A public health new deal

A review of The Five Health Frontiers, by Christopher Thomas; Pluto Books

The NHS is seen as the nearest thing to socialism in Britain (“From each according to their ability, to each according to their needs”), its “father”, Aneurin Bevan, wanting to “universalise the best”. Its universalism was soon under attack from Labour itself, with prescription charges introduced in 1951, provoking Bevan’s resignation. The one shilling charge (£0.05 = £1.30 in real terms) has now increased to £9.35.

This and other attacks have met with mainly defensive responses from the labour movement but health expert Chris Thomas wants us to go on the offensive, with his call for a Universal Public Health Service (UPHS) with a far wider remit than that of the NHS, going beyond improving health care for those who are ill to improving health by preventing or delaying illness.

Chris Thomas heads the Institute for Public Policy Research’s recently established Commission on Health and Prosperity, exploring the hypothesis that a fairer country is healthier and more prosperous. This is the message of decades of research by Michael Marmot and colleagues (e.g. the Whitehall Study), demonstrating substantial differences in health and life expectancy between subordinate and superior grades of work and between deprived and well-off areas (see Solidarity, ”Inequality kills”, a review of the WHO report on the social determinants of health and of Status Syndrome, by Michael Marmot, https://www.workersliberty.org/story/2013/03/06/inequality-kills).

Forty-two years ago, the Black Report (commissioned by Labour but published under Thatcher: https://www.sochealth.co.uk/national-health-service/public-health-and-wellbeing/poverty-and-inequality/the-black-report-1980/black-report-foreword/) revealed unequal distributions of ill-health and death among the British, inequalities that had widened since the establishment of the NHS. These were not due to failings in the NHS, but rather to other social inequalities influencing health: income, education, housing, diet, employment, and conditions of work. The Report recommended a wide strategy of social policy measures to combat these inequalities. Its release was delayed until an August bank holiday; only 260 copies were printed; and few people had the opportunity to read it. Social Services Secretary Patrick Jenkin baldly stated that the cost of its recommendations (£2bn per year) was “quite unrealistic in present or any foreseeable economic circumstances”, even if he had agreed with them.

The Black Report’s recommendations covered a better start in life for children, improved quality of life for people with disabilities, and encouragement of good health by preventive and educational action. The Labour Party called on the next Labour government to implement the report, and campaigners in the Socialist Health Association and the Politics of Health Group pushed the issues. One of these campaigners, Jeannette Mitchell, referred to the findings of the Marmot Whitehall Study, then only 15 years old, in her 1984 book What is To Be Done About Illness and Health (Penguin), calling for a radical new integrated community approach. But, despite lip service, Black’s recommendations were not followed after 1997 because of Labour’s commitment to Tory spending policies: by 2005, inequalities had widened. Eventually, however, by the end of Labour’s term, there was some decline in health inequalities, health expenditure having increased from 4.7 to 7.6% of GDP over 13 years but since 2010 these have worsened again.

It is a sign of our weakness that Thomas is now raising exactly the same concerns (and more) as 40 years ago, even though treatments have improved and life expectancy has increased. Thomas’s approach, though, encompasses more influences on health than just the NHS.

First, Thomas shows how the NHS, despite the heroic efforts of its underpaid and overworked staff, falls behind similar countries for such important health outcomes as cancer survival, infant mortality, heart failure treatment, and waiting times for joint replacements and cataract removals. By 2019, we were below average among high-income countries on 60 health metrics, with 4.5 million awaiting treatment (80% higher than under Labour), and below the OECD average for staffing, beds, medicines and technology.

However, the decline of the NHS is not the only factor affecting our health, as shown by Covid deaths. These disproportionately hit ethnic minorities and the low-paid, unable to work from home and forced by poverty to work even when unwell. They are more likely to live in overcrowded, poorly ventilated dwellings, further encouraging spread of infection. Once ill, they are less likely to be able to access the free health care offered by the NHS.

Taking these and other factors affecting people’s health into account, Thomas targets five frontiers for improvement. In addition to the obvious NHS frontier, he adds the social justice, economic, social care and sustainability frontiers, calling for a UPHS to generalise the NHS ethos of collectivism and state intervention into these areas.

NHS: Thomas wants to roll back the markets and targets approach of Thatcher and Blair. The plethora of targets did nothing for health inequality, with “post-code lotteries”, and scandals such as Stafford Hospital, where management had a perverse funding incentive to ignore poor standards of care to focus on targets and balances.

Thomas wants a return to Bevan’s “universalise the best”. This could happen rapidly, says Thomas, showing that change occurred quickly during the Covid emergency, with general practice shifting online, bureaucracy junked, and money for innovation suddenly available. He urges a reversion to ”oversupply” (of staff, equipment and beds) from the present “skeleton crew” approach, which saves money but causes the NHS to be swamped during emergencies, with consequent staff burnout. This would improve resilience but Thomas also calls for investment in social care, should those less unwell need to be discharged during a crisis.

With the increase in long-term health problems in an ageing population, Thomas wants the NHS to become a “wellness” service, helping people live productive lives, despite handicaps. He also wants it to tackle the institutional injustice linked to the legacy of colonialism. The NHS can function only with an international workforce, yet BAME staff are discriminated against and BAME patients receive worse standards of care.

Social Justice: Bad housing and low status precarious employment harm the health of the poor, as Marmot’s research on the social determinants of health shows. So also do inequalities in schooling which lead to poorer outcomes, linked to poorer health in later life. Thomas’s UPHS approach “prescribes” equal education, universal free school meals, healthy housing, ending energy poverty, and an end to low paid, dead-end work.

Economic: The market encourages production of harmful goods, tobacco, alcohol, junk food, gambling … and fossil fuels. It promotes bad work conditions, job insecurity, long hours and low pay. Higher profits come at the expense of workers’ and consumers’ health but governments put the onus on individuals to change their behaviours.

Thomas wants the liability for poor health to be transferred onto the capitalism that causes it. A new target, Public Health Net Zero, would be achieved through financial disincentives (like the soft drink “sugar tax”), regulation (as in smoking bans), and new ownership models (like the Swedish state alcohol monopoly).

Social Care: Care for people with disabilities or long-term illness was never included in the NHS. Despite increasing need, with an ageing population, provision remains low quality, patchy, unreliable and expensive, while its workers are poorly paid. In England and Wales, some 1.5 million over-65s have unmet needs impairing their quality of life.

Thomas wants a National Care Service (NCS) as a minimum. He calls for “the right to a brilliant life”, with NCS-provided personalised, empowering, high-quality, well-paid care, keeping people in their homes and communities as long as possible.

Sustainability: For Thomas, “health security” includes cooperating with global responses to climate change which makes health problems worse, and habitat loss which brings people closer to (pandemic-)disease-carrying wild animals.

Thomas costs this Public Health New Deal (PHND) at £100 billion per year, as much as cut from public spending by Tory austerity policies and dwarfed by stimulus injections by other governments.

However, the PHND is not just about money: Thomas emphasises the need to remove the private companies infiltrating the NHS. For example, he calls for GPs to be nationalised (not done by Bevan), so that practices cannot be bought up by private companies. Also, regions with greater health inequalities need greater autonomy in spending.

This sort of policy should be first nature to Labour but it is not even using its present identification with the NHS to increase support. Thomas cites the frankly incomprehensible statistic of 42% of health workers voting Conservative in the 2021 local elections, despite real-terms pay cuts, staff shortages, and Covid mismanagement. Rather than merely defending the NHS, Labour needs to get behind the radicalism of the PHND.