Labour pains left behind by a united and confident party conference
BMJ 2022; 379 doi: https://doi.org/10.1136/bmj.o2373 (Published 03 October 2022) Cite this as: BMJ 2022;379:o2373
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Dear Editor
I was surprised to see the reference to debates at previous Labour party conferences over ‘fictional NHS privatisation’.
While successive Conservative Health Secretaries like to insist that privatisation has not been happening, analysis by various think tanks suggests otherwise, with estimates that between 20% and 22% of annual public spending on health in England has gone towards procuring healthcare services from private providers (1). In fact, both the proportion of treatments and the percentage of expenditure on for-profits has risen significantly in the last 10 years (2).
That this may have a negative effect on patients has been starkly illustrated in a recent paper from Oxford showing that when spending on for-profits increases in a given area, there is a corresponding rise in mortality and a worsening of health in the following year (3). As a Lancet editorial pointed out, this implies at the very least that a cautious approach should now be taken to any further increase in outsourcing (4).
We also need to take a broad view of privatisation (5) when it comes to damage done. With the NHS already in crisis, it is currently faced with having to find £20bn in savings, with warnings that this can only lead to reductions in services and an increase in deaths of patients (6). At the same time, NHS Trusts spent close to half a billion pounds on interest charges from private companies for private finance initiative contracts last year (equivalent to the salaries of 15,000 nurses)(7). Meanwhile, hundreds of NHS consultants are shareholders in profit-making joint ventures with private healthcare firms, in arrangements that have generated more than £1bn in revenues since 2015 (8). Not only does this raise questions of conflict of interest, but also risks pulling staff away from NHS work and further increasing waiting lists. It is time to stop talking of ‘fictional NHS privatisation’ and to wake up and smell the coffee.
References
1. https://fullfact.org/election-2019/nhs-private-spending/
2. https://osf.io/preprints/socarxiv/t4x52/
3. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(22)00133-5/fulltext
4. https://www.thelancet.com/pdfs/journals/lanpub/PIIS2468-2667(22)00142-6.pdf
5. https://www.bmj.com/content/342/bmj.d2996?sso=
6. https://www.theguardian.com/society/2022/oct/23/a-real-and-present-dange...
7. https://www.theguardian.com/politics/2022/oct/25/nhs-hospital-trusts-pay...
8. https://www.theguardian.com/business/2022/jan/21/hundreds-of-englands-nh...
Competing interests: I am co-chair of Keep Our NHS Public
Dear Editor,
As a foundation doctor, I was relieved to hear the Labour party lay out plans for NHS work force expansion. However, I am concerned by the promise of doubling the number of medical school places (to 15,000) without mention of the pre-existing bottlenecks at entry to foundation and specialty training.
This year, the foundation training programme was oversubscribed by 791 students, up year on year from 25 students in 2016 (1). Although all students on the reserve list were eventually allocated a foundation post, later than their peers and often many miles away, without forward-thinking workforce planning the direction of this trend is not likely to change (2).
As I prepare to apply for core surgical training (CST), I, like many others have been disappointed to learn of the sudden addition of the Multi-Specialty Recruitment Assessment (MSRA) to the application pathway mere weeks before the recruitment window opens. Health Education England (HEE) defend this decision as a tool for shortlisting due to a 30% increase in CST applicants since 2017; whilst number of posts fell from 629 in 2017 to 607 in 2021 (3,4). Instead of increasing the number of surgical training posts in line with medical student places or number of applicants, HEE shift the burden onto applicants themselves by introducing an extra exam, originally designed for GP recruitment, at very short notice when burnout is already widespread. How will the NHS cope with the 6.84 million people waiting for elective treatment without increasing surgical training capacity (5)?
Politicians, the general public, and those working in the NHS, wax lyrical about the need for more doctors; however, the rhetoric of “increasing the number of medical students” without mirroring that growth in the number of foundation and specialty training posts does little to address the problem.
1. Lok, P. UK’s foundation training programme for 2022 was oversubscribed by almost 800 places. BMJ 376, o650 (2022).
2. Lok, P. All medical graduates who applied for the foundation programme will be able to train. BMJ 377, o1042 (2022).
3. Specialty Training > Competition Ratios. https://specialtytraining.hee.nhs.uk/competition-ratios.
4. Latest News. https://specialtytraining.hee.nhs.uk/Recruitment/Latest-News.
5. NHS backlog data analysis. https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pre....
Competing interests: No competing interests
Re: Labour pains left behind by a united and confident party conference
Dear Editor
To have any commitment to workforce expansion is addressing one fundamental problem. To dismiss NHS privatisation as fictional rather than to understand its relevance is tendentious and bizarre. There is overwhelming evidence of motive, intent, and presence in the healthcare system.
In 2005, Andrew Lansley himself introduced his HSCB 2011 as "reforms based on the privatisation of the former public utilities".[1,2,3]
Oliver Letwin wrote the book on privatisation: defined as outsourcing, deregulation, and asset sales - plenty of examples in the NHS.[4]
The fourth arm of privatisation is shrinking the NHS's staff and resources to force patients over time into the private sector, both to self-pay and to buy insurance. Now self-evident, this Conservative government policy was covered in a Cabinet Office policy document in 1982 and subsequently implemented.[5] Wilful negligence not excusable as incompetence.
US Centene is now the largest single provider of GP services in England.[6] They also majority-own Circle, BMI and shares in US Babylon,[7,8] whose dangerously flawed software was illegally (breach of licence) promoted by Govt as 'as good as a doctor'.[9] US UnitedHealth just bought EMIS and they and McKinsey have regularly advised govt and steered STP/ACO/ICSs on NHS 'transformation'[10,11]. Hospital Corporation of America own most private sector hospitals.[12] Private health companies just pull out of contracts if they're not profitable enough.[13]
Increasing medical students needs increased training places, supervised and taught. Sure, we need doctors, nurses, beds and hospitals, but how that care is delivered is the other half of the problem facing the NHS. Extra funding to Increase Centene’s profits is money wasted. Extraordinary sums and contracts fly freely out to private sector ("taking learning from Covid")[14] whilst the public sector provision is cut further. As if that has no meaning.
Conservative government’s plans to submit NHS drug-pricing in a US-UK Trade Deal to the extortionate US market was a clear warning sign that was ignored because it was Corbyn that said it.[15]
If Labour believes it can restore the NHS, it needs to avoid further enabling Tory policy - what reform? The digital landscape is a mess - piecemeal private IT and false belief in Digital First as desirable or as a solution; professional influence over care delivery is absent; "prevention" meaning unwarranted screening instead of actual Public Health policy. The NHS mechanism has been disabled and heavily loaded with industry interests. It needs restoration, not election ticketing.
Privatisation is real, impactful and here. We move towards the poorer provision of less - but more expensive - healthcare. Denial and accusations of factionalism are unfounded and unhelpful. Patients, all of us, deserve better.
References:
1. Personal communication from Prof Chris Ham; Sir Chris Ham (@profchrisham) tweeted at 10:03 p.m. on Wed, Nov 14, 2018:
“I pointed this out in 2010 when I tracked down a speech by Lansley in which he specifically said privatization of former public utilities formed basis of his NHS reforms. Nick Timmins and I both referenced in our commentary and analysis at the time.”
(https://twitter.com/profchrisham/status/1062828507452055557?s=09)
2. BMJ 2011;342:d1035
3. Lansley A. Extract from “The future of health and public service regulation” speech. 2005.
4. Privatising the World A Study of International Privatisation in Theory and Practice; Oliver Letwin. Paperback (02 Jun 1988).Not available for sale
5. CabinetOffice1982CAB-129-215-6.pdf
6. Lewis R. Centene largest UK primary care provider after acquisition. Healthcare Business International 2021 Mar 4.
7. Kleinman M. US health giant Centene invests in NHS 'chatbot' app Babylon. Sky News 2019 Aug 1. https://news.sky.com/story/us-health-giant-centene-invests-in-nhs-chatbo...
8. CMA. Completed acquisition by Circle Health Holdings Limited of BMI Healthcare Limited. https://assets.publishing.service.gov.uk/media/5e8d8c30e90e07077b526ab6/...
9. Lomas N. UK's MHRA says it has 'concerns' about Babylon Health--and flags legal gap around triage chatbots. Tech Crunch 2021 Mar 5.
10. https://www.theguardian.com/society/2014/aug/30/nhs-bosses-summits-contr...
11. https://www.thetimes.co.uk/article/mckinseys-journey-via-british-rail-to...
12. HCA Healthcare UK. About
13. https://www.telegraph.co.uk/business/2022/08/04/digital-gp-babylon-ends-...
14. https://scholarship.law.gwu.edu/cgi/viewcontent.cgi?article=2763&context...
15. https://object.cato.org/sites/cato.org/files/pubs/wtpapers/ideal-us-uk-f...
Competing interests: Member of Keep Our NHS Public