The NHS 10 Year Plan attempts to solve the problems of underfunding of the NHS and the aggravation of those problems by the inefficiencies induced by markets and a neglect of prevention. Incredibly, it seeks to achieve these goals without substantial new money and with extremely limited reference to public health, while putting the process out to competitive tender.

Funding

All parts of the NHS need more money. Spending on primary care and public health must rise faster than the general increase; public health spending needs to increase the most.

The Treasury’s view is that, unless we can generate economic growth, we cannot afford to invest more in public services. However, David Stuckler et al. have shown that Keynesian multipliers vary between different types of public spending, and that for health, welfare, education, and community services they exceed the level at which they would generate enough economic growth - and thus enough tax revenue - to pay for themselves.

This explains why Keynesianism worked in the 1950s when it was directed toward those areas, and why it ceased to work in the 1970s when it was diverted into lower multiplier sectors. It also explains why we were able to afford spending in these areas even when the country was poorer than it is today - because that spending helped grow the economy.

The reality is that unless we spend in high multiplier areas to generate growth, we will not be able to reduce the deficit or afford the spending needed in lower multiplier areas such as defence.

Those who reject this argument claim that taxation would be required and that people will not accept higher taxes.

Some measures can be taken by changing the way interest is paid by the Bank of England to commercial banks. But it is also important to understand more fundamentally the roots of resistance to tax increases.

As multinational corporations have paid a decreasing share of tax, the burden has fallen more heavily on small businesses and individuals. Small businesses that pay their tax must compete with multinationals that do not. As the proportion of the tax burden falling on individuals rises, the perceived value for money of taxation to an individual declines. This resentment is comparable to other situations where people feel corporate interests are inflating the cost of basic necessities such as fuel bills or commuting costs. People also resent the risk of losing their savings due to the cost of social care.

If we are wrong about the Keynesian self financing nature of increased health and social care spending, we would advocate raising the money by taxing multinational companies for economic activity that exploits UK markets but is declared as profit elsewhere - or is taken as a franchising fee, management fee, or royalty for intellectual property.

If multinational companies pay these taxes, the money raised can fund the increased health and social care spending.

If they choose instead not to exploit UK markets, they will create market niches that can be filled by small businesses, which will pay their taxes and fund the increased health and social care spending.

Indeed, such taxation is desirable regardless. If the Keynesian multiplier does fund the spending, the deficit can be correspondingly reduced. If it does not, at least the spending will have been financed.

• Unite should press for acceptance of the Stuckler findings and for substantial increases in spending on health, education, welfare, and community services explicitly to generate growth that will reduce the deficit and fund lower multiplier spending.

• Unite should also press for taxation of multinational companies for economic activity that exploits UK markets but is declared as profit elsewhere, or is taken as a franchising fee, management fee, or royalty.

Markets

Our concept of clinical commissioning derives from the Alma-Ata Declaration, which states that health care should be organised from its base in primary care, with communities and their health professional advisers determining the pattern of support that the local primary care system needs from more specialist services. Individuals can then be supported by their GP in navigating that system.

This is a system of strategic planning rooted in local communities.

As commissioning has developed, it has progressively departed from those roots and become a market oriented system of procurement. Instead of GPs and local communities, procurement lawyers now determine the pattern of health provision.

If markets pay for activity, the system is open to provider capture, as providers aim to generate more activity. Diagnostic drift occurs in coding systems, and demand management is destroyed.

If markets aim instead to pay for quality, the indicators of quality are not sufficiently coherent or comprehensive to be immune to distortion. There is a focus on the measurable at the expense of less measurable measures, and on moving indicators without regard to the underlying reality they are meant to reflect.

We encounter three tiers of misleading information:

1. The required information does not exist in the needed form and classifications, so unsatisfactory alternatives are used.

2. Even if the information exists, it is wrong because epidemiological and clinical data are subordinated to commercially driven data.

3. If accurate data do exist, they quickly become inaccurate once used as a mechanism for performance management - the gaming of data is an essential part of the provider response to such a procurement system.

These statements are amply justified by experience worldwide.

Forced to use competitive procurement measures judged primarily by financial targets or misleading quality targets, Integrated Care Boards (ICBs) increasingly cease to be strategic planners and become ‘bean counters’.

Planning by targets that fail to capture the underlying reality was one of the major problems of the Soviet economic system, leading to empty freight trains running in large circles in Siberia to clock up train mile targets.

Compelled to secure their income in such a market, NHS organisations behave like commercial entities and adopt the same tricks as their competitors.

Losing sight of purpose and concentrating on making money through financial distortions was one of the causes of the banking crisis, leading to the absurd belief that bundling large numbers of bad debts together created an investable proposition.

Combining one of the biggest errors of the Soviet system with one of the biggest errors of the Western banking system is not a viable process for managing a public service.

Between these two pressures, the NHS - as a coherently and strategically planned, professionally led, and democratically accountable service - simply ceases to exist.

• Unite should oppose the use of commercial approaches in the NHS not only because of their impact on workers and NHS organisations (important though those are) nor merely for ideological reasons (however strongly we believe in them), but also because, quite simply, they do not work.

It is important to explain why they do not work. This explains why the NHS has become less efficient as they have been applied. It also explains why no country has achieved better value for money than the NHS simply by using such approaches (countries that outperform us spend more per capita at purchasing power parity, even if they spend the same proportion of GDP because their GDP is higher). The only countries that have achieved better value for money - such as Japan and Cuba - have done so through investment in primary care and stronger communities.

Public Health

The NHS is not just a way of paying for health care; it is also a mechanism whereby the health of the people is pursued as a social goal. Nye Bevan’s NHS had three wings - family health services (general practice, pharmacy, dentistry, and opticians), the hospitals, and the health departments of local authorities. Since a sharp bureaucratic divide now separates the NHS and local government, we often forget that part of Bevan’s NHS was run by local authorities and focused on prevention. In its first quarter century, the NHS cleared the slums, cleaned the air, eradicated polio and diphtheria, and dramatically reduced the incidence of tuberculosis, enabling TB hospitals and wards to be closed or reused.

These early achievements show that the NHS once emphasized prevention. Since the reorganisation in 1974, it has lacked the means to do so. Important elements of public health - such as environmental health - remained with local government but were no longer seen as part of the NHS, so addressing the social and environmental determinants of health fell outside the remit and capacity of the NHS and outside the direction of public health specialists committed to analysing and improving the health of the people. Those specialists were placed in health authorities and were generally redirected away from addressing determinants of health toward health service planning. They were separated from public health nursing, which moved to the new health districts and came to be seen merely as specialist community nursing.

From 1974 to 1997, spending on public health by the NHS and by local government depended entirely on local priority. Many environmental health departments were run down by their local authority and integrated into a regulatory function in which public health was only one element. Many NHS bodies did not perceive the importance of prevention and saw health visiting, school nursing, and community clinics as sources of savings to fund hospital priorities. On the other hand, many local authorities and NHS bodies did see the importance of public health, and where such prioritisation existed on both sides of the NHS/local government divide, vibrant public health programmes could be developed.

There was a brief period under the leadership of Barbara Castle when public health had a national priority, but she thought it too late to reverse the 1974 changes, perhaps not fully realising their baleful effect, and she survived only through the Wilson Government. There was no significant prioritisation of public health under the Callaghan Government, and the Thatcher Government had an ideological antipathy to public health.

The Major Government regretted the decline of public health and expressed support for local initiatives but did nothing to generalise them. This limited support changed in 1997. The Health Department in the Major Government had not prioritised public health but permitted it to be prioritised locally. From 1997 to 2010, prioritisation was centralised and it became more difficult for localities to pursue different priorities. Public health was not a priority of the Blair Government.

This changed briefly for the better in 2010. Andrew Lansley is not a hero of ours - he did much to damage the NHS by his unnecessary reorganisation, by his misplaced belief in commercial solutions, and by his fundamentally damaging procurement laws. However, in one respect he is to be praised: he stands alongside Barbara Castle as one of only two Health Secretaries to have genuinely prioritised public health.

The adverse effects of 1974 could therefore have been reversed in England when public health returned to local government in 2013, but instead the coalition with the Liberal Democrats introduced a distinction between “the statutory comprehensive health service” and “the NHS”, with the latter being only a part of the former. Lansley’s vision was that “the NHS” had become too firmly identified with health care and that a new public health system needed to be built alongside it and become the dominant element of the Department of Health. However, like Barbara Castle, Lansley was quickly replaced by successors who did not share this vision.

Spending on public health services transferred from the NHS to local government substantially increased in 2013 and rose slightly more in 2014, but this was only a small part of total public health spending. With “public health” removed to local government, the NHS faced even less pressure to prioritise prevention, while, outside the ring fenced field of “public health”, local authorities were subject to severe spending cuts eroding environmental health services, youth services, community development, and other services central to a public health strategy. A significant portion of the new money committed to public health services was used to ease the consequences of those wider local authority cuts. Health protection resources also declined.

The 2013 division between “the NHS” and the “statutory comprehensive health service” allowed the 2015 Cameron Government to cut funds for public health in England, stating that health visiting, school nursing, drug and alcohol services, and NHS health checks were no longer part of the NHS. Lansley’s aim in introducing the division might have been to give public health a higher priority, but it was used in the exact opposite way. The argument was that, because “the NHS” had protected funding, other areas of Department of Health funding should be squeezed to help find that money. The 2013–2014 growth money was taken away, and cuts to public health spending went further, biting into the already inadequate levels that Lansley had set out to improve.

In the devolved nations, public health remains part of the NHS, but linking it to local government remains a challenge. Public health must work across local government and the NHS and be included within the concept of the NHS, at least for the purpose of the protection that the NHS provides for funding.

The cuts in “non NHS” health funding in England have had many adverse impacts, including on NHS workforce planning. Cutting public health spending was like stripping the lead off the roof to make buckets to catch the rain; failure to prevent creates the workload crisis that overwhelms general practice and hospitals. Obesity, alcohol related disease, and diabetes stoke this crisis, as does unhealthy ageing - if healthy life expectancy had kept up with life expectancy, longer lives would actually reduce demand as people lived longer before becoming heavy users. The dependency ratio (people over 65 divided by those of working age) is at its highest ever and will continue to rise. However, if we calculate the number of people within ten years of life expectancy divided by the total number of people actually working, it is actually at its lowest ever (Spijker J and MacInnes J, BMJ 2013; 347:f6598). Instead of healthy ageing reducing the NHS burden, an inequality emerged in which the poor not only die younger but also spend longer in illness within their shorter lives - a factor neglected in NHS resource allocation formulae.

Public health spending is vital to easing pressures on the NHS. Indeed, the British Medical Association, speaking for the whole profession, has said that increased public health spending will do more for the NHS than increased NHS spending.

Public health specialists - a medical specialty that also has a non medical route of entry - are health professionals who treat a population, identify health threats, and act as change agents to improve health. Their role as change agents and advocates needs recognition and protection.

Prior to 1974, the independence of Medical Officers of Health was statutorily protected. Since 1974 this has not been the case. Most public health consultants (including Directors of Public Health) were employed on contracts guaranteeing freedom of speech. This protection was stripped away at regional level in the 1990s when regional health authorities were replaced by civil service bodies, and at district level from 2013 onward when staff of Public Health England became civil servants and when TUPE-ed NHS terms and conditions were gradually ceased in local government as new staff were recruited. From 2015, protected terms and conditions began to expire. Neither the civil service nor the Local Government Association has shown any willingness to discuss protected freedom of speech. Until 1997 it was generally acknowledged that the Chief Medical Officer’s duty included telling the truth to power. That began to erode under the Blair Government and has continued. Today journalists report that they do not perceive any official public health source as independent.

Many of our members still assert, despite increasing difficulties, their duty to act as health professionals treating a population and to give honest advice, if necessary in public. However, the obstacles they face are such that they fully understand why that role is no longer trusted as it once was. This lack of a trusted, independent public health voice had a major adverse impact on communication with the public during the pandemic.

Public health requires action to address environmental and commercial determinants of health. We need healthy housing, green space, healthy transport, and good quality work. We need healthy workplaces. Asserting freedom to choose unhealthy lifestyles should not imply that commercial companies are free to maximise profits by persuading people to harm themselves. Health is improved by resilient communities, mutual support, and control over the factors that affect health. These political and environmental factors - including community empowerment - are central to the public health agenda.

In the 1990s a ministerial post was created, initially held by Julia Cumberlege, to address public health. The role rapidly became dominated by specific preventive measures within the NHS. The Blair Government pledged to develop a cross-government public health strategy led by a Minister of Public Health, but this never materialised; after the first holder left, the role was downgraded to Parliamentary Secretary and reverted to the previous duties of Julia Cumberlege. Under Andrew Lansley a Cabinet Committee was established, but after he left it ceased to be effective. Recently there has been an ideological antipathy in the Department of Health and Social Care (DHSC) to addressing the social, environmental, and commercial determinants of health.

The Minister for Public Health has never had sufficient cross-government responsibility. It needs to be a cabinet level role, joint between DHSC and the department responsible for local government, with links into all other government departments. Each department should have a minister responsible for its public health functions and linked to the Minister for Public Health. In some departments - such as those responsible for food, transport, work, and social security - that role is sufficiently important to be a full-time position and could be joint with DHSC. In other cases it could be part of a wider portfolio. Between these roles a comprehensive public health strategy could be shaped.

• Unite should advocate that the whole statutory health service be defined as “the NHS,” with the NHS as defined by Lansley’s Act called “NHS Healthcare,” and the public health system called “NHS Public Health.” Doctors in Unite have drafted a legislative clause to achieve this.

• Unite should advocate for spending on public health to rise faster than frontline healthcare spending until reasonable levels are achieved, and thereafter to rise in line with frontline healthcare spending.

• Unite should advocate for statutory protection of the independence and cross-agency role of Directors of Public Health, including powers to act as a corporation sole. Doctors in Unite have drafted a legislative clause to achieve this.

• Unite should advocate for a comprehensive public health strategy across government, led by ministers with specific responsibilities, addressing the commercial, environmental, workplace, economic, and social determinants of health.
  
  

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