weight behind winning them.

Take Cambridgeshire and Peterborough for example, where a million pounds of taxpayer money was wasted on the procurement process of older people’s healthcare and adult community health services before the CCG finally decided that Cambridgeshire and Peterborough NHS Foundation Trust should carry on running the service.

Why are such tremendous burdens being overlooked by Stevens? Or the hideous levels repayments for the same PFI loans he advocated when he had Tony Blair’s ear back in the noughties? Why no mention of the £4.5bn a year that Calum Paton, Professor of Public Policy at Keele University, conservatively estimates is the cost of administering an internal market he describes as “costly and of dubious effectiveness”, or the extortionate legal fees just being in that market forces trusts to stump up?

GP and anti-privatisation campaigner Dr Bob Gill says: “A market doesn’t work in healthcare; the administration of it just drives up costs. The NHS is being hollowed out from within, assisted by people from banking and the private sector who are dumbing down the service and delivering everything as cheaply as possible. That’s not efficiency”.

Neither is, Gill argues, a system in which a hollowed-out NHS has to pay when those private companies fail in their duty. Private companies like Vanguard Healthcare, which had its contract with Musgrove Park Hospital in Taunton terminated after a series of post-surgery complications, leaving Musgrove medical director Dr Colin Close admitting, “any financial responsibility would rest with us”.

How is all this playing out? Kathryn Anderson is a nurse at the Royal Free Hospital and NHAP general election candidate – in Iain Duncan Smith’s constituency. She says that far from bringing in greater efficiency or care, these new wasteful costs are having the opposite effect in the wards. “All that money comes from the frontline,” she says. “It comes from nurses and HCAs and doctors’ pay, and from drugs that don’t get purchased. You can’t run the NHS and expect it to perform if you flush the money out of the system, it just doesn’t work. We see this every day and it’s getting worse”.

The Conservatives are keeping very quiet about all this, perhaps wisely. With one hand Lansley and Hunt have enforced pay freezes on frontline staff claiming the pot is empty, and with the other, enforced an extortionate tendering process that has wasted vital funds. Just the cost of the top-down reorganisation alone, which a senior Tory MP recently described as the party’s “biggest mistake” in government, is estimated at £3bn.

On the pretext that the NHS is an egregious waste of public money – despite the fact that in 2012 the UK spent less on healthcare as a percentage of GDP than any other G7 country – the system has been altered from within. The result is a conduit to a £100bn-a-year pot with an NHS stamp on the side, which through some alchemy turns taxpayer money into private profits.

Stevens’ five-year plan is full of hope and some entirely sensible ideas to improve the system. But with no mention of any of the debilitating costs of running the new marketised system, which Unite head of health Rachael Maskell says could be as high as £1bn by the time of the election, nor the outcry from the profession about marketisation which the BMA itself is campaigning to see reversed in law, it seems a little hollow to say the least.

Benedict Cooper is a freelance journalist who covers medical politics and the NHS. He tweets @Ben_JS_Cooper.

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The decline of the north's sporting powerhouse

Yorkshire historically acted as a counterweight to the dominance of southern elites, in sport as in politics and culture. Now, things are different.

On a drive between Sheffield and Barnsley, I spotted a striking painting of the Kes poster. Billy Casper’s two-fingered salute covered the wall of a once-popular pub that is now boarded up.

It is almost 50 years since the late Barry Hines wrote A Kestrel for a Knave, the novel that inspired Ken Loach’s 1969 film, and it seems that the defiant, us-against-the-world, stick-it-to-the-man Yorkshireness he commemorated still resonates here. Almost two-thirds of the people of south Yorkshire voted to leave the EU, flicking two fingers up at what they saw as a London-based establishment, detached from life beyond the capital.

But whatever happened to Billy the unlikely lad, and the myriad other northern characters who were once the stars of stage and screen? Like the pitheads that dominated Casper’s tightly knit neighbourhood, they have disappeared from the landscape. The rot set in during the 1980s, when industries were destroyed and communities collapsed, a point eloquently made in Melvyn Bragg’s excellent radio series The Matter of the North.

Yorkshire historically acted as a counterweight to the dominance of southern elites, in sport as in politics and culture. Yet today, we rarely get to hear the voices of Barnsley, Sheffield, Doncaster and Rotherham. And the Yorkshire sporting powerhouse is no more – at least, not as we once knew it.

This should be a matter of national concern. The White Rose county is, after all, the home of the world’s oldest registered football club – Sheffield FC, formed in 1857 – and the first English team to win three successive League titles, Huddersfield Town, in the mid-1920s. Hull City are now Yorkshire’s lone representative in the Premier League.

Howard Wilkinson, the manager of Leeds United when they were crowned champions in 1992, the season before the Premier League was founded, lamented the passing of a less money-obsessed era. “My dad worked at Orgreave,” he said, “the scene of Mrs Thatcher’s greatest hour, bless her. You paid for putting an axe through what is a very strong culture of community and joint responsibility.”

The best-known scene in Loach’s film shows a football match in which Mr Sugden, the PE teacher, played by Brian Glover, comically assumes the role of Bobby Charlton. It was played out on the muddy school fields of Barnsley’s run-down Athersley estate. On a visit to his alma mater a few years ago, David Bradley, who played the scrawny 15-year-old Billy, showed me the goalposts that he had swung from as a reluctant goalkeeper. “You can still see the dint in the crossbar,” he said. When I spoke to him recently, Bradley enthused about his lifelong support for Barnsley FC. “But I’ve not been to the ground over the last season and a half,” he said. “I can’t afford it.”

Bradley is not alone. Many long-standing fans have been priced out. Barnsley is only a Championship side, but for their home encounter with Newcastle last October, their fans had to pay £30 for a ticket.

The English game is rooted in the northern, working-class communities that have borne the brunt of austerity over the past six years. The top leagues – like the EU – are perceived to be out of touch and skewed in favour of the moneyed elites.

Bradley, an ardent Remainer, despaired after the Brexit vote. “They did not know what they were doing. But I can understand why. There’s still a lot of neglect, a lot of deprivation in parts of Barnsley. They feel left behind because they have been left behind.”

It is true that there has been a feel-good factor in Yorkshire following the Rio Olympics; if the county were a country, it would have finished 17th in the international medals table. Yet while millions have been invested in “podium-level athletes”, in the team games that are most relevant to the lives of most Yorkshire folk – football, cricket and rugby league – there is a clear division between sport’s elites and its grass roots. While lucrative TV deals have enriched ruling bodies and top clubs, there has been a large decrease in the number of adults playing any sport in the four years since London staged the Games.

According to figures from Sport England, there are now 67,000 fewer people in Yorkshire involved in sport than there were in 2012. In Doncaster, to take a typical post-industrial White Rose town, there has been a 13 per cent drop in participation – compared with a 0.4 per cent decline nationally.

Attendances at rugby league, the region’s “national sport”, are falling. But cricket, in theory, is thriving, with Yorkshire winning the County Championship in 2014 and 2015. Yet Joe Root, the batsman and poster boy for this renaissance, plays far more games for his country than for his county and was rested from Yorkshire’s 2016 title decider against Middlesex.

“Root’s almost not a Yorkshire player nowadays,” said Stuart Rayner, whose book The War of the White Roses chronicles the club’s fortunes between 1968 and 1986. As a fan back then, I frequently watched Geoffrey Boycott and other local stars at Headingley. My favourite was the England bowler Chris Old, a gritty, defiant, unsung anti-hero in the Billy Casper mould.

When Old made his debut, 13 of the 17-strong Yorkshire squad were registered as working-class professionals. Half a century later, three of the five Yorkshiremen selec­ted for the last Ashes series – Root, Jonny Bairstow and Gary Ballance – were privately educated. “The game of cricket now is played in public schools,” Old told me. “Top players are getting huge amounts of money, but the grass-roots game doesn’t seem to have benefited in any way.”

“In ten years’ time you won’t get a Joe Root,” Rayner said. “If you haven’t seen these top Yorkshire cricketers playing in your backyard and you haven’t got Sky, it will be difficult to get the whole cricket bug. So where is the next generation of Roots going to come from?” Or the next generation of Jessica Ennis-Hills? Three years ago, the Sheffield stadium where she trained and first discovered athletics was closed after cuts to local services.

This article first appeared in the 19 January 2017 issue of the New Statesman, The Trump era