An institution both beloved and maligned, the fate of Britain's National Health Service (NHS) has become a key battleground in the general election on May 7.
A recent poll found that the NHS was the issue that matters to UK voters more than any other, more important even than the economy and immigration. Politicians from across the political spectrum have pledged to defend it. So it was a considerable blow to the parties of the ruling coalition that in a public letter this week, more than 140 senior doctors denounced them as having left health services in the worst state of the NHS's 67-year existence.
"Our verdict, as doctors working in and for the NHS, is that history will judge that this administration's record is characterized by broken promises, reductions in necessary funding, and destructive legislation, which leaves health services weaker, more fragmented, and less able to perform their vital role than at any time in the NHS's history," they wrote, describing the service as "England's most precious institution."
A 2014 study by the Commonwealth Fund rated the NHS the best health service across 11 developed nations.
Yet the Conservative-Liberal Democrat coalition has been accused of underfunding the NHS, and of expanding the influence of the profit motive within what has traditionally been seen as a public service.
Last month, the NHS agreed the largest privatization in its history, worth 780 million pounds ($1.1 billion). Eleven firms were contracted to perform diagnostic tests as well as a range of operations. The deal attracted criticism because three of the companies have been criticized for providing poor quality of care.
The doctors' letter this week alleged a catalog of failures and broken promises, including lengthening waiting lists, crises in Accident & Emergency and mental health, and the closure or downgrading of walk-in centers, ambulance stations, A&E units, and hospitals.
The Conservative Party accused Labour of orchestrating the letter, and hit back with criticisms of Labour's own record on health. Using a phrase once let slip by Labour leader Ed Miliband, they called the letter a "desperate attempt to weaponize the NHS."
Labour has promised to abolish the coalition's 2012 Health and Social Care Act, which abolished the general duty of the Secretary of State for Health to provide universal health care. Instead, care was to be accessed through membership of a General Practice (GP) doctors' surgery.
Since January, surgeries have been permitted to choose their patients, rather than patients automatically joining a local surgery. Allyson Pollock, one of the signatories to the letter and professor of Public Health Research and Policy at Queen Mary University of London, says in the long run this will lead to profit-seeking providers picking the healthiest, least problematic patients, and placing a greater burden on public services to deal with the remainder.
"You'll see reductions in life expectancy, people being turned down, people being turned away," she said at a recent seminar attended by VICE News.
The act also introduced Clinical Commissioning Groups, which are local, doctor-run bodies charged with contracting services for the NHS. The change paved the way for the greater involvement of private companies.
Dr. Jonathon Tomlinson, one of the signatories to the letter and a GP in the historically poor borough of Hackney, east London, described the CCG arrangement as a "massive hassle."
"To stop the threat of services being tendered out and being run by Virgin [the multinational conglomerate] and Boots [a UK pharmacy chain], local GPs have got together to form a federation. All the practices have chipped in some money to create this big organization so that we can then bid to run the stuff that we were already running anyway," Tomlinson told VICE News.
"Loads of GPs are spending their time sitting in meetings scratching their heads trying to figure out how to set up a federation to bid for services. And they're not seeing the patients when they doing that."
In other areas, for-profit companies may take on the role.
A study by Britain's largest trade union found that a quarter of CCG board members were linked to private healthcare companies. More than half of those were the directors of the companies.
Tomlinson said that the hardest impact on his patients in the last five years had come not from changes to the NHS itself, but through cuts to social security payments.
"Almost one appointment [in] every session that I work is trying to help someone who is extremely distressed because their benefits are being stopped and it has huge health implications," he explained.
"For example, you've got someone who has diabetes which is not terribly well-controlled, they're also depressed and have chronic back pain and osteoarthritis and when they failed their assessment and they get very stressed, and the depression worsens. They very often forget to take their medication and then they have complications from their illnesses, they're more likely to get infections, their diabetes gets out of control, they miss appointments, get stressed. And everything unravels. And of course they're desperate for someone to help, and they come either to me or my colleagues or go to A&E."
"That's probably the single biggest cause of increased work and increased complications in people's health, I would say."
A recent poll found that nine out of 10 GPs have a similar experience, with cuts to social welfare adding to overcrowding at surgeries and accident and emergency departments.
In a statement, a Conservative Party spokesperson said: "We have cut the number of managers and increased funding for the NHS so we can have 9,500 more doctors and 6,900 nurses treating patients. The NHS in England continues to perform better than other parts of the UK, with patients more likely to be seen within four hours in A&E than in Wales, Scotland, or Northern Ireland."
They said that under a Labour administration the NHS in Wales has suffered a real terms cut.
Signatories to the letter, however, including Tomlinson, argued that it was not a party political initiative.
The introduction of the market into the NHS, which has accelerated under the coalition, began under Labour, and the latest changes are "an evolution, not a revolution," according to Tomlinson. Labour's Private Finance Initiative contracts have been criticized across party-political lines for leaving hospitals heavily indebted. More have been signed under the coalition.
Successive major reform programs have dented budgets, and have reportedly left staff feeling demoralized and disorientated. The head of NHS England has said that an extra 8 billion pounds over and above inflation will be needed over the next five years to keep the NHS operating at its current level, in the context of an ageing population.
For Tomlinson, the problem runs deeper.
"Throwing 8 billion at the NHS is not going to solve the problem of why people keep going to the NHS, which is feeling stressed, austerity, loss of welfare," he said. "The NHS is kind of a temperature gauge of everything else that is going on. A happy country doesn't spend the time sitting in GP surgeries, they are doing other stuff."
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