Some blogs should be expressions of indignation, and this one certainly is. Not that being angry/passionate can be allowed to obstruct evidence-based argument. Towards the tail end of 2011 Wendy Savage and I responded to medical students moving on from campaigns against the threefold hike in student fees and the abolition of the EMS to campaign against the ConDems’ Health and Social Care Bill. Wendy ‘s resistance already had its own momentum. But I engaged too and we gave joint lectures at UCL and Imperial. Later, handed a megaphone outside a BMA gathering, I shouted that this was a Bill to be aborted not revised. It was not an option to ‘keep talking’: to compromise was to lose! In March of this year the Bill became law with the passing of the Health and Social Care Act. Its substance had remained essentially intact, the pause for further consultations the sham it was always going to be.
This is not the place for a history of the NHS, but a few comments are in order. The Bill of 1946 that led to a service available to all citizens irrespective of circumstance and free at the point of need led to the introduction of the NHS in 1948. It had cross-party origins: Beveridge was a Liberal, the wartime PM Churchill a Conservative, and The Atlee/Bevin axis represented Labour. This political consensus survived intact until Thatcher’s election in 1979. If the years 1948-74 were relatively uneventful, the years 1974-82 were years of organizational reform, and the years 1982-87 of management reform (unsurprisingly aping a corporate model). Thatcher’s promotion of a pseudo- or ‘internal’ market, installed in 1991, was as far as she could go in her deference to the market place without provoking an electoral mishap.
Major’s innovation, the Private Finance Initiative (PFI), was a far more threatening move. It was Allyson Pollock and her team who bravely constructed an evidence-base to demonstrate why. The advantage of the PFI to government was that it delegated the costs of providing new hospitals, schools and so on to the private sector, these electoral assets not appearing on its own balance sheet. The disadvantages: in the future our hospitals, schools and so on would be owned by private companies and leased back to usvia long-term and extortionate contracts. What else to expect of for-profit businesses? Chickens had eventually to come home to roost.
New Labour under Blair/Brown abolished the internal market but continued to be susceptible to markets and positively relished PFIs. For all its ‘real’ increase in spending on the NHS, the aspirations of the Tories were not set back between 1997-2010. There is a sad continuity here (neo-liberalism mark I (Tories) and II (New Labour), as Bauman put it). Following the global financial crash of 2008-9, Brown’s government signed up in mid-2009 to efficiency savings in the NHS of £15-20 billion over three years to start in April 2011. This is the context in which Cameron set Lansley loose.
But Lansley’s Bill was a shock nevertheless. Cameron had chased votes by promising no top-down reorganization of the NHS. The LibDems had campaigned under a manifesto totally at odds with what was to happen, and could only happen, with their connivance. It was a Bill, the polls told us, opposed by virtually all bodies representing health professionals as well as the public. What should have alarmed all health professionals was the ‘real’ Cameron/Lansley agenda: to ‘re-commodify health care’. It was surely hard not to grasp the subtext of the Bill’s fine-sounding clauses? Barely concealed in the rubric of ‘improving services’ was an unprecedented neo-liberal assault on the core principles and practices of the NHS. These disingenuous clauses have been interminably rehearsed so I will simply precis them here: by April of 2013 the 152 Primary Care Trusts (PCTs) would be abolished and the GPs would join commissioning consortia; these consortia would control 80% of the NHS budget; services would be purchased from ‘any willing provider’; all NHS hospitals would become Foundation Trusts by 2014; and the commissioning would be overseen by the NHS’s financial regulator, ‘Monitor’. Upfront costs would be approximately £1.4 billion (much of it for redundancies), but the reforms would cut administrative costs by a third. No significant changes were secured during Lansley’s expedient hesitation. The major private health care providers had been licking their lips; before the end of 2010 they had coalesced into a lobbying group ‘H5’ (accounting between them for 80% of private hospitals and 85% of private beds).
Let’s pause for a moment to reflect. When Thatcher was elected the NHS cost us between 5-6% of GDP and was remarkably free of bureaucracy: only 5% of the budget went on administration. Unfortunately, as US economist Galbraith argued, bureaucracy in the public sector is highlighted by media-savvy and connected vested interests while bureaucracy in the private sector remains largely ‘invisible’. Under Blair/Brown expenditure on health care rose in real terms towards the OECD average (to around 7% of GDP), but so did administrative costs (on the way to doubling). In the 1980s Thatcher called on the American Eindhoven as her adviser, so let’s look at the USA. At the time of Thatcher’s introduction of the internal market, a first step towards accommodating the private sector, US health care consumed approximately 14% of GDP, while bureaucracy gobbled one dollar in four. In short, her interventions relied on policy-based evidence, not evidence-based policy. Moreover the USA was the only ‘developed nation’ not underwriting universal care for its citizens. On the contrary, one in six had no health insurance and did not qualify for Medicaid (a federal plan for the poor) or Medicare (a federal plan for the elderly). What an exemplar! Currently, American health care absorbs 16%+ of GDP and one dollar in three is committed to bureaucracy (essentially because every intervention has to be billed and most providers are for-profit). So Thatcher/Major/Cameron are pulling the wool over people’s eyes (and disappointingly, Blair/Brown too). The Health and Social Care Act is in every sense regressive.
Back to the Health and Social Care Act. Alex Scott-Samuel, a public health physician, anticipated its outcome in a typically shrewd letter to the Guardian. In summary:
‘The NHS will be a publicly funded budget and a brand name for a subcontracting operation for competing private sector organizations, subject to European competition laws which will allow private companies to predominate over other (eg third sector) providers’.
And more:
- The post-credit crash NHS has a more or less fixed budget, so services of ‘low clinical priority’ will cease to be free.
- This will lead to a market for health insurance, affordable for the affluent, which will drive up costs (administrative, fees, private profits).
- Personal health budgets will lead to personal charges as commissioning groups will operate on an individual basis in order to be compatible with the insurance companies (no more population-based pooling of risk).
This last point is vital: I’d like to think it insults those of us fortunate enough to be in good health as much as it will our less fortunate neighbours. After all, this was the point of Bevins’ NHS, the most eloquent articulation of the postwar ethos.
I participate in twitter/blog networks of like-minded pro-NHS campaigners. This blog celebrates their sharp investigative postings. PFIs have predictably led to financial distress on the part of extant providers, and this on top of a brutal inherited programme of efficiency savings. Now, eight months after the passing of the Act: (a) Cameron’s real agenda must be obvious even to those who once favoured more talking, and (b) its implementation is brazen even beyond my (sociological) expectations. Scott-Samuel’s predictions are coming to pass. But even blogs of passion should not go on too long, so here are my summary bullet-points:
- we are experiencing an undemocratic/regressive re-commodification of our (English) health care system, bearing witness to a return to the pre-NHS health care of liberal capitalism where only the affluent are guaranteed the treatment/care they need;
- this is a paradigmatic instance of policy-based evidence masquerading as evidence-based policy;
- 200+ of our representatives in Parliament – or, differently put, ‘voters’ on the Bill – stand to profit personally from a shift to private, for-profit providers of health and social care;
- political party donors are seeing a return on their investments, as are those in and around the – now more uniformly career-oriented – political class (+ their new middle-class acolytes and advisers);
- more sociologically, these moves to destroy our NHS epitomize what in an earlier blog I called the ‘greedy bastards hypothesis’ or GBH: predatory class interests, disinhibited under post-1970s financial capitalism, buttressed by the ideology of neo-liberalism, have prevailed on the political elite to trade away our postwar entitlements as citizens under cover of a rhetoric of consumer choice.
This final point matters, and not just because I happen to be a sociologist. What I have analysed as the new class/command dynamic (see previous blogs) is at the very core of any credible attempt to understand/explain what is happening to English health care. The wealthy/powerful cannot believe what this historical moment is allowing them to do to those they purport to serve. And it’s social structures that matter, not the individuals who happen to be surfing them. Cameron/Osborne are frankly neither here nor there. Allowing for the requisite theoretical adjustments in the 150 years since Marx committed his analysis/call for action to paper, this is a form of class conflict.
This blog is also an expression of gratitude to all those fighting back. Our evidence-based, morally trumping NHS matters. So, what next?