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NHS Under Siege details the ways in which the NHS has long been undermined, the consequences for covid, and why it must still be defended, finds Caitlin Southern

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John Lister, Jacky Davis et al, NHS Under Siege: The Fight to Save It in The Age of Covid, forward by Michael Rosen (Merlin Press 2022), xiv, 289pp.

Split over two sections, NHS Under Siege: The Fight to Save It in The Age of Covid first covers the decade leading up to the pandemic. Here it details the conditions that led to the eviscerated state of the health service once the pandemic struck. Secondly, it covers the impact of Covid-19 on various sections of the population. Coming in the aftermath of the People’s Covid Inquiry and featuring contributions from several people involved as well as other interested parties, NHS Under Siege examines what went wrong in the UK’s pandemic response and how the NHS was underprepared to cope with a mass health emergency. The People’s Covid Inquiry, while unofficial, is probably the closest thing to a full examination of the pandemic that is likely to be forthcoming. The current government certainly has no plans to hold an official enquiry before the next general election as it continues to dodge all accountability.

John Lister and Jacky Davis set out the ways in which the NHS has been undermined by a decade of ideological austerity, with vast amounts of money going to the private sector. While a large portion of the blame lies at the door of the Conservatives and Liberal Democrats, New Labours’ PFI deals caused havoc, with many hospitals being paid for several times over, yet still indebted to the financiers. New Labour also commissioned the infamous ‘McKinsey report’ to identify areas to cut spending, a plan which the Conservative/Liberal Democrat coalition was happy to consult and attempt to implement.

Privatisation and destructive re-organisations

More than a decade of austerity has inflicted serious damage on the NHS, but it would not have been possible without the privatisation groundwork laid by Thatcher and Blair. Central to the text is the permanent crisis that the NHS is in, with health-trust bosses being expected to find ‘efficiency savings’ year on year, leading to drastic cuts in both staffing and beds while the service is still expected to improve continually.

The book notes various attempts to reorganise the NHS and ways in which these have been fought, sometimes successfully, but often these plans have been simply repackaged and presented as something less obviously damaging. An example of this is the Sustainability and Transformation Plans (STPs) which were initially defeated in the middle of the previous decade, but have now been resurrected in the form of Integrated Care Boards to fragment the NHS regionally, and make it harder to work and campaign on a national level.

As Lister and Davis detail throughout, cuts and top-down reorganisations are generally pushed through behind closed doors to prevent a public backlash, as was seen against STPs. However, the latter’s successful rebranding as Integrated Care Services/Boards, being pushed through with the latest Health & Care Bill, should ring alarm bells for activists and concerned citizens. This highlights that government ministers and health-trust bosses know that these cost cutting reforms are not popular and will be resisted where they are known about, so they go to a lot of effort to keep them out of the public eye.

A lack of transparency and accountability from the top makes for a fragmented workforce that struggles to perceive the full scale of the problems and fight back in an informed and unified manner. Lister and Davis stress the importance of dedicated campaigners who are willing to track the Byzantine layers of bureaucratic secrecy that shrouds much NHS organisation in order to bring the information clearly into the public eye.

Suggestions on how to fight against cuts and privatisation are largely to join existing campaigns and making links with seasoned activists, which are appropriate to the arguments presented in the wider text, if not immediately invigorating. The importance of collaboration between trade unions and campaigners is mentioned, as government is less likely to negotiate with a campaign that has no ‘official’ backing, but the difficulties of these collaborations is also stressed.

Subordination to the private sector

While highlighting how much of the NHS has been carved up by privatisation and government policy, a major point made by Lister and Davis is that there is still a lot of the NHS to fight for. This argument has been voiced by Keep Our NHS Public more generally as a rallying call to those who share Nye Bevan’s ‘faith to fight for it’, and shown in smaller, local campaigns to save individual services. These campaigns are often well supported, but the increasing, deliberate fragmentation of the health service makes it more difficult to coordinate a general campaign to save the entire structure.

The book highlights the predatory role of the private health sector, and the ideological commitment of successive governments to it, that have seen it given excessive bail outs in order to survive both austerity and the pandemic, despite doing nothing to deserve such consideration. It also consistently poaches staff from the NHS, avoiding the expense of training them, but reaping the benefits of their experience.

Rather than making the simplistic claim that the government and private-sector vultures want to fully privatise the NHS, Lister and Davis feel that it is to be ‘subordinated’ to the private sector. The public sector will foot the bill for expensive, chronic and emergency care in addition to providing the staff, while the private sector continues to skim the cream in the form of lucrative contracts for care, despite often failing to provide adequate provision.

While the subtitle suggests that the focus is on the pandemic, much of the first section recounts failings and outright betrayals of services, staff and patients in the decade prior. The book also covers the woeful mishandling of the continuing Covid-19 pandemic, from the white-elephant Nightingale Hospitals that were largely unused due to lack of staff, to the corruption and incompetence that characterised the PPE procurement process and further undermined the capabilities of the health service to respond to crises.

The impact of covid

The second part brings together thirteen chapters from other writers which demonstrate more clearly the effects of covid, not just on the NHS, but on areas including education, childcare and elderly care, together with the lessons that the government has not learned. The importance of this interlinked approach cannot be overstated as healthcare is only one strand in understanding how the ongoing pandemic is affecting the population, especially those already made more vulnerable by austerity.

There are important contributions from Covid-19 Bereaved Families For Justice, who rightly want to know why their loved ones had to die to ‘keep the country running’, and health-policy analysts to highlight how, where and why things went so badly wrong, despite the existence of clear World Health Organisation pandemic protocols. This is partially explained by a government idea of British exceptionalism, that infection control was only required in poor or developing countries, but also by a simple lack of care on the part of politicians and ministers.

Sections from education unions explain the impact on pre-existing education and attainment gaps which were exacerbated by the failure to provide timely and fair access to vital learning resources, while medical experts show the effects of long covid, burnout and moral distress in key workers forced to function continually during a prolonged crisis, in ways that go against their morals. Legal experts illuminate the effects on law and order and public perceptions of government, as the realisation that there was always one rule for the population and quite another for the ruling class becomes more apparent. The second section draws out the picture of a society that has failed on basic provisions of social care, using the health service to alleviate the worst symptoms, while doing nothing to combat the circumstances that cause damage in the first place. These chapters also highlight the role of trade unions in the push back against government assaults on the health service, although a call for unified action across all sectors is lacking.

Overall, while much of the information in the main text is not new, the book provides a solid round up of the circumstances that the NHS faces and the ways that it has been routinely attacked by successive governments that are ideologically opposed to the principle of universal healthcare. It is clear on the challenges facing the NHS, although somewhat vague on how to fight back due to the multifaceted nature of the attacks. Other areas of campaigning face similar issues too, which is why The People's Assembly is a crucial organisation with which to focus activism against austerity and privatisation. While the health service has been systematically hamstrung by successive governments, and the pandemic has uncovered and exacerbated the underlying issues, NHS Under Siege is a useful source of information and organisations to contact for every person who wants to understand and join the fight for the future of our health service.

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