Britain's voters might not know it, but the country faces severe cuts to its treasured National Health Service, no matter who wins the election. Chaminda Jayanetti talks to NHS campaigner John Lister about the gathering storm in health funding.

“Once people realise the scale of the threat to their local hospitals and services, I think there will be protests that we’ve never seen before.”

John Lister has been fighting NHS cuts and hospital closures for more than a quarter of a century as an official with campaign group London Health Emergency. Currently he’s helping campaign against a stream of underreported hospital cuts, which are taking place up and down the country.

But it is after the General Election that he feels a real crisis will confront the NHS. “We’re potentially at quite a tipping point here. We can already see beds that are starting to close for the first time in a dozen years. These are going to massively accelerate after May 7th as these plans start to take shape.”

The £20bn bloodbath

The looming NHS financial crisis is one of the biggest dogs not to bark during the election campaign. With all three main parties coy over the impact the financial crisis will have on the NHS and other public services, the specific threat to hospital funding has largely remained off the agenda.

According to The Times, hospital trusts are preparing to cut at least 650 doctors’ posts and 2,000 nursing positions over the course of the next parliament.

But Lister says that figure is a massive underestimate. “That’s just a tip of the iceberg. It’s going to be much, much bigger than that. You can’t cut £20 billion off a labour intensive service like health without cutting tens of thousands of jobs.”

The £20 billion figure is the financial shortfall predicted by NHS chief executive David Nicholson over the next five years. If you’re not familiar with it now, you will be once the election is out of the way.

Both the Conservatives and Labour have pledged, in various terms, to maintain current levels of NHS funding – be it for ‘frontline’ services or across the board. But if NHS spending is maintained at or just above levels of inflation, this will not keep pace with rising healthcare costs.

“The costs for the NHS are going to go up,” says Lister, “because you’re going to have a growing elderly component of the population that are more expensive to look after, you’re going to have more expensive drugs coming onstream, you’re going to have new treatments which are more expensive.

“There’s going to be a whole variety of new cost pressures that are going to come on the NHS – NHS London calculates it as 4 per cent a year. So if you take five years at 4 per cent a year, and if you start with roughly £100 billion of spending, that’s where the £20 billion gap comes from. Because that’s extra cost that you’re not getting extra money to cover.”

Freeze on the frontline

The language of the election campaign would have us all believe this £20 billion will magically disappear by ‘efficiency’ savings – cutting management, bureaucracy, waste and a dozen other panaceas. Not so, warns Lister.

“There’s nothing that’s been changed that’s going to reduce the need for backroom staff because they’ve got a more and more complicated system. They’ve insisted on driving through all these market changes, which actually make it a more complicated and more bureaucratic system than it was before.

“They can’t make big cuts in that unless they close down whole trusts and merge them together,” adds Lister. “That’d be the only way to do it. Which is quite possible, because the scale of these financial problems is going to be so big that there are some really desperate measures that are going to be resorted to.”

But if the NHS can’t save enough money just by cutting back on management and administration, where will the axe fall?

Lister sees frontline cuts on the horizon, noting that NHS London plans to close a third of hospital beds by 2016.

“In London alone, if you were just looking at acute hospital beds that’d be 5,500; if you’re looking at the whole spectrum of beds that’d be 8,500 beds just in London. It’s hard to see how you can keep frontline capacity up and running if you’re facing a squeeze on that scale on your budget.

“There could be whole areas of service that in some areas are just no longer considered financially viable to provide. They close and the beds and the staff go with them. We can expect by the end of this year consultations to be being driven through at local level to shut down hospitals, services, and to axe the staff that go with them.”

In addition to cutbacks and closures, some services could be centralised – a process already underway with children’s services. With hospitals under pressure to divert people from A&E units to newly built ‘polyclinics’, A&E services could also be under threat.

“There are clinical arguments for some centralisation – some rare cancers, for example,” says Lister. “But there are others that you can see are cash driven, and if they’re cash driven then there’s a good chance they’re going to squeeze down the size while they’re doing it.”

This then has a knock-on effect, as squeezing services can threaten hospitals’ ability to meet central targets. “From the hospitals’ point of view, you’re better off closing something altogether than running it and risking breaching these targets and facing all the hassle you get.”

Lister says it then becomes easier to just let another hospital run the services instead. “There’s going to be a lot of buck passing and a lot of people looking for ways of shunting the problem somewhere else rather than facing up to it locally.”

A bitter pill

During the election campaign, leading figures from a number of medical colleges signed a letter to the Guardian supporting cutbacks, saying they could help save lives through greater efficiency and expertise – although the College of Emergency Medicine and British Medical Association disagreed. Lister is unimpressed.

“I think these people are whistling in the dark. Most of these are ways of reducing capacity. In practise you wind up with real people needing real beds and real resources, and if they’re not available then the service is worse for most people, not better.

“The reality is that this £20 billion is going to be accompanied by massive closures of beds. Now massive closures of beds means you’re not going to have your big centralised purpose-built units. You’re not going to have that. The ideal world won’t exist, so the scenario in which this might work won’t exist either.”

Lister argues that instead of trying to cut back £20 billion in NHS funding, the politicians should raise taxes to meet the funding gap.

But with the three main parties united in their support for the cuts agenda, it seems that no matter who wins, the NHS is heading for intensive care.