When will public anger over the NHS reach a political tipping point? | Polly Toynbee

There is an ebb and flow in reporting on the NHS as Trump, Syria and Brexit dominate front pages. But the pressure-cooker state of the entire service still worsens. This morning’s latest figures are just a snapshot of deterioration – but every target is missed, for A&E, ambulance response times, for treating psychosis within a week, for cancer waiting times, blocked beds and diagnostic tests.

“Demand” is rising, the government says, as if serious illness were a choice, though the pressure comes from well-predicted rapidly increasing numbers of old, sick people: this February’s A&E figures are, as ever, better than deepest winter January, but worse than February last year, as this crisis ratchets up. Major A&E centres are treating 81.2% of patients within four hours, against a target of 95% that used to be hit before 2010. The government likes to blame frivolous users of A&E, but those are easily triaged to on-site GPs. Serious delays are due to very ill people needing to be admitted with no empty beds: bed occupancy is at dangerous levels, as Chris Hopson of NHS providers warns, where doctors often have to decide “one in one out”, discharging those who still need more care too early.

Take the temperature in virtually every part of the NHS and the wonder is how the heroically overstretched staff keep the wheels on the trolley. Take this week alone: the Royal College of Physicians says 84% of doctors have to cope with staff shortages and gaps in rotas. GPs? Two years after a government promise of 5,000 more GPs, numbers are still falling. They dropped by 400 just in the last three months of last year: as doctors find the workload unmanageable some escape abroad, take earlier retirement or become locums. Too few new doctors want the burden of running a GP partnership, so 92 practices closed last year, tipping hundreds of thousands more patients on to already overloaded neighbouring GP lists.

Today the Royal College of Nursing starts consulting its members on whether to hold a strike ballot, the traditionally most reluctant of unions to take action. But with public sector pay frozen yet again at 1%, when inflation will shortly hit 3%, nurses are departing, like doctors, for less stressful, better-paid work. Recruitment from the EU is plummeting, as predicted.

As everyone firefights, all the preventative services are being cut that might prevent patients needing a crisis bed

As everyone firefights, hand to mouth, all the preventative services are being cut that might help keep patients from needing a crisis bed. The government has lines to take but no answers, and some of those “lines” are fictions. No, the NHS has not had £10bn, as Theresa May keeps claiming: it’s more like £4.5bn over four years, says the Kings Fund.

No, the £2bn given to social care will not ease the beds crisis, for all the exhortations to councils to use every penny of it in releasing bed-blocking patients with new care packages at home. NHS Providers, representing NHS hospitals, mental and community trusts, says councils are using that money to stem the collapse of existing care services and care homes, as the higher minimum wage and rising costs cause multiple closures. Cuts leave at least half a million old people getting no care, who would have done, and that risks falls, neglect and extra hospital visits. The care crisis is seeing 900 care workers a day leaving underpaid and overworked jobs.

Money, you might think, comes last in hospital managers’ priorities. But they are being severely harried and punished by NHS England to rein in ballooning debt by plundering capital funds and selling bits of land to cover running costs, one-offs many say they can’t repeat this year. An NHS England-commissioned report says £10bn is needed to cover this depleted capital: that’s not for grand new projects, but for basics like outworn dialysis machines.

A chair of a leading teaching hospital tells me “heroic assumptions” are being made by most trusts agreeing their “control totals”, their spending limits for this year. Debts will swell again. This year the NHS gets just a 1% increase, next year an unprecedented zero.

One of the Labour’s NHS triumphs was to cut waiting times for operations from 18 months to 18 weeks – but now that totemic 18-week limit has been abandoned. However, that only adds to hospitals’ financial woes as they rely on income from elective surgery, while every extra emergency costs them money.

This is the dismal background to the reorganisation that NHS England head Simon Stevens is attempting, almost undercover. His state of play review of his five-year forward plan passed hardly noticed, announcing a first tranche of England’s 44 STPs, (sustainability and transformation plans) to reconnect local services fragmented by the Lansley 2012 act.

Most observers think it the right way to go, putting the NHS and social care under a united structure with one finance hub, ending destructive and expensive competition and tendering of services. But hardly anyone thinks this can be done with no new money: every STP calls for capital for new beds and units. Virtually all involve closures and mergers stirring a local political outcry.

Jeremy Hunt, who always presented himself as the patient’s ally, rooting out poor quality, wallowing in the Labour disaster at Mid-Staffs, has fallen uncharacteristically quiet. He has nothing much to say about patient safety in A&Es or elderly patients turned out of beds too soon. Not even deaths on trolleys in A&E corridors in Worcester roused his usual righteous ire.

Concern about the NHS has risen high in recent polling: what no one knows is when public anger will reach a political tipping point. May and Hammond stay iron-clad adamant: all this is NHS shroud-waving and there will be no more money. Lack of any opposition helps, but can they really tough it out where Thatcher, Major and Blair all bent in the face of NHS crises?

When will public anger over the NHS reach a political tipping point? | Polly Toynbee

Labour’s failure on the NHS is prolonging this health crisis | Polly Toynbee

Remember Mavis Skeet? In 2000 the 74-year-old led the news for weeks when her operation for cancer of the oesophagus was cancelled four times, until it became inoperable and she died. Liam Fox, then shadow health secretary, exclaimed: “This is not an isolated case. The NHS is not coping!”

When does a rumbling NHS crisis erupt into a volcanic political eruption? Labour’s miserable failure to “weaponise” the NHS into a winner in Copeland makes it worth looking back.

Mrs Skeet was the tipping point for Labour. The worst flu epidemic in a decade blew away Tony Blair’s pre-election “waiting lists cut” pledge. Instead Labour stuck to a draconian Tory budget, but this one case sent Blair into the TV studios promising to match average EU spending – and Labour did. The best NHS decade followed: 7% annual budget increases saw waiting times plummet, as heart and cancer results improved.

Margaret Thatcher’s eruption came in 1987 with the NHS squeezed dry. Babies died waiting for operations at the Birmingham Children’s Heart hospital. Through gritted teeth, the NHS “safe in our hands”, she bunged it £100m and punished it with the internal market.

In this latest seismological era, political vulcanologists can’t predict exactly when the top will blow. With its lowest ever funding rises, its hardest years are still to come, despite soaring numbers of the old, hospital admissions up by 31%, and 22% more A&E patients since 2010. Staff shortages follow cuts in nurse training and worsening GP and specialist recruitment. Even if extra is found for social care, the National Audit Office suggests it won’t stem the flow of patients into hospitals.

Are things bad enough yet? The British Medical Association reports that 15,000 hospital beds have been cut in the past six years. The Royal College of Surgeons protests at cancer operations being cancelled. Ambulances frequently stack up outside hospitals. Look at all that molten lava bubbling away.

Mavis Skeet’s death in 2000 became a tipping point for the NHS under Labour. Her operation for cancer of the oesophagus was cancelled four times. Photograph: PA

Ahead of next week’s budget, Theresa May pretends the NHS has an extra £10bn – at loggerheads with Simon Stevens, the head of NHS England, who publicly disputes it. What forces a U-turn? Before it was deaths, but already two patients have died on Worcester Royal hospital trolleys, one after a 35-hour wait. Coroners have protested to the health secretary, Jeremy Hunt, after two recent deaths due to lack of intensive care beds: the case of Teresa Dennett, who died from a stroke, and Mary Muldowney, who died after a brain haemorrhage.

The war zone of A&E has featured nightly on BBC news, with a graphic documentary series on the controlled mayhem in barely coping hospitals. When is enough enough? Not quite yet, it seems. The government has been lucky, with no flu epidemic in any recent winters or any Arctic freeze-over. With beds at full capacity, it would only take a mild outbreak to tip over the NHS.

The pressure-cooker is finance: monumental debts swell by millions a month as hospitals receive absurdly frantic threats if they don’t cut back. In December they were told to free beds by cancelling operations, causing longer waiting times and lost revenue from missed operations. Look at King’s College hospital, in south London: its chair, Bob Kerslake, calls official finances “kidology”. Ordered to make a surplus this year, King’s can’t avoid a £2m loss – yet the punishment is a cut in funds, sending its deficit to £30m, and an instruction to make a £26m surplus next year: this is mirage accounting, mirrored everywhere.

So far these debts are Hunt’s and chancellor Philip Hammond’s problem: what do patients care? But if the Treasury really means to recoup the money, plus the £22bn in savings it demands of the NHS by 2020, then Vesuvius will blow. Wards and units will close, staff will be laid off, the chaos will be unprecedented. It can’t happen.

When the government is forced, kicking and screaming, to pay up, who will it blame? It will call the NHS “unsustainable” and “a bottomless pit”. (Hammond already has.) Yet more “reforms” and re-disorganisations will be hurled at it: payment for services, top-up insurance and tax rebates for private payers will resurface. The government will ignore the UK’s fall in the EU spending scale since 2010, and is now sixth out of the G7 countries, with fewer beds, doctors and nurses per capita.

Who has the political heft and credibility to defend it? Fear of Labour’s NHS moral hegemony kept Thatcher, John Major and David Cameron in check. No longer. Labour thought the NHS was its big bazooka in Copeland, where a maternity unit is under threat. But the naked desperation of Labour’s “Babies will die!” leaflets shot the very last bolt in Jeremy Corbyn’s arsenal. Each time he raises the NHS at prime minister’s questions his feeble attempt at “weaponising” sounds pathetically opportunist: May bats him away with balderdash statistics he is too incompetent to refute.

This has never happened before: polls find May more trusted than Corbyn to run the NHS by 45% to 35%. Far worse, Labour’s failure to counter the right’s message has left more people blaming the NHS crisis on migrants and patients’ bad lifestyles than Tory underfunding or rising numbers of older people. As ever the Mail and the rest carry endless NHS tourism or obese wastrel stories – but Labour has always had to fight twice as hard to get a hearing for the facts on the NHS.

Whoever follows Corbyn will now find it ferociously hard to regain that lost NHS ground. By 1997, hammering away in opposition, Labour had made the threadbare NHS the top issue and owned it. Hard-won economic credibility earned it the trust to run the NHS better. Now Ben Page of Ipsos Mori finds the NHS the second issue after Brexit, but Labour doesn’t own it, or anything else: Corbyn falls behind on everything, with every demographic, so even Labour voters prefer May.

Because the NHS crisis has so far exploded in debt rather than closures, most people’s experience is not yet bad enough to reach tipping point. Page says satisfaction is down on 2010, but not rock bottom, with always a long lag in perception. A third would pay more tax for the NHS, but the rest want savings by denying obese people and migrants.

Austerity has entered the nation’s blood stream: Page finds most people still think it necessary – despite the reckless tax cuts ahead. Banging on about “austerity” without specifics gets Labour nowhere. May’s own polling and her Copeland result tell her this – but hubris is her greatest peril. There may be no opposition, but if she and her chancellor really try to squeeze the gargantuan debt out of the NHS, all hell will break loose anyway.

Labour’s failure on the NHS is prolonging this health crisis | Polly Toynbee

NHS crisis: the one act of self-sacrifice that could rescue our health service | Polly Toynbee

From every previous NHS crisis, the tipping point should have come last week. Prime ministers crumple when people die – as they have in the Royal Worcester’s corridors. When opinion polls send concern about the NHS soaring above everything else at 61%, above immigration at 41% and Brexit at 36%, sirens should wail inside No 10. But no, not yet.

When the Royal College of Surgeons protests at cancer operations cancelled, is that a tipping point? When nearly half of all hospitals declare major alerts for lack of beds, that’s an emergency. There’s no winter flu, no Arctic weather, just pressure from underfunding, like an aneurysm about to burst. But the prime minister is not for turning, not yet.

King’s College hospital is typical – as its clinical director of emergency medicine, Malcolm Tunnicliff, explains. He stands in the middle of a 10-cubicle emergency section where this week he had 17 trollies crammed in, jammed around the nursing station with barely enough room to squeeze past.

Other hospitals call a “divert” – to send away ambulances from their doors. “We never do that, on principle, because every hospital’s in the same boat. We are here for everyone, all the time,” says Tunnicliff. Like so many NHS staff you meet, his natural blend of enthusiasm and determination to cope leaves him perplexed by what’s happening. “The last four weeks are the worst I’ve experienced. We all worry all the time.”

Recently he’s had 6% more patients – with 10% more needing resuscitation – and he can’t fill all his vacancies, leaving him scouring the world for staff because of the government’s failure to train enough people: 19% fewer nurses are in training. “Day after day my staff here go the extra mile, like Duracell bunnies,” he says. But he fears many may leave as a result of the pressure.

The last straw may be the flame-thrower of blame from Westminster, attacking staff and patients and GP opening hours. No, Tunnicliff says, only 4% come here with things GPs should see. The blockage is a lack of beds for skyrocketing numbers of sicker and older patients. Nationally, 13,822 beds have been cut since 2010, losing 5m bed days. The 40% cuts in social care multiply the blocked bed crisis. NHS funding has never had a six-year squeeze like this, falling far behind similar countries in beds, staff and cash per head. Yesterday the axing of 538 staff from the Department of Health looked like panic, while public health is cut by cash-starved councils – storing up worse problems for the future.

Hospitals usually afraid to blow whistles now talk to anyone who’ll listen. I’ve never known normally cautious managers and senior staff show such unguarded urgency to reveal all. But one exception is the Royal Berkshire, where Theresa May’s Maidenhead constituents go in an emergency. They maintain omerta, allow no visit, put up no spokesperson, apparently paralysed with fright: the care quality commission brands it “needs improvement”, not “safe” or “responsive” nor “well-led”. Does May ever visit?

She should listen to Kings College hospital’s chair, Bob Kerslake – another NHS leader who has become extraordinarily outspoken. Here is a man of exceptional experience and wisdom, a former chief executive of Sheffield city council, elevated to permanent secretary of the communities and local government department and on up to head of the home civil service. He’s a maths graduate and chartered account, an exceptionally numerate civil servant. The government’s numbers are “kidology”, he says. As the Kings Fund showed, the NHS got £4.5bn, not £10bn, extra to 2020: and this was its frontloaded year, with far less to come after April, and zero – yes, zero increase – for 2018, the NHS’s 70th anniversary year.

Jeremy Hunt: up to 30% of people using A&E departments do not need emergency care

Here’s more kidology, Kerslake says. “Some 98% of trusts signed up to control totals that most know are impossible.” His own trust was told to make a surplus but has a £2m deficit, so they will be punished by losing their sustainability and transformation money, which will leave them with a £30m deficit instead. I asked him to repeat it twice, it was so incredible. Yet next year they are told to make a surplus, yes, a surplus of £26m – fantasy accounting that no one believes is remotely achievable. “And we have used every wheeze, holding off paying bills … using our capital budget so we have nothing for essentials, like replacing worn-out dialysis machines.”

But when he talks to the Treasury, “They give me the line. I don’t know if they believe it.” The line says what May says: “It’s only a winter blip, we gave the NHS more than they asked for, and GP opening hours are to blame.” Chancellor Philip Hammond is immovable: he says that to give more to the NHS’s “bottomless pit” would create a moral hazard. Kerslake says NHS England’s Simon Stevens forthrightness at the Commons public accounts committee last week has “opened the floodgates, letting others speaking out”.

Is May listening? Talk to the hand. No 10 hopes compassion fatigue will stop the flow of drearily identical stories from A&Es as the news moves on. Brexit has the merit of driving the NHS off front pages. Politically, why worry when there’s no opposition? Polls show that even the NHS is regarded as safer in the hands of May than Jeremy Corbyn. She has plenty of her own ignorant and partisan commentariat opining that “money isn’t the problem, it needs reform” – calling for top-ups and private insurance.

But May can’t defy the NHS laws of gravity that force every prime minister to U-turn on underfunding. Margaret Thatcher, John Major and Tony Blair all buckled. This crisis looks set to outdo all those, says Chris Ham, NHS historian and head of the King’s Fund. History shows – and this was proved in the Blair years – that when the NHS reaches roughly EU funding levels, its results soar. When funding falls too far, trolleys pile up in corridors.

What’s the tipping point? Disasters forced on to the Mail’s front page, the only media she cares about (yesterday it ran instead with a Nigerian health tourist mother giving birth to twins at taxpayers’ expense). What else would it take? Nightly news from the A&E war zone, more care homes going bust – and deaths. Until her final hubristic year, Thatcher knew when to swerve – but May’s obstinacy might do for her.

One thing would force her hand – a joint resignation by Simon Stevens and Jim Mackey of NHS Improvement, announcing they can no longer be held legally responsible for the safety of patients. They just might, as a final act of service to rescue the NHS.

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NHS crisis: the one act of self-sacrifice that could rescue our health service | Polly Toynbee

Sending fat smokers to the back of the queue is a betrayal of NHS values| Polly Toynbee

The Vale of York has been granted permission this week by NHS England to put fat people and smokers to the back of the queue for operations. Starting in January, their treatments will be delayed a year; the obese must lose 10% of their body weight, and smokers give up for at least two months.

The Royal College of Surgeons says it is “very disappointed that NHS England and No 10 seem to be backing this arbitrary policy”.

It’s always good advice to live healthily, but this crosses a new red line. The clinical commissioning group (CCG), which buys services for people in York and Selby, is the first to be given official permission, agreed by Downing Street, to discriminate against particular patients – something forbidden in the (non-justiciable) NHS constitution. But the CCG is in trouble, in July judged “inadequate” and put into special measures and prescribed a “financial turnaround” for its debts.

Rationing will always be a part of the NHS social contract. Every system in the world rations: just look at the strict limits in US health insurance policies. There never was, or can ever be, an instant, ever-open door – however much politicians pretend, with their impossible seven-day pledges on no extra money, that there can be. But the UK system is judged one of the most efficient in the world, getting the biggest bang for its modest bucks, spending less than similar countries.

The key is its unique gatekeeping GPs who dispense the great bulk of treatment, while the National Institute for Health and Care Excellence (Nice), devised by the last Labour government, judges which drugs and treatments are good enough value for money for the NHS. The rule of thumb is to spend up to £30,000 for an extra year of good quality life.

Right from 1948, when the NHS was first set up, waiting lists were the traditional rationing mechanism. When governments tightened spending, waiting times grew, which was good for surgeons’ private practice.

For the first time in history, the last Labour government all but abolished waiting lists, something seasoned NHS experts never thought possible. With a spending increase of 7% a year, new targets saw waiting times drop from sometimes two years to just 18 weeks maximum, and two weeks for suspected cancers. Surgeons’ incomes plummeted, as did payments for private healthcare.

But in the present crisis, rationing is tightening everywhere. You get only one cataract fixed where CCGs think one eye is enough. The list of treatments being struck off is lengthening, and the postcode lottery of what your CCG pays for produces injustices.

I reported recently on a podiatry clinic treating severe diabetics that can give some patients a cast that cures ulcers in eight weeks. Those in other CCG areas get a cheaper bandage, which means healing takes 52 weeks. In the past, old people were often denied many life-enhancing treatments. All such rationing may be unfair, but at least it was never personal.

The abiding principle was that the NHS treated people in order of medical need, according to resources available. Minor complaints went to the back of the queue. Urgent cases were treated first, followed by those people likely to be rendered wheelchair-bound and needing social care if they did not get surgery on hips or knees – as will many of these obese patients.

The system was blind to everything but medical priority, a founding NHS principle that treated viscount and vagrant according to urgency, priest and sinner in next-door beds regardless of rank or virtue.

But once a patient’s personal failings can be taken into account, where does that lead? More people on low incomes are obese and smoke, and therefore already suffer worse health. This is for a host of psychosocial reasons, including the sheer stress and hardship of being at the bottom. (See Michael Marmot’s work, or the irrefutable evidence from Richard Wilkinson and Kate Pickett, authors of The Spirit Level, on the link between low status and poor physical and mental health.)

The poor often get worse NHS treatment, having less sharp elbows, and living in areas where the best doctors are harder to recruit. Undoubtedly most will have tried to lose weight and quit smoking, but public health budgets for obesity and smoking programmes have been cut, and are set to shrink again. This blaming of the individual conveniently shuts out social context. Don’t they have free will, these people? Politically, they will be easy to cast to the back of the queue, shamed into silence for their fatness and addiction. They will make much less fuss than local campaigners against any closures to hospital units.

This opens up new horizons: how much easier rationing becomes when we can blame the patients. Hey presto, waiting lists can be pared right down, targets hit, leaving only the virtuous on the lists.

But who are they? Let’s weed out anyone in any way responsible for the burden they put on the NHS. Away with the boy racers smashing themselves up with their first motorbikes and cars. Out with the extreme sports addicts – the climbers, potholers, boxers, base jumpers paragliders, skiers and F1 drivers, who get their adrenaline kicks at the NHS’s expense. Forget all sports injures.

Away with my own age group, too: drinking too much wine of an evening, slowly corroding our livers: a host of cancers are caused by drink and diet. And what about people bitten by their own horrible, fierce dogs? Or idiots tripping over while texting on smartphones?

As Hamlet said, use every man after his desert (or perhaps desserts) and who shall ‘scape whipping? Until now, in the NHS, the service may have creaked under the strains of the worst funding crisis in its history, but the quality of mercy was not strained. That has been the NHS’s great moral strength, as with the Red Cross or Médecins Sans Frontières, or indeed the Hippocratic oath itself. In treating the sick, let there be no discrimination over their moral worth.

Sending fat smokers to the back of the queue is a betrayal of NHS values| Polly Toynbee

Jeremy Hunt can’t fix the NHS. No one now believes a word he says | Polly Toynbee

Expect trouble. On Tuesday, health secretary Jeremy Hunt and NHS England head Simon Stevens appear before the Commons health committee. Sarah Wollaston, GP and chair, has already said she wants no one quoting the mythical “£10bn extra” the government pretends the NHS has received, yet Hunt brazenly used it again on the Today programme.

Thankfully, Stevens is unlikely to indulge in the same delusional fantasies about the state of his service. He already warned the public accounts committee in September of this “incredibly financially challenging period”, and “incredible” is the word he should cleave to. As every trust is forced to produce a financial plan that balances on paper, most – in private – admit these are fairy-tales; Chris Hopson of NHS Providers makes plain these pigs won’t fly. Hunt relies on threats and micro-managing. Just yesterday he put another three debt-ridden trusts into “special measures” to warn others their heads will be on Whitehall spikes. But there’s safety in numbers: he can’t sack them all.

Theresa May has said there is no more money: the NHS must save £22bn by 2020, despite three quarters of trusts being up to their ears in debt and missing waiting targets by miles. If she could cut police costs by 20%, why can’t the NHS, she asks. Because crime has dropped like a stone over recent decades while NHS need heads skywards, with growing numbers of the old, and collapsing social care. She risks a brutal brush with NHS reality before long.

But that’s not all. By Friday all 44 areas have to produce a sustainability and transformation plan (STP), unleashing vehement local protest against any mergers or closures.

After Lansley’s catastrophic 2012 act blew the NHS into myriad competing fragments, this re-reorganisation was meant to repair the damage and glue the fractured parts together again – a good idea. Stevens devised STPs to bind each area into a single unit, combining GPs, mental health and hospital services in one budget as a coherent whole. That might mean amalgamating maternity or A&E departments, rationalising stroke or cardiac care. Good idea, in theory.

Junior doctors protest in London during April. Photograph: Joe Pepler/Rex/Shutterstock

But these plans collide with the £22bn “savings”, so how will local people trust the good intentions of these plans? NHS England has rightly taken fright: the Health Service Journal reveals there have been orders requiring each area to send every STP announcement to the headquarters communications team to make sure they “articulate tangible benefits for patients” in language that is “clear and compelling”. But it may take more than “compelling” language to assuage local fears.

Few of these plans have yet been agreed, allowing rumours and fears to fester – and when they do emerge, the government can expect no backing, not even from their own MPs and councillors. Expect every politician, irrespective of party, to dash to join the local “Save Our Hospital” demo. Any who pause to suggest some plans might be good for patients will be mown down in the stampede. Bandwagon campaigners will join every protest, regardless.

A cluster of hospital protesters went to Downing Street and the Commons last week, with petitions about closures from Barnstaple, Dewsbury, Chorley, Huddersfield, Grantham and St Helier. Each has their own circumstance, so it’s well-nigh impossible for local people to know which units should be “saved” and which rightly closed.

Among them were protesters about the Horton hospital in Banbury. At last week’s prime minister’s questions, the Tory MP for North Oxfordshire, Victoria Prentis, asked an impassioned question: “Does the prime minister share my sadness that the majority of Banbury’s babies cannot be delivered, as I was, at the Horton general hospital? Will she join with me to put pressure on the trust to reopen the unit?” The PM replied: “Every effort is being made …”

Horton swears they’ve moved heaven and earth to hire doctors but none would come: there’s a 24% vacancy rate

The Horton maternity unit closed abruptly this month after failing to hire middle-grade doctors, leaving a midwife-led unit. Part of the Oxford University Hospitals, its HR director swears they have moved heaven and earth to hire doctors but none would come: there’s a 24% vacancy rate in the district. The Horton obstetric unit lost its validation for training doctors as too few babies were being born there to qualify, so junior doctors won’t apply. They are still advertising, promising to reopen if they can recruit. Managers spell out the situation in painstaking detail, answering every possible query. But all this is to no avail.

A vociferous local Keep the Horton General campaign gathered 5,000 people to hold hands round the hospital, amid longstanding suspicions that it might be axed despite a plan to rebuild it. Every party supports the protest, with their Tory MP as militant as the rest. She says she doesn’t trust the management: “They make decisions about us without us.” She and the campaigners mistrust whatever they are told.

The Banbury Guardian relishes the story, as the local press always does. “It’s lovely how the community has come together,” Prentis says. Banbury businesses are offering any obstetric doctor recruited free shirts, free beer, cheap accommodation and discounted fees at a local private school. A packed meeting roasted NHS managers about the journey time for mothers in labour to travel to the John Radcliffe in Oxford. Nothing creates such feelgood community cohesion as a local NHS threat.

Talking to both sides, I am inclined to believe the managers’ good faith. But with deeper cuts scheduled for the years to 2020, can anyone know for certain where they might fall? At the Witney byelection, the Horton and other Oxfordshire NHS closures feature prominently. How Tory MPs get away with it beats me: they voted for these NHS cuts.

Watch this pattern repeated around the country as STP plans unfold. “Clear and compelling” language may not be enough when the NHS professionals, even the doctors, struggle to be believed. In the fog of war, with suspicions rife, local people have no way of detecting the good plans from dangerous cuts. As Stevens warned MPs: “Let’s be clear, there are going to be significant challenges, there will be choices, there will be controversies.”

The tragedy is that STPs were a progressive way to reunite NHS community, hospital, GP and social care services. But with no capital for rebuilding and even less for day-to-day spending, they risk wreckage. The cuts dig deep. How long before Simon Stevens decides to walk away?

Jeremy Hunt can’t fix the NHS. No one now believes a word he says | Polly Toynbee

We can afford the NHS. The question is whether we are willing to pay for it | Polly Toynbee

What can the NHS afford? Every week one pressure group after another protests at rationed treatments, as the NHS suffers its greatest funding shortfall since it was founded.

Today, it’s Breast Cancer Now – and its case is exceptional. Usually rows over cancer drugs involve extraordinarily expensive new treatments, often not properly proven, offering a few months’ extension at the end of life. But here is a cheap drug – bisphosphonates to be taken for three years at a cost of just 43p a day – that would prevent one in 10 deaths if given to all eligible breast cancer patients. A study in the Lancet shows it cuts the risk of cancer returning by 28% and the risk of death within 10 years by 18% – a significant effect. But it has been caught in a money row that is a typical symptom of the fragmented, competing service created by the 2012 NHS Act, where everyone offloads costs on to everyone else: should it be paid for locally (yes, says NHS England), or funded nationally (yes, say local clinical commissioning groups – CCGs – and providers). The National Institute for Health and Care Excellence (Nice) – excellent but often too slow due to lack of resources – will not adjudicate until 2018.

And what of IVF? It’s constantly picked on as if it were a mere lifestyle choice, like cosmetic surgery. But Nice decrees that every woman who needs it should get three free cycles of infertility treatment on the NHS. A survey shows only one in four areas in Britain offers all three cycles: who gets a baby is a postcode lottery as arbitrary as delivery by stork. Instantly on the Today programme, IVF campaigners were grilled as to whether desire to have a baby should really be a priority compared with, say, cancer treatments?

That’s the way it always goes – one lot of NHS needs pitted against another, when the answer of course, is both. The pain of childlessness – a health malfunction – can be a lifelong agony, far worse than minor ailments that are treated unquestioningly. Nice recognises it and it is the best judge we have of value for money treatments when even a well-funded NHS always has to prioritise. Rationing is inbuilt in every health system – and it’s far more brutal under US private insurance plans. The only question is only how much are we willing to pay for what? The RNIB reported this week that people are waiting up to 15 months for cataract treatment, as cash-strapped CCGs, ordered to cut their debts, ration non-life-threatening treatments, even if delay may be life-crippling.

What can we afford? A strong report emerged on Wednesday from the Office for Budget Responsibility – the government’s getting and spending arbiter. Yes, it concludes, the NHS will still be affordable in 2030 and it could increase its share of GDP by almost a fifth. Just as growing numbers of politicians thrash around for new ways to pay – insurance or top-up fees – here come the official budgeteers saying the growth the NHS needs is affordable. Leading health economist Professor John Appleby, of the Nuffield Trust, says the OBR report shows the NHS can comfortably be paid for through general taxation.

We spend 7.4% of GDP on the NHS, but that’s due to fall to just 6.9% by 2020: can that be kept to in the current crisis? Though Theresa May has told top health officials that there will be no more money, she may be forced to relent. The OBR says spending could rise to 8.8% by 2030, an annual real-terms increase of 3.5% a year, still less than the NHS’s 4% average increase since 1948. Appleby says: “The real debate the UK needs to have is over how much more we want to spend on the NHS, not whether we need to change the way the health service is funded.” The OBR figure for 2030 simply puts us in line with most equivalent countries – such as France, Japan, Germany and the Netherlands.

The House of Lords long-term sustainability of the NHS committee will report in March. This is a never-ending story, as the cost of the NHS has caused untold anguish to one government after another. Only five years after its foundation, the Tory government set up a commission to look into whether its long-term funding would meet future demand, though it only cost 3% of GDP then.

The NHS always had enemies – and its affordability is a 1950s question very like grammar schools. However often the evidence shows that the cheapest and most efficient way to pay for health is collectively through general taxation, there are some who imagine private insurance, or some kind of complex semi-private system, or top-up fees would magically see us all pay less for more. Year after year the US Commonwealth Fund points to the UK system as being the best bang for the buck – but mere evidence seems to count for less and less.

The one big question is how much tax we will pay for what standard of treatment. The NHS tops public concerns right now, and so it should. What politicians should really be asking themselves is how best to put this honest question to voters – what will you pay?

We can afford the NHS. The question is whether we are willing to pay for it | Polly Toynbee

The NHS is in trouble. Jeremy Hunt can’t afford this junior doctors’ strike | Polly Toynbee

The knives are out for the junior doctors as they threaten five-day strikes, starting on 12 September. They can expect both barrels from the Tory press: “How dare the doctors barter lives for cash” asks the Mail. “It will be only a matter of time before the body-count begins.”

The BMA says it will call off the strikes if the government abandons imposing a tougher new contract in October, but the health secretary, Jeremy Hunt, was in a no-turning-back mood on the BBC’s Today programme this morning. The junior doctors’ leader, Ellen McCourt, says appeals to re-open talks have met a “deafening silence”.

Let’s remember where all this began – and it wasn’t with the junior doctors, ploughing on night and day through ever-worsening conditions in the NHS.

This is another of David Cameron’s disastrous legacies. Looking for bright ideas for his 2015 manifesto, he plucked “a seven-day NHS” out of thin air. He used a set of figures purporting to show high weekend death-rates that have since been resoundingly rubbished by health statisticians. Senior figures in the health department warned that squeezing yet more work out of an already stretched NHS was unrealistic and unwise. It was an election slogan, not a worked-out policy.

And why now, of all times? The NHS has never seen such a deep financial crisis, receiving an average 0.8% funding increase over the years since 2010, compared with an average 4% uplift since 1948. The department of health press office dutifully puts out near-mendacious factoids, such as “funding is at record levels, with the highest number of doctors employed in the history of the NHS.” But with the population rising, and especially soaring numbers of elderly people and people with diabetes, Britain still has many fewer doctors, nurses and beds per head of the population, and less money to spend than comparable countries.

What started as a stunt has turned into a confrontation from which the government now feels it cannot retreat

As the DoH knows well, the shortage of doctors and nurses leaves many rotas unfilled, putting extra pressure on staff, especially in A&E. The risk is doctors will flee abroad and to Scotland, while the Brexit vote could mean EU doctors and nurses decide to go home. Is this the time to provoke the precious doctors we have?

Let’s remember who these “juniors” are. They are not rebellious reckless youth, but 50,000 of the cleverest and most hardworking adults of their generation; the cream of their school science classes, serious-minded grown-ups in their 20s and 30s. Doctors are not known for political radicalism, either, so the health department’s statement that they are “playing politics” is well off the mark. They are angry, very angry, that the most dedicated workhorses of the NHS have been picked on at random to have their weekend pay and working conditions worsened. Why? It isn’t even going to save money for the NHS.

What started as an electioneering stunt has turned into a full-on confrontation from which the government now feels it cannot retreat. Theresa May had a long talk with Hunt before reappointing him, arguing for the need to see off these strikers as a matter of her authority. That was a bad mistake. What she needed was a fresh, open mind, someone whose pride was not at stake.

The BMA did all it could: the previous junior doctors’ leader, Johann Malawana, reluctantly agreed a deal which he told his members was the best he thought he could get, and he tried hard to sell it to them. But 58% rejected it in a ballot, he had to stand down and McCourt has taken over. When I interviewed her in April, she was just about to begin her 13-hour Saturday shift in a North Yorkshire hospital, to be followed by 13 hours on Sunday. The new contract will make her work every other weekend and cut her pay. She said “I love what I do in emergency, the variety of cases, working with the sickest patients when you can help them most.” So how did the government manage to provoke such people to this?

On this issue, as with Brexit, May has stamped her political identity. Retreat is unlikely. In a lifetime of covering hundreds of strikes, in my view they rarely begin for good reasons or end well, especially for strikers, however justified. The public has staunchly backed the junior doctors so far, and maybe still will support this most trusted of professions, with the NHS near the top of public concerns. But since many people die every day in hospital, you can bet the rightwing press will find a good case or two where they can claim, however spuriously, that it was the strikers’ fault. That’s the risk the doctors take.

But the risk May and Hunt take is greater. The NHS is paralysed with debt, as hospitals put out bogus plans pretending they will balance their books. The public is rumbling that major re-organisations are planned locally without anyone telling them, under the 44 new STPs, local sustainability and transformation plans. Persuading people that often good plans for joining up health and social care and reconfiguring local services, are not just cuts – when they are happening at a time, in effect, of cuts – would be a Herculean task for a trusted health secretary, but how is Hunt to do that?

These noisy strikes will add to local objections to any changes on the ground. Forcing doctors into this new contract is virtually irrelevant to the current state of the NHS.

The public think they were promised £350m a week more for the NHS as a Brexit bonus, but instead will come to hear of unpopular amalgamations of some A&Es and maternity units. Anyone sensible looking at the current state of the NHS and the problems it faces, would clear the decks of all extraneous trouble – and settling with the doctors would come first.

The NHS is in trouble. Jeremy Hunt can’t afford this junior doctors’ strike | Polly Toynbee

Feet first, our NHS is limping towards privatisation | Polly Toynbee

A fish rots from the head, but the NHS may be rotting from the feet. Podiatry is not up there in the headlines, yet what’s going on in that unglamorous zone is an alarming microcosm of the downward path of the health service. This is a story of the NHS in England in retreat and the private sector filling the vacuum.

Related: How much is the government really privatising the NHS?

You know the big picture from the ever-worsening monthly figures: deteriorating A&E, ambulance and operation waiting times, and a steep rise in bed-blocking. As debts pass £2.5bn, the NHS feels the tightening financial tourniquet.

Now look at it through the prism of just one small corner, as seen from the feet up. Every week 135 people have amputations because diabetes has caused their feet to rot: their circulation goes and then the sensation in their feet, so they don’t notice damage done by rubbing shoes, stubbed toes or stepping on nails. Minor injuries turn into ulcers that if left untreated turn gangrenous, and so the toes, then the foot, then the leg are lost – horrific life-changing damage. Numbers are rising fast, with nearly three million diabetics. The scandal is that 80% of these amputations are preventable – if there were the podiatrists to treat the first signs of foot ulcers. But the numbers employed and in training are falling.

In his surgery, the head of podiatry for Solent NHS Trust, Graham Bowen, is unwrapping the foot of a lifelong diabetic to reveal a large missing chunk of heel, a great red hole nearly through to the bone. This man has already had some toes amputated. He has been having treatment with maggots, bandaged into his wound to eat the dead skin and help healing – and he is slowly improving. Everyone Bowen sees now is at similarly high risk. Small ulcers, incipient ulcers, the ones that need to be caught early (and cheaply) no longer get NHS treatment. “On the NHS we’re essentially firefighting the worst cases now,” says Bowen. “We are going through our lists and discharging all the rest of our patients.”

‘On a 15-minute visit carers can’t check feet.’ Photograph: Andrew Bret Wallis/Getty Images

But not even all these acute patients get the same optimal treatments, due to the vagaries of the 2012 NHS Act. Solent, a community trust that covers mental health and a host of other services, is used by five different clinical commissioning groups (CCGs), including Southampton, Portsmouth and West Hampshire. Each has its own criteria for what it will pay for, and each is toughening those criteria. Depending on their address, some patients get the very best, others only get what their cash-strapped CCG pays for.

You need to know about diabetic feet to understand the difference in treatments: the conventional and cheapest treatment is a dressing and a removable plastic boot, and telling patients to keep their foot up for months. But patients who can’t feel their feet tend to take off the boot and hobble to make a quick cup of tea. “Ten minutes of putting pressure on the ulcer undoes 23 hours of resting it,” Bowen says, so it takes 52 weeks on average to heal ulcers that way. For £500 extra, a new instant fibreglass cast saves any pressure on ulcers and cures them within eight weeks.

Although the National Institute for Health and Care Excellence says this total-contact cast is the gold standard, most of Bowen’s CCGs won’t pay for it. I watched him putting one on a patient in under half an hour: after nine weekly replacements, that ulcer would be completely healed. For every 10 of the new casts, one amputation is prevented – and each amputation costs the NHS £65,000. Such is the madness of NHS fragmentation, divided between multiple commissioners and providers, all in serious financial trouble, that no one spends a bit more now for others to save later, even when the payback is so quick.

This clinic lost four podiatry posts to save money: though diabetic numbers soar, its budget has been static for five years. “Doing more for less,” he says with the same weary sigh you hear echoing through the NHS. As Bowen goes through the clinic’s books removing all but the most acute cases, he turns away diabetics whose problems should be caught early. He turns away others he used to treat: the old and frail who have become immobile due to foot problems; the partially sighted or people with dementia who have poor home care. On a 15-minute visit carers can’t check feet and find out if they are the reason someone doesn’t get out of bed, toes buckled in, leaving them needlessly incapacitated and heading for residential care sooner than necessary.

What happens to those he takes off his books? “They have to go private, if they can afford it. If not, then nothing.” He used to send them to Age UK, but lack of funds shut that service. Only 5% of podiatry is now done by the NHS so Bowen has set up TipToe, a private practice attached to his NHS clinic. It’s not what he wants, but it keeps prices low and all proceeds go to the NHS.

Next year podiatry trainees, like nurses, will no longer get state bursaries, so fewer will apply

Alarm bells should ring here: how silently the NHS slides into the private sector. Labour leadership contender Owen Smith has flagged up his team’s research showing private practice has doubled since 2010. Now that many CCGs only pay for one cataract, how many go private for the second eye? As the Guardian’s health policy editor, Denis Campbell, has asked, how many more vital treatments will go this way?

Podiatry is the ground floor of the NHS hierarchy. The profession reckons the NHS in England needs 12,000 practitioners but only has about 3,000 – and that’s falling, despite so many high-risk diabetics needing weekly appointments. Next year podiatry trainees, like nurses, will no longer receive state bursaries, so fewer will apply. They tend to be older, with families, unable to take on a £45,000 debt for a job paying around £35,000 per year. Already student places have been cut by nearly a quarter in five years. Most of the 7,000 amputations a year are preventable. A shocking statistic: half of those who undergo amputations will die within two years.

Only in the details of what’s happening on the frontline can we understand the daily reality of Britain’s shrinking state. Step back and ask how it can be that a country still growing richer can afford less quality care than when it was poorer? Is that the country’s choice? As the NHS slides into the private sector, here is yet another public service in retreat.

Feet first, our NHS is limping towards privatisation | Polly Toynbee

Jeremy Hunt has saved his own skin but let the NHS sink | Polly Toynbee

How did Jeremy Hunt keep his job? On reshuffle day the BBC reported he was gone, but after an exceptionally long session inside No 10 he saved his skin, emerging with that grin and a tweet saying he was “thrilled”. Junior doctors were less than thrilled, since Hunt’s survival signals no turning back on the dispute he has caused. Full speed ahead to impose a contract, threatening yet more strife.

Related: Jeremy Hunt narrowly survived the cabinet reshuffle – so what now? | Denis Campbell

But here’s the great question: did Hunt tell Theresa May the truth about the NHS? That was the time to warn the new prime minister of just how critical the financial crunch is, building into imminent crisis. He needed to report to her what all the leading health economists say, what Whitehall’s most senior civil servants say and what NHS managers are warning: nine out 10 trusts have deficits from which they can’t escape, with missed cancer waiting times up 56% and no chance of restoring the four-hour A&E waiting time limit. The Department of Health to all intents and purposes busted its budget last year, an extraordinary event only redeemed through one-off wheezes that can’t be repeated.

Simon Stevens, head of NHS England, warns that capital funds needed for “overcrowded and clapped-out buildings in need of a makeover if not a bulldozer” are being diverted to fire-fight day-to-day treatment. His £1.8bn transformation and sustainability money – supposed to be invested in joining up NHS and social care and creating larger conglomerations of care – is being burned up on basic services. That £10bn promised at the general election? Nigel Edwards of the Nuffield Trust says much was Treasury sleight of hand, stolen from other parts of the NHS, and less than half was new money.

The NHS is on life support, but we can still save it

Did Hunt tell her? He has never confronted NHS underfunding, preferring to apply his own screws by naming and shaming inadequate care. By talking up the scandal in Mid Staffs he encouraged the Care Quality Commission to set higher nursing and doctor numbers per ward, but that added to the financial pressure he never mentions. He never took up the cudgels over public health and social care cuts in local councils needlessly filling up hospital beds with the frail.

The word is he instead beamed from ear to ear and told May the NHS was safe in his hands, he could fix it, knock sense into the moaners and shroud wavers, just leave it to him. If he failed to warn her that the Treasury must find big sums very soon, she may not thank him for pretending there are magic solutions.

Nearing its 70th birthday, the NHS has the lowest funding increase ever, with worse to come in the next two years. And Brexit voters will be expecting that fantastical £350m a week NHS windfall.

To prove to the Treasury that NHS heads are “getting a grip”, all trusts have been sent a threatening “reset” letter where fines will be imposed on those in debt – a curious perversity. Of the many in deficit, a handful were chosen for “special measures” to frighten the rest. The letter warns that trusts will also lose 30% of promised funds if they fail A&E, cancer and operation waiting times, with a cap on hiring staff or temps. Cut debts and improve quality – or else.

Related: NHS bosses launch ‘reset’ plan to tackle £2.45bn deficit

Or else what? All the trusts I’ve spoken to regard this threat as showboating for the Treasury, a bit of play-acting, because nobody – including the NHS England and NHS Improvement heads – can think the deficits will be wrung out, or the old waiting targets resumed. Savings are being made by sharing HR and back offices, buying equipment in bulk and shutting down Andrew Lansley’s wasteful plethora of CCGs, commissioners still wasting money on competitive tendering.

But the big cost is people – and more staff are urgently needed. Failing to train enough, still scouring the globe for nurses and doctors, after Brexit the fear is that many here already may depart. Stevens publicly begs for “early reassurance to international NHS employees about their continued welcome in this country”, but May still refuses.

Take one finance director of a major teaching hospital, anonymous because everyone feels intimidated by this “reset” letter. “NHS funding is back to the year 2000 as a share of GDP, so I say to my consultants, think back to how it was then. What do we do now we didn’t do then?” They say back then, before Labour’s investment, “we had 18-month waits, many fewer nurses and doctors, lower pay, winter crises, no Nice and CQC minimum standards”.

Consider what is expected now on the same funding share, such as state-of-the-art drugs costing up to £100,000 a year per patient. There used to be leeway for cutting corners, but in all hospitals the chief executive must report to the board every month that the correct number of nurses and doctors have staffed every shift. This finance director challenges the government, “Come clean, be honest. You tell us what we should ration.”

The National Health Service explained

So how does the NHS burst at the seams? Chorley hospital in Lancashire abruptly shut its emergency department – downgrading it to urgent care for safety – because it could only fill five of its 14 middle-grade doctor posts. The only applicants were unregistered or struck-off doctors. This was not done to save money: ambulances cost as much to ferry serious cases to Preston hospital, which is already under pressure. What’s more, Chorley’s walk-in patients numbers are still rising fast due to 18 local GP vacancies.

Dewsbury hospital in Yorkshire has just done likewise, with many others in similar staffing straits. But those near to downgrading unsafe emergency units fear suffering Chorley’s fate, where managers are under savage personal attack. The public and local MPs accuse them of a closure plot, when government failure to fund the NHS or train enough clinicians should take the flak.

“Reset” will be nothing of the kind and NHS England knows it, despite rattling sabres at trusts and intimidating managers. Most trusts have signed up to “control totals” pledging deficit reductions they know for certain they can never achieve. There is safety in numbers: they know they are a high-calibre cadre doing an impossible job: they can’t all be put into “special measures”, with no army of ultra super-managers to replace them. They will go on trying to do the impossible. What they all say is the public must be presented with the resoundingly obvious truth: pay more or get less from the NHS, that is the choice.

Jeremy Hunt has saved his own skin but let the NHS sink | Polly Toynbee

Mentally unwell men and women need to have to be aided, not hounded | Polly Toynbee

‘A jobcentre manager … told me how the sick are taken care of and what harsh targets she is below to push them off rewards.’ Photograph: Oli Scarff/Getty Photos

Once upon a time, David Cameron said that basic wellbeing matters as much GDP. What is it all for if a nation grows richer but its individuals truly feel no far better? A genuine attempt at prioritising wellbeing would be revolutionary, simply because the happiest folks reside in a lot more equal societies, are significantly less ridden by anxiousness, appreciate very good employment, are nicely housed and far more trusting. But in Britain all these fundamentals indices of wellbeing are in retreat.

If aiming for happiness is past this government, minimising extreme pain could be inside of attain, if it began by prioritising scarce NHS sources entirely in accordance to struggling. If discomfort was measured in a Benthamite way – the relief of the best struggling for the greatest amount of sufferers – psychological sickness would trump most other conditions. One particular sufferer describes getting his broken leg slammed in a door as less excruciating than the agony triggered by his depression. However an ingrowing toenail gets treated inside a mandatory 18 weeks, although there is no waiting restrict at all for treating psychological sickness. Much more than half of individuals referred by GPs never ever get any treatment, and of individuals who do, some wait for over a 12 months in the deepest despair. It truly is even more surprising that so usually kids get no assist.

Professors Richard Layard, an economist, and David Clark, a clinical psychologist, ratchet up their campaign for far better psychological remedy with their new guide, Thrive. These champions of cognitive behavioural treatment have carried out much more to flip mental overall health into useful politics than any individual prior to, however progress is slow. Their ability has been to produce evidence that a program of CBT, costing £650, can permanently rescue half of those who consider the program from disabling psychological illnesses. For politicians, their proof exhibits that a hugely systemised treatment method with exclusively trained therapists saves lives and funds. Great guidelines say everybody with depression and anxiousness should referred for CBT – but that is not binding, so most are not. The mechanised approach invites criticism, but this strictly evidence-primarily based therapy has the very best likelihood of gaining political traction.

The coalition promised that mental wellness would get “parity of esteem” with bodily well being, but so far there is minor sign of it. Rather the government has just minimize the tariff paid for mental healthcare by a lot more than it lower the tariff for bodily remedies. Norman Lamb spoke at the launch of the Layard and Clark campaign in the Commons, protesting that psychological health “was first to be reduce and is not obtaining a fair share of focus”. Had he forgotten that he is himself a well being minister who could say no?

On some other planet, Nick Clegg produced an eye-catching announcement in December that all psychological individuals could pick the place they go for treatment – NHS or personal – but most wait for anything, anyplace, and several get nothing at all. A shortage of beds indicates in-individuals are now usually sent hundreds of miles from home, certainly not by choice. NHS England’s internet site claims “parity of esteem” but only guarantees that 15% will get CBT by 2015.

As it is, cancer and heart illness rule the roost, surgeons are king and psychiatry is low in the pecking buy. Politicians are not fully to blame they know that psychological and local community providers, the place 90% of patients are treated, must get priority, but NHS politics is governed by front-web page demands for every new drug, and for intensive care to prolong the miserable last six months of lifestyle. Oppositions protest at rising waiting lists or ambulance waiting occasions. Jeremy Hunt isn’t going to phone local community psychological companies to inquire who they’re neglecting, he calls A&ampE to bellow at them for overstepping a four-hour wait. Can psychological well being be made as politically sensitive?

Neglect of the mentally unwell is bad adequate, but now take into account how the Division for Perform and Pensions deliberately torments them. I just met a jobcentre manager. It had to be in secret, in a Midlands hotel, several train stops away from where she performs. She informed me how the sick are handled and what harsh targets she is below to push them off positive aspects. A large proportion on employment and assistance allowance have mental illnesses or studying issues. The department denies there are targets, but she showed me a printed sheet of what are referred to as “spinning plates”, red for missed, green for hit. They just missed their 50.five% target for “off flows”, receiving people off ESA. They have been told to “disrupt and upset” them – in other words, bullying. That is officially described, in Orwellian trend, as “giving further support”. As all ESA claimants method the target deadline of 65 weeks on benefits – advisers are advised to report them all to the fraud department for greatest strain. In this manager’s area sixteen% are “sanctioned” or reduce off positive aspects.

Of program it is not written down anywhere, but it truly is in the development programs of individual advisers or “work coaches”. Managers repeatedly query them on why far more people have not been sanctioned. Letters are sent to the vulnerable who never legally have to come in, but in such ambiguous wording that they search like an order to attend. Tricks are played: these ending their contributory entitlement to a year on ESA want to fill in a type for earnings-based ESA. But jobcentres are forbidden to stock individuals forms. These sick people’s benefits are out of the blue stopped without explanation: if they call, they’re informed to acquire a type from the jobcentre, which does not stock them both. If a person calls to query an appointment they are told they will be sanctioned if they don’t turn up, whatever. She mentioned: “The DWP’s hope is they won’t pursue the declare.”

Great advisers genuinely try out to assist the mentally sick left marooned on sickness benefit for many years. The manager spoke of a woman with acute agoraphobia who hadn’t left residence for twenty years: “With small measures, we had been acquiring her out, helping her see how her life could be far better – a lengthy procedure.” But here’s one more perversity: if an individual passes the 65-week deadline, they are abandoned. All additional support is a dead loss to “spinning plates” success costs. That girl was sent back to her existence of isolation: she undoubtedly wasn’t referred for CBT. For all this bullying, the work programme finds handful of jobs for people on ESA.

Failing to deal with the mentally unwell is undesirable adequate, but this is maltreatment. There has been a lot outrage about lack of kindness and care in hospitals. Neglect of psychological patients is every single bit as bad, but deliberate cruelty by the DWP defies any concern for the wellbeing for the most vulnerable, let alone “parity of esteem”.

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Mentally unwell men and women need to have to be aided, not hounded | Polly Toynbee

Now troubled young children are an investment opportunity | Polly Toynbee

Excellent investments are hard to come by in these minimal-interest instances. But here is an eye-catching brochure from Gravity Global. It shows the outstanding revenue a canny investor can make from providers the state outsources to the personal sector.

Here’s the supply: a phenomenal 18% return guaranteed in 1 year, with your investment securely secured on a residence (although in reality absolutely nothing is ever that secure). What is the company? Caring for the most disabled, disturbed and needy kids in residential homes.

As soon as I utilized on-line for a brochure, eager Luke, the portfolio manager, referred to as to challenging-sell the investment. Caring for these kids is hugely lucrative, he explained, with each child well worth at least £2,500 and up to £5,500 a week for the multiply disabled, abused and broken. “The naughtier kids spend much more,” he explained, with a bit of a laugh – even though “naughty” may well not be in the official social care lexicon. There are, he explained, prolonged waiting lists of young children needing places. He rattled via the figures: their 4-bed properties will make £214,000 a yr revenue at 75% occupancy and a whacking excellent £624,000 profit at total-bed occupancy. The brochure breaks down all the expenses: employees at £232,one hundred, food at £12,600 and so on.

The young children in the brochure (posed by models) are the most superbly healthful, happy specimens you could discover. “Our philosophy,” says Gravity, encourages them “to flourish and attain their total possible” – just like their investors’ wallets. Perusing Gravity’s promised equestrian and outdoor pursuits centres, these sound like holiday camps. And so they ought to, because a spot for a “naughty” youngster charges the identical as 9 young children at Eton. Or you could place each one in the Savoy with a personalized tutor. I have no idea no matter whether these houses are Dotheboys Halls or providers of exceptional care. But, even so excellent, the huge sums skimmed off the best in revenue would be greater invested on added psychotherapy and education for young children whose outcomes are so dismal. A quarter of prisoners come from care.

There is, says the brochure, possibility right here since “Uk government restrictions on public spending have had an effect on presently overstretched assets of many local authorities”, but they have statutory obligations in direction of kids. “The results of government fiscal policy are now being felt by those authorities who have an beneath-supply of good properties.” As nearby authorities can’t increase capital to create new residences, nor even to fix their present houses, the possibility there is for the organization to create new ones and buy up current council properties to promote their companies back – at this large revenue.

In other words, because councils can not borrow to invest – even at borrowing rates far lower than any personal business can raise – they should outsource at far better expense. That’s the accounting insanity that pervades this era of austerity. It’s the same with housing: getting offered off 2 million council homes without using the cash to exchange them, the state rents back these offered-off properties from private purchase-to-allow landlords at 3 instances the value to the housing benefit bill. Treasury guidelines on borrowing often finish up costing the state more.

Children’s houses are just a especially graphic illustration of some of the far more dubious “cost savings” from the outsourcing that started in the 1980s. In quality, Ofsted information somewhat better ratings for local authority-run residences compared with personal (the non-revenue sector is extremely small), but the grim fact is that a third of all properties across all sectors are only rated “adequate”, with the Children’s Society and other people claiming Ofsted sets its requirements bar worryingly lower. Good results rates for looked-soon after youngsters have improved, says the Workplace for National Statistics, but present a massive gap between the 15.three% receiving the benchmark 5 excellent GCSEs in contrast with 58% of other young children – a gap that has grown since 2009.

Flip to LaingBuisson, the study analysts of personal well being and social solutions, for an insight into this market place. William Laing tells me the sector is establishing. His most latest report on the children’s social care sector provides loads of encouragement for traders. In the two many years between 2010 and 2012 outsourcing to personal children’s properties rose 8% to 67%, “encouraged by capital shortages” and this “momentum even now has some way to run”. His report warns that the personal sector has more trouble hiring extremely certified personnel for its residences than the council sector, which also fees much less while paying employees much better. LaingBuisson says the potential is brighter for investors in social care than in privatised NHS providers because the “political environment stays benign” with “public sector vested interests in the social care sector so weak and poorly represented” in contrast with the NHS, in which “political help against outsourcing can even now be readily mobilised in robust help of NHS vested interests”. Which is the significance of unions.

Nevertheless, traders are warned that “worries about the top quality of children’s companies run deeper than Ofsted ratings”, with the schooling select committee just lately complaining that a lot of kids are positioned hundreds of miles from their families, beyond reach of the social staff supposed to care for them. The danger, says LaingBuisson, is residences place in “low cost locations for economic factors that may incorporate an extra of predatory men and women with likely for sexual exploitation”. Children’s companies can be “a large chance activity for suppliers in which injury to track record could be extremely expensive”.

But it’s a rising marketplace, with much more than 68,000 in care last yr, up 2%, partly due to instances such as Baby P. Of these, 5,000 are in residential houses, usually after multiple foster-care breakdowns. Children’s social companies directors say they have numerous much more substantial-price multiply disabled teens with extreme studying troubles, who employed not to survive premature births. The Independent Children’s Properties Association claims councils send it the hard situations, while maintaining less complicated kids in their authority homes. Income, it claims, common just 3% – however LaingBuisson puts profitability at 14.4%. G4S and Serco are between these in the children’s residence enterprise.

Generating funds out of tragic young children is the excessive end of the outsourcing culture. As the High Shell out Centre has analysed, the history of contracting and privatisation has primarily been large expense and substantial revenue for worse service. This 30-12 months policy has, without proof, been driven by contempt for the notion of a public ethos, and conviction that private is often best.

• Comments on this report will be launched later this morning (Uk time)

Now troubled young children are an investment opportunity | Polly Toynbee

The NHS is on the brink: can&nbspit survive until May 2015? | Polly Toynbee

The clock is ticking: ‘the mildest winter on record nonetheless noticed 3% much more emergency admissions. So far deft NHS management has contained an explosion’. Photograph: Christopher Thomond for the Guardian

Magical thinking and false accounting constantly hit the crash barriers at some point. That is what happened this week as the Guardian exposed belated panic in excess of the Greater Care Fund (BCF) prepare to slice £2bn out of hospitals to give to nearby government to integrate with social care. Every little thing about this scheme illustrates this government’s phenomenal ineptitude in the essentials of policy delivery.

There was absolutely nothing wrong with the objective: every person agrees that pooling NHS and social care funds is the only way to cope with the soaring numbers of older and disabled men and women. But the policy leapt from very good notion to fantasy and fraud. It was Tony Travers from the London School of Economics who spotted it: George Osborne’s spending evaluation for 2015-sixteen creatively accounted a total including up to more than a hundred%. In devising the BCF, Osborne shifted funds out of overall health into social care, but he double-counted so that it nonetheless appears in the two columns. This meant he could fool the two sides: nearby government cut by 27% and in crisis over social care eyed the “ring-fenced” plenitude of the NHS, even though the NHS was advised it was new income – prior to it found that £2bn was getting stripped from its funding. The fantasy was that merging two bankrupt outfits – the NHS and social care – miraculously creates 1 solvent services.

Following April, the NHS loses £2bn to nearby government Wellness and Wellbeing Boards who, collectively with nearby clinical commissioning groups (CCGs), should style local community providers to lessen hospital admissions. Practically no hospitals have been consulted, regardless of losing £15m every. Developing up the neighborhood indicates beefing up GP providers, extra nurse practitioners, some Darzi polyclinics, reopening misplaced Walk-in centres and day centres, much more property adaptations, and community and mental nurses locating the regular hospital end users prior to they reach a crisis. Professor Azeem Majeed, creating in the BMJ, calls for the NHS to directly employ GPs, which may iron out enormous variations in hospital referrals and prescribing routines. But none of this is low-cost.

To make the sums operate, NHS England tiny print demands 15% fewer emergency hospital admissions in the very first yr: every single CCG has to stop a fixed number, which no one particular thinks is remotely achievable. Beds are beneath this kind of stress that they will go on currently being filled with no saving. No hospitals strategy to cut beds or workers post the Mid Staffs scandal they are rightly employing more. Nuffield Believe in research shows that 15,000 much more beds are necessary more than the following 7 many years just to hold tempo with ageing individuals and a lot more premature babies surviving with disabilities. With virtually half of hospitals already in deficit, the BCF calls for that from next year each and every should minimize yet another 7%, although none succeeded in cutting the four% ordered for each and every of the past four years, since it really is extremely hard.

Does switching to community care ever save money? The very best illustration is the excellent closure of psychological hospitals. It took 10 many years with double-funding to construct the local community services just before shutting the hospital doors the new system never grew to become less expensive. Well being economist Professor Alan Maynard factors to scores of evaluations of integrated care experiments, such as the health department’s personal, which he says identified no evidence of financial savings. On the contrary, “extra neighborhood companies reveal large unmet want, costing a lot more, with more hospital bed use.”

Nigel Edwards of the Nuffield Believe in says it is frequently more affordable to treat individuals in a ward rather than travelling to care for the frail at home. “Our evaluations show you can stop some admissions, but they are replaced by other folks as far more neighborhood require is unveiled. Hospitals have 80% fixed charges, so fewer admissions do not conserve much.” Everyone, except the magical thinkers, says the exact same: switching to the local community is no get-out-of-jail card. The Cabinet Workplace panicked more than a report that stays below lock and key: however the BCF plan is delayed it will appear to proceed to cease hospitals easing up on the squeeze.

All NHS organisations are sending up distress flares. The King’s Fund calls subsequent year’s price range “totally unrealistic” the Nuffield Trust talks of “flawed logic” and “wishful thinking”. Hospitals undergoing more and more savage Care High quality Commission inspections (as the CQC covers its own back) refuse to take the blame for deficits. Waiting lists are swollen to nearly three million, waiting instances are lengthening, and A&ampE targets are starting up to be missed: the mildest winter on record nonetheless noticed 3% a lot more emergency admissions. So far deft NHS management has contained an explosion. Can it hold to up coming May?

ONS figures last week showed that amid G7 countries only Italy spends less per head on wellness than the United kingdom. Tony Blair pledged to raise us to the EU average, which Labour did briefly with an eight% yearly improve. Now the NHS has had 4 years of the lowest funding rises ever.

The British Social Attitudes survey finds fulfillment is still quite higher at 60%, but not recovered from the fantastic drop brought about by Andrew Lansley’s upheaval. The Commonwealth Fund regularly scores the United kingdom substantial on fulfillment and paying efficiency. Unsurprisingly, with this kind of minimal investing we still score reduced on numerous avoidable deaths – often excellent ammunition for NHS opponents. Wiltshire GPs calling a BMA vote on charging for appointments will be resoundingly trounced by the excellent majority, but they are a vanguard for rightwingers permanently claiming that NHS deficiencies can only be cured by privatisations.

The NHS and its thinktanks say that every celebration going into the up coming election pretending that the services will stick to current paying ideas is “wildly optimistic” – or, frankly, lying. A cut of seven% next year and another 5% or a lot more every single of the following three many years is never ever going to happen – so who will get the credit for fiscal honesty by saying so? Simon Stephens, new NHS England supremo, politely told parliament he hoped a growing economic climate would increase NHS revenues let us hope that behind the scenes his message is much more urgent.

Labour rushed to reject any suggestion of a hypothecated 2p on national insurance coverage or income tax, regardless of the Wellness Service Journal reporting that two-thirds of voters are inclined to shell out more for the NHS. Labour can’t keep warning of the crisis without having saying how it will cope. Andy Burnham’s plans for integrated health and social care are evolutionary and neighborhood – but Labour can’t pretend they will conserve ample to rescue the NHS. Which is the exact same homeopathic accounting as the BCF, on which Jeremy Hunt has waxed uncharacteristically silent. Amount 10 has advised him to pipe down and hold the NHS out of the information, just praying it doesn’t explode just before next Might.

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The NHS is on the brink: can&nbspit survive until May 2015? | Polly Toynbee