An in-depth report by Daniel Smith on the Save Our Surgeries campaign in London’s East End – and its implications for the wider battle to reverse a decade of privatisation in the NHS.
Up to a thousand people joined protests in east London earlier this month against the threat of GP practice closures. The rallies and march held across Newham, Hackney and Tower Hamlets followed a four-hour demo of several hundred in June which snaked through the East End visiting 14 surgeries.
Health workers and activists from Save Our Surgeries (SOS) have called for a “Lewisham style” campaign, referring to the successful community mobilisation in south east London last year which halted plans to downgrade the local A&E.
More than 20 GP practices across the east London boroughs are under threat of closure as a result of recent funding cuts. Some 98 practices across England have been identified as being most at risk, while a survey by Pulse magazine found that 109 surgeries face “imminent closure”.
Many other practices are affected and will be forced to make cuts. Some have already begun doing so, making salaried doctors and nursing staff redundant and reducing services and opening hours. GP partners at some practices have stopped taking wages in order to maintain services.
The 11,000-patient Jubilee Street Practice in Tower Hamlets – an award winning practice, recognised as one of the best in the country – says it will close this autumn unless funding is found to make up for the losses. The knock-on effect on neighbouring practices and patients would be devastating. Diane Abbott MP put it starkly at a recent SOS rally: if surgeries close then people will die.
At the root of the threat lie changes to the national GP contract – GPs have been independent contractors since the formation of the NHS – imposed by health secretary Jeremy Hunt in 2012. This will cut a chunk of funding that many practices rely on to survive: the Minimum Practice Income Guarantee (MPIG).
The MPIG is a top-up introduced in 2004 for practices which, due to specific needs in their communities, cannot survive on funding allocated through the standard national formula. Practices that receive it include those in areas of high deprivation, in sparsely populated rural areas, and those serving student populations.
Jubilee Street Practice’s MPIG funding is set to be phased out over the seven years costing the practice over £900,000. This year’s total cuts at the practice clock in at just under £80,000. Funding is set to drop by around a quarter by 2020. Doctors at the surgery have already taken wage cuts to keep the practice running.
NHS England, a new quango running parts of the health service across England, says that MPIG funding is being redistributed rather than cut. The official mantra in London is that most practices will gain from redistribution, and that the overall net effect of recent changes is a funding increase of over £700,000 for more than 700 practices across the capital.
But that redistribution happens through a funding formula that disadvantages those practices that rely on MPIG. Inner city GPs say the redistribution will take money away from communities with greatest need and hand it to those with less need. GPs in Hackney estimate 10 practices across the borough face combined MPIG loses of £8m.
Meanwhile leaders of the BMA doctors’ union fear further changes to practices on local contracts. These are being rolled out over the next two years and pose an even greater threat of up to £260m cut from GP funding.
These recent changes follow years of NHS cuts that have culminated in a crisis which threatens the very existence of general practice, according to Maureen Baker, chair of the Royal College of GPs.
Some 90% of patient contact takes place in general practice, yet the share of NHS funding spent on it has fallen over the past decade. Overall funding for general practice in England is down £9bn in real terms since 2005. While NHS funding rose 18% between 2005 and 2013, spending on general practice fell 8%. The Royal College of GPs predicts a 17% real terms cut in GP funding by 2017 while consultations are set to rise by 69m.
There is a danger here that campaigners respond to the severe crisis in general practice by calling for a shift in resources from secondary to primary care. This is the approach advocated by politicians, NHS managers and some doctors’ leaders.
But behind that approach often lurks an attitude that sees general practice and community services as a cheaper alternative to hospitals – which can then be “reconfigured” or shut down.
GPs and campaigners around Save Our Surgeries appear to have rejected that argument. They have taken an explicitly political approach, calling for increased NHS funding and the repeal of 2012 Health and Social Care Act which handed funding decisions to the unaccountable officials at NHS England.
Those officials, for their part, appear paralysed. There have no money to help practices and no understanding of the effects of the policy they were lumbered with by ministers.
The wider context is the fallout from the 2012 act, alongside ongoing commercialisation and privatisation of the NHS in England. GP practices have always been run as small businesses contracted by the NHS, and have long been seen by privateers as a soft target. But the “corner shop” infrastructure and poor profit margins have hitherto made general practice unattractive to big health firms.
With health spending frozen, skyrocketing costs and the demands of a growing, ageing population mean the NHS faces a £30bn funding black hole by 2020. A five year “efficiency savings” programme has left the service crippled, with staffing costs bearing much of the pain. There is no chance of ministers increasing spending, at least under the current regime – so policy makers are running wild with plans to “reconfigure” services.
Some GPs and campaigners have suggested the attacks on general practice are a deliberate policy to destabilise “weak” practices and allow commercial firms to take over. That theory was given weight when Dr Paul Charlson, a Tory health insider, GP and private healthcare boss admitted to doctors’ magazine GP that his own firm was eyeing up practices under threat of closure.
NHS England’s general practice strategy document says it wants to change contracting mechanisms to make it more attractive for commercial firms to take over practices. NHS leaders are pushing practices to merge and federate into larger provider organisations, along the lines of US health maintenance organisations, which can then compete to provide services.
This is already beginning to happen in some areas, where NHS hospital foundation trusts (set up to be run as independent businesses) are moving to take control of general practice. Those who control GP surgeries can control patient flow, which in turn lets them control funding.
Simon Stevens is the new chief executive of NHS England. He is former boss of US healthcare giant United Health and has previously called for an equivalent of Michael Gove’s free schools policy in primary care, “opening up underserved parts of the country to any willing provider”.
The drive across the whole NHS is to create provider organisations that compete with each other to win contracts, to further expand the internal market, and to further opening up public healthcare to commercial interests.
The current model of general practice has its weaknesses, especially when judged against the ideal of an integrated, public health service. This makes it a soft target for underfunding and privatisation. But the roots GPs have in their communities, the loyalty patients feel towards them, and the independence GPs have to resist attacks are all advantages in the wider campaign to save the NHS.
The east London protests brought a serious cross section of the community onto the streets this month. All of east London was there, including parts of the local political and NHS establishment. This looks like a real community campaign.
There is also serious support from the Unite union, which is ramping up its NHS campaigning in the run up to the general election. GP members of the union want to put pressure on the BMA to ballot for industrial action as the “only thing that will save general practice”.
Labour has given its support to the campaign. Andy Burnham told GPs at Jubilee Street the party would not allow the practice to be closed. Burnham appears to be winning an argument in the party leadership to make the NHS a central focus of next year’s election campaign, although he has so far declined to commit to making necessary spending increases.
There is anger and militancy around the east London campaign: hundreds cheered when Tower Hamlets councillor Oliur Rahman called on patients to tie themselves to surgeries to stop them being closed. And there is momentum too: the campaign is spreading. Earlier this month a threatened practice serving the University of Essex organised a joint protest with the students’ union.
As Diane Abbott suggested, there is potential here for a campaign that goes beyond defending threatened practices or individual hospitals, as vital as that is. The prize is a galvanised national campaign that can halt the destruction of the NHS and reverse all the recent defeats at the hands of the privateers.
• Daniel Smith is a socialist and journalist living in east London. Pictures by rs21.