Wrightington Hospital, in the countryside near Wigan, grew in fits and starts around an eighteenth-century mansion that Lancashire County Council bought in 1920 after the death of its last resident, a spendthrift with a fanatical attachment to blood sports. The hospital promotes itself as ‘a centre of orthopaedic excellence’. National Health Service hospitals have to promote themselves these days. In 2011 it survived a brush with closure. It’s neat and scrubbed and slightly worn at the edges, unable to justify to itself that few per cent private firms set aside for corporate sheen, although it does have a museum dedicated to John Charnley, who, almost half a century ago, invented a reliable way to replace human hips with artificial ones, creating a benchmark by which the success and failure of the NHS would always be judged.
They still do hips at Wrightington, and knees, and elbows, and shoulders. They deal with joint problems that are too tricky for general hospitals. There’s a sort of blazer and brogues testosterone in the corridors, where the surgeons have a habit of cuffing one another’s faces affectionately. At the end of a hallway lined with untidy stacks of case notes in wrinkled cardboard folders Martyn Porter, a senior surgeon and the hospital’s clinical chairman, waited in his office to be called to the operating theatre. He offered me his intense, tired, humorous gaze. ‘The problem with politicians is they can’t be honest,’ he declared. ‘If they said, “We’re going to privatise the NHS,” they’d be kicked out the next day.’
The patient Porter was about to operate on was a sixty-year-old woman from the Wirral with a complex prosthesis in one leg, running from her knee to her hip. She had a fracture and Porter had got a special device made for her at a workshop in another part of the NHS, the Royal National Orthopaedic Hospital at Stanmore in Middlesex. The idea was for the device to slide over the femoral spur of the knee joint, essentially replacing her whole leg down to the ankle. ‘The case we’re doing this morning, we’re going to make a loss of about £5,000. The private sector wouldn’t do it,’ he said. ‘How do we deal with that? Some procedures the ebitda is about 8 per cent. If you make an ebitda of 12 per cent you’re making a real profit.’ You expect medical jargon from surgeons, but I was surprised to hear the word ebitda from Porter. It’s an accountancy term meaning ‘earnings before interest, taxation, depreciation and amortisation’.
‘Last year we did about 1,400 hip replacements,’ he said. ‘The worrying thing for us is we lost a million pounds doing that. What we worked out is that our length of stay’ – the time patients spend in hospital after an operation – ‘was six days. If we can get it down to five days we break even and if it’s four, we make a million pound profit.’
I felt I’d somehow jumped forward in time. A year had passed since the 2010 election that brought the Conservative-Liberal Democrat coalition to power. The Coalition’s programme promised: ‘We are stopping the top-down reconfigurations of NHS services, imposed from Whitehall.’ A few weeks after they gained power, a new health secretary, the Conservative Andrew Lansley, announced his plans for a top-down reconfiguration of England’s NHS services, imposed from Whitehall. When I talked to Porter, Lansley had barely been in his job a year, and hadn’t yet, supposedly, shaken up the NHS. But here was a leading surgeon in an NHS hospital, about to perform a challenging operation on an NHS patient, telling me exactly how much money the hospital was going to lose by operating on her, and chatting easily about profit and loss, as if he’d been living in Lansleyworld for years. Had the NHS been privatised one day while I was sleeping?
When the NHS was created in 1948, it had three core principles. It would be universal: everyone would get medical treatment whenever they needed it. It would be comprehensive, covering all forms of healthcare, from dentistry to cancer. And it would be free to use. No matter how much the system cost to run, no matter how much or how little any individual had contributed to those costs, no matter how expensive their treatment or how many times they went to the doctor, they’d never be billed for it. Through dozens of reorganisations since then, these principles have remained, along with another: that it’s never a bad time for a fresh reorganisation. Otherwise, much has changed.
The main source of the money that funds the NHS is still, as it was in 1948, general taxation. For the first thirty years of the health service’s existence, civil servants in Whitehall and the regions doled out annual budgets to hospitals and GPs according to the populations they served. Money flowed down from the Treasury, but it didn’t flow horizontally between the different parts of the NHS. Each element got its overall allowance, paid its staff, obtained its equipment and supplies, and co-operated, sometimes well, sometimes not, with the other elements, according to an overarching plan. The aim was fairness, an even spread of care across the country. In a monopoly healthcare system, competition has no place; on the contrary, it seemed sensible to the planners to avoid duplication of services. It was patriarchal and democratic, innovative and hidebound, cumbersome and cheap. For the majority without private insurance, if you were ill, you knew you’d always be cared for; if you were cared for carelessly, you had nowhere else to go.
Trying to describe in generally comprehensible terms how money flows through the NHS today would be hard enough without the shifting channels of policy. In England – Scotland, Wales and Northern Ireland have gone along divergent health paths – the various parts of the NHS had already begun altering or abolishing themselves in response to the reorganisation announced in 2010 when the reorganisation itself was reorganised. In 2012, the Coalition responded to the clamour against Lansley’s reorganisation by sacking Lansley and keeping the reorganisation. Truly you can’t step in the same NHS river twice. The last period of relative stability was just before Lansley came along, when, crudely speaking, the money flowed like this. Every so often – perhaps every year, or every two or three – the Department of Health made its pitch to the Treasury for the amount of money it thought it should get from the overall tax pot, and was then told how much it would actually get. Most of the money came from general taxation – income tax, VAT, corporation tax, duties on booze and tobacco – but a proportion came directly from national insurance, a vitiated form of the link between that levy and the welfare state its architects intended. In the last pre-Lansley allocation, Health got £101.5 billion for the following year, a slight increase. Most of it – £89 billion – was divided up between about 150 local agencies called Primary Care Trusts, or PCTs, spread around the country. PCTs acted as the ‘commissioners’ of health services, ordering a community’s medical care from hospitals, GPs and mental health professionals and paying them accordingly.
~~Private Island: Why England Now Belongs to Someone Else -by- James Meek
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