BORIS JOHNSON’S five-minute broadcast on leaving hospital, in which he enthused about the NHS as the “beating heart of the nation” and named two overseas nurses who he believed had saved his life, might have been a pivotal moment.

It might yet prove to be the moment where the right-wing Cabinet of a Tory government was persuaded to pull back from the process of running down the NHS.

Indeed the entire coronavirus pandemic and resultant crisis facing every major country in the world has been a wake-up call for ministers, who have been forced to put their previous financial model and restructuring of the NHS on the back burner — or conceivably discard previous ambitions altogether.

The operation of the widely despised 2012 Health and Social Care Act has been effectively suspended: NHS England has taken over control at local level from clinical commissioning groups, the complex system of “payment by results” and contracting that was part of Andrew Lansley’s plan for a competitive market in healthcare has also been halted during the crisis, and replaced by an old-style system of block contracts.

Financial savings targets have been paused as well, to allow management to focus on their primary role of delivering healthcare. 

One top NHS hospital boss told the Health Service Journal: “It’s completely unrealistic to think about how we can make workforce reductions and workforce savings [given the expected coronavirus demand] … We have to be 100 per cent focused on clinical need.”

NHS England has paused implementation of its long-term plan, and urged local health bosses to do the same: already at the beginning of the year new NHS England guidance had called for an end to any further bed closures, and for bed numbers to be maintained at the level of winter 2019-20 — meaning that various plans for cutbacks and “centralisation” of services will have to be rethought.

Some £13.4 billion of loans run up in recent years by trusts struggling to contain their deficits have now been written off.  

A completely new regime is now operating in the NHS, while its place in public affections has been reinforced.

So the question that arises now is how much of this can be reversed, to restore pre-Covid-19 “business as usual” — with all the pressures on NHS management and staff?

The 2012 Act has proved itself to be an obstacle to proper planning and co-ordination of services: so now it has been suspended, who can make a sensible case for bringing it back into operation, rather than scrapping the already widely ignored and unpopular legislation?

And how can ministers who have so repeatedly, and on so many different platforms, professed their affection and admiration of the NHS during the epidemic follow the ending of the lockdown with a new financial crackdown that would require draconian cuts in key services?

There are other dilemmas too.

The NHS has block-booked 8,000 beds in private hospitals (the vast majority of Britain’s small-scale private hospital network) — to allow NHS trusts to continue with some of their more pressing elective surgery while switching their own capacity towards Covid-19 patients and increased intensive-care units.

Unlike some other countries, the private hospitals have not been requisitioned, but commissioned at an estimated £300 per bed per day: this gives a lifeline to a small private sector that is heavily dependent on income from elective care for NHS-funded patients — treatment which is suspended for at least three months and probably longer.

Not all the private hospitals are large enough or near enough to NHS hospitals to be of value, but should those that are be nationalised and integrated into the public system that delivers care to all?

The wider role of the private sector must also come under the spotlight in any reassessment.

The highly publicised 3,600-bed Nightingale Hospital created in London’s Excel Centre opened in record time — but with cleaning, and other support services contracted out to private companies including ISS, the company that triggered strike action from angry GMB members at Lewisham who had not been paid their proper wages as the epidemic set in.

So while the rhetoric of NHS England in recent years has focused on “integration,” and Tory ministers have insisted we must all pull together, the same NHS England has decided that the support staff at the Nightingale should not be part of the NHS team, but part of the profit-seeking private sector.

Across the country, cleaners, porters and other support staff face the hazards of working with Covid-19 patients, many with inadequate personal protective equipment. At least two porters have died. Yet many of these services are contracted out to cheapskate employers, offering terms and conditions inferior to in-house NHS staff.

Recent research, looking at NHS data for 130 hospital trusts from 2010 to 2014, found that an average of around 40 per cent of hospital trusts had contracted out their cleaning services, suggesting these contracts alone were worth £500 million per year. 

The Covid-19 crisis is reminding so many more people that “unskilled” and underpaid staff in all public services are doing vitally important work, so it is important to ensure that the end of the crisis marks the start of a fresh campaign to bring all of these outsourced services in-house.

Department of Health and Social Care figures show the amount spent by the NHS on private providers of clinical services rose each year from 2006, from just over £2 billion to almost £9bn by 2016, and the private sector share of NHS spending increased from 2.8 per cent to 7.7 per cent over the same period. However this flat-lined in 2016-17, and declined to £8.7bn (7.3 per cent) in 2017-18.

Other analysis by the Centre for Health in the Public Interest argues that the real level of spending on private providers of clinical services is much higher, with around 18 per cent of NHS spending going to private providers other than GPs and dentists. 

This means £13.5bn was spent on private providers in 2013-14, rising to £18.4bn in 2018-19, a 36 per cent increase.

Where does this money go? The British Medical Association in 2018 found that 44 per cent of NHS private spending was on community health services, 25 per cent on general and acute services and 11 per cent on mental health — although some sectors of mental health are extensively contracted out to private hospitals.

Analysis by Laing & Buisson in 2018 estimated 30 per cent of mental-health hospital capacity is now in the private sector. 

Other reports reveal 44 per cent of the £355m NHS spending on child and adolescent mental-health care goes to private providers. 

The private sector domination is most complete in the provision of “locked rehabilitation wards,” in which a massive 97 per cent of a £304m market in 2015 went to private companies.

NHS acute trusts, including prestigious teaching hospitals such as King’s College Hospital in London have been driven to outsource elective care to private hospitals. 

Institute for Fiscal Studies figures show that up to a third of NHS elective knee replacements and 20 per cent of hip replacements are carried out in private hospitals.

In Devon, University Hospitals Plymouth Trust has an 18-month partnership deal that moves 75 per cent of the trust’s elective orthopaedic work to Care UK’s neighbouring private hospital.

However it’s worth remembering that the overall scale of the private sector is still very small: according to the Independent Healthcare Providers Network, just 6 per cent of NHS elective admissions are now going to private hospitals. 

This leaves the NHS to deal with the other 94 per cent — as well as 100 per cent of the emergencies, complex and chronic care.

In the post-pandemic rethink, it’s important to shine the spotlight on the scale of spending on private providers, and make the case once again for these contracts to be terminated and brought back in-house, with staff reintegrated into the NHS team, on NHS pay grades, terms and conditions.

Will post-pandemic Boris Johnson and his right-wing Cabinet be open to this? You are urged not to hold your breath waiting — but to press opposition MPs and the unions to take up the issue. 

A properly integrated NHS must not be seen as only for pandemics — we need it all year round.

John Lister is editor of Health Campaigns Together and co-founder of The Lowdown, a free access fortnightly online news magazine lowdownnhs.info.