We’re so used to having the NHS it’s easy to forget it’s not a given. The average family in the US pays about $10,000 a year for health insurance — i.e. just to get coverage. Even for those who have insurance, services and costs not covered in one way or another typically come to thousands more, and have consistently expanded.
Tens of millions don’t have insurance or qualify for the limited government support that exists. Even for relatively well-off workers, there is enormous insecurity built into the system: Will you be able to continue to make your insurance payments? What if you lose a job whose benefits include contribution to insurance costs? Is your health problem serious enough to justify using insurance or incurring costs? What happens if you, or a dependent, get a problem requiring long-term treatment which swamps your insurance coverage?
A true US-style system is not imminent in the UK: but we are moving in that direction, as private healthcare continues to expand and the NHS is undermined through multiple mechanisms.
The NHS is being undermined through underfunding. It got substantial temporary funding last year to deal with the pandemic, but its core funding was actually slightly lower in 2020/21 than in 2019/20. This coming year it will increase, but only by a few percent in real terms, after a decade of very small increases — 1.4% on average, real-terms, compared to 3.7% since the NHS was founded and 6% under the Blair-Brown governments.
Under Labour between 1997 and 2010, NHS spending as a proportion of the UK’s Gross Domestic Product went from 4.65% to 7.69%. Since then it has stagnated or, mostly, slightly declined every year.
If the 1997-2010 increases had been matched since, the core NHS budget this year would be over £200bn rather than £150bn.
The health service has not been literally “defunded” in the way local government has. But NHS care has long been more and more rationed, with many services in effect no longer freely available. Sustained underfunding has meant a system desperately over-stretched even in quiet times, with very little flexibility or reserve capacity, even before March 2020. Thus the health service's repeated near-overwhelming during the pandemic, and probably a lot more Covid transmission within hospitals than there would be if they were less crowded.
If Covid disappeared tomorrow, the NHS would still urgently need substantial extra funding just to catch up, with a record five million people now on waiting lists for treatments.
The billions slashed from councils’ public health budgets, and the impact of austerity in general, have functioned as de facto NHS budget cuts by increasing demands on the health service.
US healthcare spending as a proportion of GDP is more than double the UK’s, but only a third is from government funding and much less goes to any kind of public provision. Healthcare there is a profit-making industry at most levels. It is deeply fragmented and its administration costs are vast (a third of spending, three times the NHS figure).
The Blair-Brown governments pushed up NHS funding, but also substantially increased the amount going to private companies, for building and managing facilities and for providing services, as well as into the increased admin costs of a marketised system (about 10% now, double what it was in the 1980s). Since 2010 the Tories have enthusiastically built on those foundations.
Labour recently published figures showing that at least £100bn of NHS spending had gone to non-NHS providers since 2010, with the amount increasing every year — by 72% in the decade, against a 17% increase in the overall NHS budget. Last year it was £14.4bn, 11.7% of NHS spending. It looks like this has accelerated during the pandemic.
Now NHS England is being reorganised into 42 “Integrated Care Systems” which will entrench and promote the role of private companies, including in management of the health service. The NHS and social care motion being promoted by Momentum for Labour Party conference says the change “sidelines local authorities, threatening the integrity of social care and reducing local accountability. It will mean more private contracts, deregulation, downskilling, outsourcing, and reduced services.”
National NHS campaigns like Keep Our NHS Public, local campaigns to save services, and groups of workers and trade unionists have waged heroic guerrilla warfare, over many years, to defend the health service. If the Labour Party and the NHS unions nationally launched a bigger campaign to defend and rebuild the NHS, or even just put backing and resources into existing struggles, we would be in a much better position. That is what we must demand.
What they do about this is a test of the new left-wing majority on the national executive of Unison, the largest health union.
At the moment, Labour is not only failing to promote an active fightback but not even clearly opposing the Tories’ reshaping of the NHS — let alone proposing a radically different shape.
What is needed is to reorganise and adequately fund the NHS to push out the privateers, eliminate market-mechanisms and establish a solid and democratically run public structure providing healthcare on the basis of need.
Instead of a logo above an increasingly fragmented healthcare market, we must return to a genuine National Health Service — this time pushing for far more democracy, including for its workers.
Alongside a fully public health service, we need a full public social care system. There should be debate about how the NHS and social care fit together, but current proposals or slogans about “integrating” the NHS and care are not good. They give little regard to the kind of social care system we need, and threaten to create yet more channels for corporate infiltration of the health service.
• More: Support a 15% rise for NHS workers!
• Demonstrations for the NHS and a decent pay rise for NHS workers have been called all across the country for 3 July. Check out action in your area here. London protests include 11am at St Thomas’s Hospital (Westminster Bridge), 2pm at Lewisham Hospital, noon at Ealing Hospital, and 1pm at St Pancras Gardens.