The New Serfdom

by Angela Eagle

  The story across almost every measure of squalor – homelessness, poor housing standards, the environment and crime – has been one of considerable improvement thanks to serious intervention and clever policies by the Labour Party between 1997 and 2010, and retrenchment since then under the coalition and Conservative governments. We should be proud of that in the Labour Party. But there’s also an underlying story that Labour didn’t manage to put in place the fundamental structural reforms that would keep things getting better. In particular, the relationship between capital and labour remained out of kilter in the housing market and Labour didn’t have the time to take advantage of the growing renewables sector to fundamentally rebalance our energy mix and industrial policy in the sector. Given time after 2010, and had we won in 2015, our policies and priorities would, we hope, demonstrate a greater political will to do so, particularly after the housing crisis exposed the problems in the market. There is no doubt they must be major political ambitions for the next Labour government.

  CHAPTER SEVEN

  DISEASE

  Created shortly after the Second World War, the NHS is the most universally cherished achievement of Attlee’s Labour government. It is seen around the world as a beacon of British civilisation and holds a special and central place in Britain’s identity as a nation; one of the reasons Danny Boyle made it a centrepiece of his showcase of British culture at the London 2012 Olympics opening ceremony. But why is it so cherished? Because it recognises that some things are too important to be left to the ‘free market’. Because it responds to need regardless of personal income. This is at the core of its success.

  The majority of British people alive today were safely delivered in an NHS hospital. The NHS has helped to eradicate or seriously diminish the prevalence of many once-deadly communicable diseases, like tuberculosis, measles and polio. All British citizens, regardless of wealth, have been able to take advantage of rapid advances in pharmaceuticals, medical technology and techniques in recent decades; poorer citizens in many other countries would not have been given such equitable access. As a result, British people live far, far longer and enjoy better overall health than ever before. A child born in 1901 in Britain could expect to live around fifty years or so. A century later, a child born in 2001 could expect to live over seventy-five years. The ONS predicts that by the middle of the twenty-first century, life expectancy will reach 100 years.

  The second extraordinary thing about the NHS is that it is paid for by all of us. It is a truly heart-warming notion to think that when we get poorly, every one of our fellow citizens has contributed to ensuring we get better. It is as pure and profound an expression of compassion and solidarity as you can get. Free at the point of access, from cradle to grave, paid for by each according to their means. It is the essence of democratic socialist values, and a perfect example of collective solidarity. No wonder it is so popular and inspiring.

  The success of the NHS, however, has had huge knock-on effects on every area of social policy.

  Take housing, for example. Because British citizens now live much longer, it means we are far less likely to pass on our houses to our children when they are in their young adulthood – instead they must wait until much later in life. That simple fact increases demand for housing considerably; indeed, extended lifespans is one of the biggest components in the housing crisis we face today.

  It has also altered the demand for education, since longer lives mean we can afford to spend more time educating ourselves in preparation for our longer working lives. (If you thought you might only spend thirty years working, rather than fifty years, you’d be more reluctant to give up an extra few years to education.) It also increases the demand for mid-career education, as our economically active lives can span entire industrial cycles. Someone who started working in the 1970s would have seen the nature of the workplace change radically and our economy’s composition change substantially. The ability to retrain is even more important than ever before.

  The NHS’s success has also had knock-on effects on the service itself.

  Before it was created seventy years ago, children would die in the thousands of now easily preventable diseases like pneumonia, meningitis, tuberculosis, diphtheria and polio. The infant mortality rate – i.e. the number of children dying before they turned one – just before the Second World War, in 1938, was around 6 per cent. By 2015, that figure was 0.4 per cent. Indeed, it has gone down consistently every year in all but two years since the NHS was created. An international team of researchers led by the University of Bristol and funded by the British Medical Research Council, the Department for International Development and the European Union, has shown that even sufferers of HIV – which has caused millions of deaths – are now able to live for as long as people without HIV, if they are given effective, early treatment.

  While this is all good news, the sheer success of the NHS in delivering high-quality healthcare to all citizens means we are now more likely to live long enough to encounter diseases and conditions like cancer, cardiovascular disease, dementia and deterioration of our musculoskeletal system by wear and tear. Indeed, the leading cause of death in Britain in 2016, according to Department of Health statistics, was dementia.

  The number of people in their fifties is now far higher than the number of people in lower age brackets. This issue of changing demographics is being confronted by all those societies that have developed successful healthcare systems. Proportionately, citizens in their late middle age are over-represented within our age pyramid compared to citizens in younger age groups – and that means that in ten years or so we’re going to have a real challenge as this age group reaches retirement age. Though a challenge, it’s a great one to have, because it flows from the huge success of earlier social policy. It does, however, signal the need for a fundamental restructuring of our health and social security system to cope with future demographics. We’re going to need to ensure our young people are much more economically active and productive in order to pay for the retiring baby boomer generation, who tended not to have as many children (which is why we have been highly reliant on migration to bolster the numbers of economically productive people that pay taxes in Britain and support our older citizens).

  The average 65-year-old costs the NHS 2.5 times more than the average thirty-year-old. An 85-year-old costs more than five times as much. That is because chronic conditions, like cardiovascular disease, diabetes and dementia, require long-term clinical management. By the age of sixty-five, most people will have at least one of these illnesses. By seventy-five they will have two. Despite, or perhaps because of this, the global life sciences industry has spent a fortune on discovering drugs and developing protocols and techniques for intervening medically to manage these problems.

  The number of people dying as a result of cardiovascular disease went down by 70 per cent between 1970 and 2013, according to a study published in the British Medical Journal. Even cancer is not the death sentence it once was – half of people now survive for a decade or more. The NHS, the pharmaceutical industry and the array of scientists and medics in hospitals, universities and research institutes around the world have done an incredible job in changing our health and how we live. But it all costs money.

  In 2015/16, we spent £144 billion on the NHS: around 20 per cent of total annual public expenditure. It is the second biggest area of public spending after pensions (the rising cost of pensions itself being a reflection of how long we live). In real terms (after adjusting for inflation) we spend ten times more than we spent each year in the first decade of the NHS. Public spending on health in the UK rose by an average of 3.7 per cent per year between 1949/50 and 2013/14 in real terms. Public spending on health outpaced economic growth over this period and, as a result, public spending on health as a share of UK GDP has more than doubled from 1949/50 to today.

  The period between 1999/2000 and 2009/10, when Tony Blair and Gordon Brown dealt with the underinvestment of the Thatcher years, saw a hug
e rise in health spending. It rose from 5.0 per cent to 7.8 per cent of GDP. Remember that next time someone asks why Labour didn’t spend on one priority or another: just the increase in the NHS was quite staggering in absolute terms. That’s why the NHS today is the fifth biggest employer in the world, with 1.7 million staff. It stands only behind the US Department of Defense, the Chinese People’s Liberation Army, Walmart and McDonald’s.

  The proportion of total UK government spending devoted to health also rose from 9.3 per cent in 1949/50 to 18.1 per cent in 2013/14. That means that of every £5 spent by the government, nearly £1 goes to the NHS. If the NHS needs more resources because of understandably growing demand, that just squeezes everything else in the budget – social security, education, defence and the rest of the government’s spending priorities. It’s why driving efficiency in the NHS has always been so important. Making the money stretch further is a priority for governments that want to liberate more cash to spend on other things.

  Let’s put that £144 billion into context. We spend just over £102 billion a year on education, £34 billion on public order and safety and just over £2 billion on unemployment benefits. The NHS, while incredibly cheap by international standards, is a big portion of UK public spending. But other countries do spend far more on healthcare as a proportion of their economy. The OECD tries to compare total healthcare expenditure across countries. This is made slightly more difficult because in many countries there is both public and private purchase of healthcare. Their data shows that, in 2014, we spent a total of 9.9 per cent of GDP on healthcare in the UK. In Germany, they spent 11 per cent; in France 11.1 per cent and in the USA, despite their well-known problems with coverage, they spent a staggering 16.6 per cent. That’s the premium you pay for having private companies involved in every stage of your health system.

  The central question for healthcare in Britain is becoming ‘what are we willing to pay to get the services we expect?’ The truth is that we will need to address both efficiency and absolute spending if our NHS is to be fit for purpose in the twenty-first century. That almost certainly means we will have to spend more. Indeed, money is at the very heart of the NHS’s stresses and failures. Budgets may have risen beyond the rate of inflation consistently until very recently, but demand has also continued to rise. Every year the media report on a ‘winter health crisis’, with waiting times soaring, non-urgent operations cancelled, and patients being turned away from A&E for non-emergency conditions, as happened again in December 2017. We know as well that the time people spend waiting in A&E to be treated or have to wait to get a GP appointment is rising. Anyone who has had to have an operation in recent years for something non-urgent, like a knee reconstruction or cataract surgery, knows the wait can be months long and they can all too often be postponed if the system is under particular pressure.

  The reason for this is that whereas our health system, for the main part, works effectively to deliver healthcare – hence the improvements in lifespan and general health – it is very heavily stretched, especially so in some parts. It’s worth looking at what and where things are going wrong to better understand why it’s happening and how we can fix it. The most acute pressures are noticed by patients in A&E, in getting a GP appointment, in waiting times for procedures and in the adult social care system.

  In 2016/7, there were a record number of A&E attendances in the UK – 23 million, equivalent to around one attendance per three people. Once a patient attends A&E, they will be initially assessed rapidly and clinical staff will make a judgement on whether they need to be prioritised – this is called ‘triaging’ patients. Someone with trouble breathing, for example, will be examined carefully and, if showing signs of acute distress, admitted and given emergency treatment. That person would always be dealt with more quickly than someone coming in, for example, with a twisted ankle after slipping on some ice.

  Labour introduced a target that 98 per cent of all patients should be seen within four hours of attendance. The coalition government reduced this target to 95 per cent of all patients to cover up growing waiting times. However, performance deteriorated further. Last year (2017), only 89 per cent of people were seen within four hours of arriving at an A&E. On average, patients spent around two and a half hours in total in A&E from arrival to departure, up from around two hours in 2011 and 2012.

  So, beyond the raw number of attendances, what else explains the crisis in A&E departments? It’s a complicated story. All too often reporting of crises focuses on immediate problems in one hospital or another rather than trying to understand the underlying problems and how they are or are not being addressed.

  Of the 23 million people attending last year, 37 per cent were discharged without follow-up, and 19 per cent were discharged with GP follow-up. Only 20 per cent of patients required admission to hospital. Services like NHS Direct and its successor NHS 111 have helped to alleviate some pressure on A&E departments by providing advice to those who aren’t sure what to do in the hours that their GP surgery isn’t open. They can help divert people from A&E to other services, thus reducing the overall load on A&E as well as the number of people who will wait the longest in A&E, because they have been assessed in triage as being non-urgent. A report by the Health Select Committee illustrated the sorts of numbers going through the system, saying: ‘On average each day in 2015/16, the NHS saw nearly 63,000 people through its A&E departments … and offered over 38,000 NHS 111 calls.’

  Meanwhile, the number of staff working in A&E has increased: consultants by 37 per cent in the past five years; non-consultant doctors by 19 per cent; and nurses by 17 per cent. Yet the United Kingdom has one of the lowest ratios of emergency doctors to attendance in the developed world. The Royal College of Emergency Medicine has said it is the lowest in the developed world.

  At the same time, the Royal College reports that

  since 2010–11 the total number of beds has decreased by 8.91 per cent (12,875) and the number of general and acute beds has declined by 6.44 per cent (7,127). The combination of increased demand and diminished physical capacity has led to a predictable increase in rates of bed occupancy. Since 2010–11 general and acute bed occupancy has increased from 86.3 per cent to 91.2 per cent. This is the figure recorded at midnight – daytime occupancy rates frequently exceed 100 per cent in many hospitals. Such occupancy levels mean there is no surge capacity, rendering hospitals hostage to fortune.

  It is true that the number of beds overall in the NHS has reduced drastically in recent decades, in great part because of improvements in how we manage patients and clinical innovations. Procedures like keyhole surgery, improvements in anaesthesia and also simply a better understanding of when people need in-patient treatment and when they are better off at home have all contributed to a reduction in the need for beds. However, it is also quite clear that we have serious problems with the number of A&E beds available. They appear to have been cut too far to meet demand. There is some evidence that this is because the complexity of problems of patients presenting at A&E is increasing; the number of emergency admissions to A&E has increased in recent years much faster than the rate of attendances.

  This will, in part, be down to the number of older patients attending, who have more complex health needs in general and therefore require more sophisticated clinical scrutiny. There is also a serious problem with beds being taken up in A&E by those needing transfer to other types of wards and facilities. One of the fastest growing causes of delayed transfer is a lack of capacity in the adult social care system, administered by local councils, which have suffered particularly deep cuts under the coalition and Conservative governments. If patients are not fit to go home on their own, hospitals have no choice but to keep them under supervision. Some hospitals have even gone so far as to hire domiciliary care workers so that patients can be taken to their homes and cared for there, freeing up beds for new acute cases.

  Apart from A&E, the other way most of us access healthcare is through our GP. If you’ve trie
d to get an appointment recently, it will be no surprise to you that the statistics show we are waiting longer to see a GP and that the time available per appointment is being reduced. This is a clear sign that the general practice system is under increasing strain.

  A survey by NHS England reported that a fifth of patients wait a week or more to see their GP or are unable to get an appointment at all.

  The survey of more than 800,000 patients showed that the proportion of patients waiting longer than a week to see a doctor rose 56 per cent in five years. The number unable to get an appointment rose to 11.3 per cent. A separate survey of 830 doctors by the GP magazine Pulse in 2017 suggested that average waits for an appointment are now thirteen days, up from ten days two years ago.

  If and when you do get an appointment, they are on average shorter than the recommended fifteen minutes needed for a proper assessment. A study by Cambridge University, published in BMJ Open in November 2017, found British patients are seen for on average nine and a half minutes per appointment. That’s less than in the US, Canada and most European countries.

  There are around 51,000 GPs in the UK, 42,000 of whom are in England. GPs in England deal with 340,000,000 consultations a year. That number has been growing very fast; the Health and Social Care Information Centre found that the average member of the public sees a GP six times a year and that this is double the number a decade ago. Demand is being driven by a host of factors but an ageing population and people with more complicated conditions such as diabetes and heart disease, which are in turn connected to soaring obesity rates, increase the workload considerably. Despite a government pledge to increase the number of doctors working in general practice by 5,000 by 2020/21, the number of ‘full-time equivalent’ GPs fell by 0.3 per cent in 2016.