This week, the Express published an article headlined 'taxpayers billed £100 million for NHS translators – could pay for 3,000 nurses'. The story completely missed the point of what the health service does.

The standfirst went on to explain that taxpayers "pick up the bill" for translation and interpretation" to ensure that the NHS can be "accessed in languages other than English”.

Given health and healthcare access inequalities, surely spending money to ensure people get the right care they need is a good thing – not to mention a legal requirement.

The Express article published on 2 April about NHS spending on translators

The Express packaged the story to suggest that it had uncovered a scandal. It included data revealed through Freedom of Information Requests (FOI) to 251 NHS trusts and 42 integrated care boards, which “routinely convert standard hospital and health literature into languages including Romanian, Arabic, Urdu, Bengali and Punjabi”.

The article included comments from a Reform Party spokesman, claiming that translation and interpretation services "were simply not necessary" and that artificial intelligence apps, such as Google Translate, could do the job – or that patients could use family members to translate for them.

The Express article followed the Mail’s report last week on National Trust cafés selling “woke scones” (made with margarine and not butter). It was another example of 'stories’ aimed at stirring up problems, rather than solving them.

The Mail article published on 31 March on 'woke scones'

Helping those in need be heard appears to be a bizarre issue to weaponise in manufactured 'culture wars’.

For starters, the total NHS spend in England for the last financial year was more than £180 billion, with a further £20 billion in local government spending on social care. So £100 million on translation might sound like a big number, but it is a tiny fraction of expenditure and would make little dent in nurse staffing across all NHS organisations.

Citizens or legal residents who don’t speak fluent or even basic English are, just like people with hearing loss, learning disabilities or cognitive impairment, as entitled to NHS care as the rest of the population. And there is already considerable evidence that they are not getting it, with health and healthcare access inequalities between different ethnic communities.

Denying people written information in their own language will only make matters worse.

When people who are sick, scared, vulnerable, distressed or have symptoms to discuss, treatments to understand, or complex psychosocial factors to explain, how can the quality and safety of the care they receive be improved if they can neither express nor understand key information?

There are also legal considerations. To provide valid consent to treatment in common law, patients must have sufficient information about the details, risks, potential harms and benefits of a proposed treatment (which could in some cases involve major surgery, powerful drugs or admission to intensive care). Language barriers must be overcome to make this a reality.

The Mental Capacity Act states that all reasonable efforts must be made to establish decision-specific capacity for treatment or care – which may include overcoming language barriers.

If patients lack capacity, then speaking to those closest to them is a key part of establishing their best interests for further decision-making. Again, this may require translators or clear written information in their first language. We do this for people with hearing loss via written communication or sign language.

Regulatory codes of practice for healthcare professionals are also clear that we must treat people equally, irrespective of characteristics including race, religion or nationality.

Using AI translation apps of variable reliability has its limits in a time-critical or emotionally-charged and challenging situation. And relying on family or friends to translate isn't always possible as not every patient is accompanied. If they are discussing personally sensitive or intimate information, they may be inhibited from doing so. If there are safeguarding concerns regarding abuse or neglect one could suspect the person translating of being coercive when doing so.

The thinly-veiled xenophobia and racism being whipped up by the Express (even against people who pay tax and National Insurance contributions and have precisely the same entitlement to care as native and confident English speakers) is part of a wider set of 'wedge issues’ being pushed by right-wing media outlets and sections of the Conservative and Reform parties.

They share a similar fixation with 'woke’ diversity managers or diversity, equality and inclusion (DEI) policies in the NHS or other public services. Several Government ministers have lined up to call for a 'war on waste’ to remove such posts and policies.

Steve Barclay, when Health Secretary in 2023, wrote to integrated care boards in England instructing them to stop recruiting staff as dedicated EDI managers, arguing that the money should be spent on “frontline staff” instead.

The Express has published a number of articles lamenting 'wokery’ in the NHS – including, in January in a story headlined 'NHS spends £40 million on woke non-jobs that could pay for 1,150 nurses'.

Last year, the Spectator ran a FOI-based story showing that, out of an NHS workforce of around 1.5 million people, there were only 800 employees in dedicated EDI roles – yet called for those roles to be abolished.

Again, those employed in such posts account for a small fraction of 1% of the entire NHS workforce or spend. Their presence is de facto required due to the Equality Act and Equality Duty on public organisations and protections in employment law.

NHS organisations do have a very diverse workforce, yet there is clear evidence of ongoing and endemic discrimination towards minorities within it. There is also consistent evidence of discrimination and care inequalities between different ethnic and socio-economic groups the NHS serves.

The idea that a focus on EDI is somehow a bad thing and a distraction from real work, or that organisations should not employ a small number of people to oversee it, is not so much a dog-whistle as a wolf-klaxon. It is a classic distraction from the real issue – the 14 years of Conservative-led mismanagement of health and social care and of wider public health.

This decline has been well-documented by the Institute for Government think tank; as well former King’s Fund chief executive Professor Sir Chris Ham, who set out in expert detail the rise and decline of the service from the late 1990s through to the 2010 election and the current crisis in performance and public satisfaction.

Blaming our NHS crisis on the cost of translation and interpretation services, and diversity and inclusion managers, foments hostility against people from ethnic minorities, white people with poor English skills, and even those with full entitlement to use our public services and who contribute towards their costs.

They aren’t all rich enough to pay for their own personal translator or digitally equipped enough to auto-translate NHS information documents into their own languages.

I don’t see commentators on the right arguing against hospitals in France or Spain finding translations for ill white British expats or embassies around the world employing translators to help British citizens who have found themselves in a spot of bother with the local law. I wonder why.

A damning new survey reveals that less than a quarter of people are still satisfied with the NHS, with satisfaction levels around social care also hitting an all-time low.

Satisfaction levels around social care were the worst ever recorded, the Nuffield Trust noted, with just 13% of people questioned thinking they were acceptable.

The annual analysis by the King’s Fund and Nuffield Trust in the past year’s British Social Attitudes Survey (BSA) - carried out by the National Centre for Social Research (NatCen) in 2023 - and released March 27, makes grim reading for anyone who values the NHS and wants it to survive and thrive.

In the survey's 41-year history, this was the first year that less than a quarter of people were “very or quite satisfied” with the NHS. This peaked in 2010, in the last year of the Tony Blair/Gordon Brown government when 7 out of 10 people were satisfied. The fall to 24% was from 29% in 2022, and 53% as recently as 2020.

A new survey on public satisfaction in the NHS and social care has revealed some of the worst statistics ever recorded. Photo: Nuffield Trust and the King's Fund

The top reasons for respondents' dissatisfaction were long waits for GP or hospital appointments, 71%, staff shortages, 54%, and a view that the Government does not spend enough on the health service, 47%.

Respondents’ top priorities for change were making it easier to get a GP appointment, 52%, and increasing the number of staff in the NHS, 51%. Improving waiting times for planned operations, was next at, 47%, and in A&E, 45%.

Every year since 2015, a majority of respondents have said the Government does not spend enough on the health service, but this has hit a new peak of 84%.

Almost half of respondents, 48%, would support the Government increasing taxes and spending more on the NHS, with that view most prevalent in people with the highest household income, while 42% felt taxation and spending should remain the same. Some six per cent wanted cuts.

Of those satisfied with the the level of service, the top reason was because the NHS care is free at the point of use, 66%, followed by it having a good range of services and treatments available, 53%, and the quality of care, 52%.

The BSA results come just weeks after the annual NHS Staff Survey which mirrored public attitudes.

The 2023 survey, which received a massive response rate of over 50%, showed that 30% of respondents felt burnt out by their work, and 34% found it emotionally exhausting. Just over half, 57%, said their organisation took positive action on health and wellbeing.

Less than half felt able to meet the conflicting demands of their work, and only a third felt their workplace had enough staff for them to do their job properly. A quarter said that they never faced unrealistic time pressures.

These are just the conditions to create “moral distress” where staff are coming to work every day, unable to deliver the professional standard of care they want to, knowing they are letting patients down but constrained by a system lacking resources, capacity and staff.

A quarter of NHS workers said that they’d been subject to harassment, abuse, or bullying from members of the public, and another 28% had experienced it from managers or colleagues. Only half of those workers said that they’d reported such incidents.

Only 54% of those surveyed believed their organisation acted without discrimination and with fairness regarding career progression, yet we still have ridiculous weaponisation by the right of culture wards about equality, diversity and inclusion policies, training and a handful of designated staff to manage this clearly needed work.

It is especially concerning after a whole series of public care failings, scandals and inquiries and both a professional duty of candour and transparency (for clinical staff) and a statutory duty of candour for organisational leaders) that only 62% of respondents felt safe speaking up about concerns affecting patient safety in their organisation, and 50% believed that those concerns would be listened to or acted on by managers.

Most concerning of all was the finding that only 61% of respondents would recommend their organisation as a place to work, and only 64% would recommend it as a place for their friends or family to receive care.

Is it any surprise that the NHS has such a retention problem, with so many clinical staff leaving or signalling an intent to leave?

Social Care’s crisis is even more pressing. The annual Skills for Care report on the State of the Social Care Sector and Workforce for 2023 showed that 1 in 10 posts were unfilled and serious problems with retention, due to poor terms, conditions and support, compounded by the impact of immigration rules, pay and competing sectors on recruitment. This, along with the growing crisis in social care and local government funding is making provision unviable.

No wonder public satisfaction with social care is so low, further compounded by it being heavily rationed and means tested, with the Government repeatedly ducking sustainable solutions and a growing gap opening between requests for assessment, care and support and their provision.

What strikes me about these two surveys it that the staff experience - also at an all time low over the past two years’ surveys - and public satisfaction are so closely aligned. The staff know they are working in a broken system, close to a cliff edge, close to a critical transition point from which there may be no return. The public see it. And it is no fun working in a service that the patients and families are so unhappy with.

Among all this gloom, there are some points of hope and unity. The overwhelming majority of BSA respondents expressed high levels of support for the founding principles of the NHS, when asked if they should still apply in 2023: that it should be free of charge when you need it, 91%, primarily funded through taxation, 82%, and available to everyone 82%. There is no clamour for a sea change in funding mechanism or a shift to market-based provision and competition.

As for the staff survey, commitment to the NHS values and spirit remained strong. Nearly 9 in 10 staff thought that their role made a difference to patients, and 7 in 10 said that the care of patients was their organisation’s top priority.

This year's survey shows little difference between what Conservative and Labour voters want to see change - so you'd think the politicians would be pushing at an open-door and act on voters' priorities and the commitment of the staff who are still keeping on keeping on even after the traumas of COVID.

Despite mental health being arguably the most significant health crisis facing the UK, Jeremy Hunt didn't mention it once during his Spring Budget.

One in four people in the UK are affected by mental health, with mental illness costing the country an estimated £118 billion annually – equivalent to 5% of GDP.

According to NHS data, the number of people in contact with mental health services has increased by almost 500,000 since 2020.

For these reasons, mental health charities did not welcome the Budget.

Mind was particularly critical of the decision not to commit more funding to the roll-out of 'Right Care, Right Person’, an initiative that aims to ensure that the right agency deals with health-related calls, rather than police forces being the default first responders.

"It is simply impossible to take a million hours of support out of the system without replacing it with investment," the charity said. "Failing to properly fund NHS mental health crisis services while instructing police forces to step back from mental health calls is an unsafe and frankly irresponsible decision."

Given that the NHS is facing extreme challenges in almost every aspect of its running, it does not have the capacity to handle the increasing number of people in the UK reaching crisis point with their mental health.

The Budget promised to deliver an NHS productivity plan, by making its technology more efficient and reducing healthcare time on admin. While this may ease time pressure for healthcare workers, it is not focused enough to address the broader, more systemic issue of underfunding and under-resourcing.

A recent British Medical Association report highlights an additional problem: mental health professionals are becoming so disillusioned that they are unable to work themselves. In September 2023, one in seven medical posts in NHS mental health trusts were vacant.

According to a report shared with The Independent on March 25, emergency departments are so overwhelmed, A&E staff are unable to look after the most vulnerable mental health patients or treat them with compassion. According to medical records, more than 40% of patients who needed emergency care due to self-harm or suicide attempts received no compassionate care, the newspaper reported.

It appears as if the Conservatives view our mental health crisis as a primarily financial burden, reprimanding the growing population of people out of work, many for mental ill-health.

The Autumn 2023 Budget, for example, announced the Government’s plan for short-term changes to how the Department for Work and Pensions classifies who is fit to work. It proposed stricter sanctions for people previously deemed unable to work, potentially pushing those who are too mentally unwell back into work to avoid losing access to support.

The driving force for these changes seems to be primarily one of labour, productivity, and money rather than addressing the underlying socio-economic factors such as, but not exclusively, racism, homelessness, poverty, and sexism.

People under 25 seem to bear the brunt of these pressures.

A week before Hunt's Budget, Young Minds delivered an open letter to the Chancellor, signed by 15,000 campaigners, urging the Government to invest in early intervention hubs for young people struggling with mental health.

Meanwhile, a new report published by the Children’s Commissioner showed that more than a quarter of a million children and young people are awaiting mental health support, and referrals for under-18s are up by 53%.

According to the Mental Health Foundation, 50% of mental health conditions emerge by the age of 15 and 75% by 24, so early intervention could help prevent severe mental health issues which may impact work and life quality into adulthood.

Responding the the Budget, Laura Bunt, chief executive at YoungMinds said, “Ultimately, until we focus on the systemic drivers of poor mental health, we will be fighting a broken system. We need a plan that works across Government, one that prioritises early intervention and prevention; we need this Government to wake up and take steps to stop this crisis from getting worse.”

The Government has also repeatedly fallen short on promises to deliver on mental health reform.

A previous commitment to a 10-year mental health plan to "level-up mental health across the country and put mental and physical health on an equal footing" was scrapped and absorbed into a ‘Major Conditions Strategy’. That aimed to tackle wider ill-health and removed the focus on mental health.

Recently announced National Insurance cuts will also do little to help those with low incomes, providing almost no support for those on the lowest threshold. Financial insecurity is a crucial indicator of poor mental health. Children from the poorest 20% of households in England are almost four times more likely to have serious mental health difficulties by age 11 than those from the wealthiest 20%.

Fazilet Hadi, head of policy at Disability Rights UK, told Byline Times that the Budget “totally ignored the deepening poverty and lack of support being experienced by millions of disabled people, including those experiencing mental distress".

"There are to be no further cost of living payments and the Household Support Fund, which enables councils to give discretionary payments, is only extended by six months,” she added.

The burgeoning mental health crisis is evident, with a high cost to the long-term productivity and growth the Conservative Party desires. Unless the Government prioritises mental health service funding and effective measures supporting the young and most vulnerable are in place, the crisis will only get worse.

Is the NHS really being privatised on the quiet, before enough of us realise it?

It remains a taxation-funded, largely publicly-provided, universal, free at the point of use service, notionally based on need not the ability to pay, in line with its founding principles. And you can’t buy shares in the NHS – a million miles away from the situation in our privatised utilities and public transport providers.

International health system comparisons and league tables have consistently shown that the NHS is a leader in terms of efficiency, cost, equity of access, not financially charging patients, and not damaging them financially by the cost of care or avoiding care due to fear of cost.

That said, the World Health Organisation defines privatisation as occurring “where non-government bodies become increasingly involved in the financing or provision of health care services”. Use that yardstick and the situation warrants further scrutiny.

Services such as dentistry, community pharmacy, and eye testing have been provided by the private sector for many years without considerable pushback (although the recent crisis in the provision of NHS dentistry and a contract that makes it unviable for dentists to deliver at any kind of scale has raised doubts about this).

Support services such as catering, car parking, cleaning, security and maintenance, and records storage have been outsourced for years – although not without concerns regarding their value for money, quality, competence, or comparison with traditional in-house provision (not to mention NHS frontline staff being fined for parking at their own workplace and companies profiting from patients or their families visiting hospital).

Legislation in recent decades has created an internal market with a 'purchaser-provider split’: the “any qualified provider” clause in Andrew Lansley’s 2012 Health and Care Act made it compulsory for the Government to put NHS contracts out to competitive tender. This has since been repealed with the creation of 42 "integrated care systems" and the Alternative Provider Medical Services Contract, enabling primary and community services to be bid for by non-NHS providers.

NHS trusts are also saddled with debts from the private finance initiative (PFI) for building and maintenance of facilities. In 2022, the Guardian found that 101 trusts owe £50 billion between them and several are spending more than 10% of their revenue on servicing PFI contracts. There are numerous ongoing disputes between NHS trusts and providers about the quality of the contractors’ work and plans when the contracts come to an end.

Despite all of this, respected health policy think tanks such as the King’s Fund have pointed out that notwithstanding the growth in clinical contracts being awarded to the private sector after the 2012 Act, they have often been of low value (with a total spend of only about 7 % of NHS expenditure).

Meanwhile, adult social care – including personal care at home or long-term care in residential and nursing homes – unlike the NHS, has long been rationed by highly restrictive eligibility assessment. It is far from universal and is also subject to means testing and personal payments. Cuts to local government funding, competing pressures on councils, repeated failures of government to provide social care funding solutions, and the crisis in the poorly paid social care workforce, have seen a growing gap between requests for support and provision.

Earlier this month, it was reported by the director of the Centre for Healthcare in the Public Interest that private equity funds and US health corporations were taking more than £1 billion in profit annually from their stakes in care homes for older people and homes for looked-after children. These facilities are currently essential to service provision and represent a stable opportunity for return on investment.

It was also reported that half of the UK's sexual assault referral centres were backed by private equity and that companies had made several millions in dividends during the past two years, not only from these centres but also from healthcare provision for people in custody and secure units.

Around one in three inpatient mental health beds, and the majority of addiction, drug and alcohol rehabilitation facilities, are now private sector provided. Local government cuts have also impacted capacity in such services.

This is despite a major evidence review this year in the Lancet, which found that research in the past 40 years had shown that an increasing aggregate of private sector provision has been linked with worse outcomes for patients. It concluded that the evidence for the benefits of privatisation was weak.

A review by the British Medical Journal last year of the literature on private equity investment had shown that a growing involvement of private equity in all healthcare settings was associated with higher and harmful costs to patients and “mixed to harmful” impacts on care quality.

The Guardian also reported this month that private hospitals are now carrying out 10% of all elective NHS operations (a record high). The biggest areas among the 1.67 million NHS-funded operations carried out in the private sector were in routine orthopaedic surgery, eye surgery and dermatology – a 29% increase in the numbers reported in 2019.

The Independent Health Provider Network praised the increasing access and choice for patients as helping to reduce waiting lists (as part of the NHS referral to treatment scheme).

The Centre for Healthcare in the Public Interest has also reported that cataract operations being conducted in the private sector are also being clinically coded as of higher complexity than those in the NHS – with more complex codes attracting a higher price.

Meanwhile, between 2019 and 2022, the proportion of British citizens taking out private medical insurance nearly doubled from 12% to 22%, bringing the UK more in line with other industrialised nations from a historic low uptake.

Again, the insurance industry is pleased with this progress. Last year, both Aviva and Axa celebrated the opportunities this provided and the growth in their market share.

We know that more than one third of patients having private sector surgery are now paying out of their own pocket, even without any personal insurance policy, and that this too has seen a steep rise in recent years.

The pandemic caused a sharp rise in privatisation tendencies.

The National Audit Office published a series of reports on pandemic procurement, showing tens of billions of pounds squandered on personal protective equipment – much of it unusable, on test and trace, apps, ventilators, and consultancy contracts often from unqualified and unsuitable commercial organisations with insufficient scrutiny and transparency and poor value for money. 

As Byline Times has reported on extensively, some of the individuals and organisations who won contracts had links to the Conservative Party or were known donors, with a 'VIP lane’ created to facilitate this.

The private hospital sector was also given an additional £2 billion of government money between 2020 and 2023 to help with pandemic elective care, but its activity continued to be dominated by private work.

There is also the issue reported by Byline Times of several MPs or peers holding shares in private healthcare providers, or private equity firms who fund them and lobbying on their behalf.

The private healthcare sector employs and poaches staff trained by the NHS and bears none of the training costs itself; selectively cherry-picking low-risk elective procedures it can monetise and avoiding acute, urgent or complex care – including the provision of emergency departments, intensive care, or inpatient care for sick older people.

It evades the degree of regulatory scrutiny the NHS must rightly meet. And it ships thousands of patients each year back to NHS hospitals when they develop acute complications that private hospitals are not staffed or equipped to deal with.

Analyses by the King’s Fund, the Nuffield Trust, Health Foundation, and even global consulting giants McKinsey, have shown that there is no inherent advantage in an insurance-based system with greater marketisation and profit motive compared to predominantly tax-based and publicly-provided systems.

Nor is it true that those systems do not exist outside of the NHS. Versions can be seen in Italy, Spain, Portugal, New Zealand, Canadian Provinces, Malta and Scandinavia – albeit often with less centralised political leadership and control.

Data from the British Social Attitudes Survey, the Health Foundation and Ipsos Mori has shown no public appetite, and no political mandate, for a change in the current tax-funded and notionally publicly-provided NHS model or its founding principles.

The same goes for support for an European-style insurance-based models (repeatedly touted by small state lobbyists from the Institute of Economic Affairs, the Adam Smith Institute, or columnists in right-wing publications who ignore the presence of perfectly decent, publicly-funded, models in their selected examples).   

Sadly, a major reason why so many more people are now feeling they must take out private insurance or use their savings to pay for treatment or consultations – and why the NHS itself is placing ever-growing volumes of business with the private sector – is the years of declining performance since 2010.

I believe the majority of the public wants the existing NHS model to work like it used to, in terms of access, waiting times, staffing, patient, and staff satisfaction – rather than a complex market involving multiple payers and competitive providers.

With a Labour government likely after the next general election, it would be good to see it openly defending the NHS’ founding principles – and to stop and reverse the expansion of the profit motive and markets in the service. I have seen no such commitments yet.