I have not blogged about the NHS for quite some time. In fact the last occasion I explicitly did so was when Wendy Savage and I were campaigning together in 2011 to strangle the Health and Social Care Bill at birth (our talks to students still reside somewhere on YouTube). I remain sceptical and confused about the BMA’s slipshod, innocent or opportunistic failure to act decisively. I was alongside many others literally yelling at them through a megaphone even as they reached their momentous resolution to step aside and raise the white flag. In doing so, as Wendy and I had both tried to spell out, they effectively condemned the NHS as we had come to revere it through the post-war, social democratic or welfare statist era. The post-2011 careers of the principal decision-makers should be researched? Who won? Who lost?
In this offering I draw on a paper co-authored with Sasha Scambler and Ewan Speed and published in Social Science and Medicine. It represents an extension of an argument I have been pushing for some time. I have maintained that not only the national distribution of longevity and health but also the planning and delivery of health care have been undermined and perverted by the very predictable implementation and extension of the Health and Social Care Act of 2012.
Trading on a plea for forbearance, I must refer once more to the greedy bastards hypotheses (GBH), namely, the announcement that it is the rich who – mostly indirectly, but issuing nevertheless from an expedient strategic amorality – restrict and sometimes totally cut the supply of oxygen from those asset flows conducive to health and well being and threaten the NHS.
So how to understand the prospects/plight of the NHS? I will offer a summary (sociological) analysis before committing to a series of personal/political interventions.
In the 1970s the American abrogation of Bretton Woods and the emergence of the Eurodollar freed up money capital from national regulation by central banks; plus the international recession drew banks deeper into the global arena. The word financialisation was used to encompass not just this deregulation and internationalisation, but also a shift in the distribution of profits from productive to money capital, and to a reorientation reaching deep into industrial corporations towards the financial sphere. Within banking, deregulation precipitated capital centralization in banks with ‘global tentacles’, whose activities ranged from financial production to speculation in derivatives, while institutional investors controlling capitalized deferred wages became important centres of allocative as well as strategic power. This was all before the global financial crash of 2008-9.
The greedy bastards referred to above comprise a small proportion of the 1% who have profited most, and obscenely so, from post-1970s ‘financial capitalism’. A cabal or hard core of CEOs/directors of largely transnational corporations, major rentiers, and, most conspicuously, financiers or ‘banksters’, now provide financial capitalism’s cutting edge. They epitomise fine-tuned class action (or ‘class warfare’). We are witnessing a new breed of ‘super-rich’ pitted against a squeezed middle, enlarged ‘precariat’ and a US-like category of the abandoned. Their class supremacy has been accomplished via the purchase of power from Britain’s political elite (whether New Labour, Coalition or Tory), which has in turn become more controlling of its publics, even repressive. Britain is now ruled by a governing oligarchy or plutocracy. Capital buys power, and in financial capitalism it gets more for its money than during the preceding postwar era.
In the early Thatcher years, attempts were made to introduce ‘corporate’ management structures to the NHS, leading commentators to talk of a ‘new managerialism’. Her commitment to markets prompted the NHS and Community Care Act of 1990. The resultant ‘internal market’ sat on a spectrum somewhere between a bureaucratic ‘command and control’ economy and a private fee market. If it was closer to the former it was also a sign of things to come.
Thatcher’s displacement by Major saw the introduction in 1992 of the Private Finance Initiative (PFI). This allowed for the private sector to build (and own) new hospitals and other health care facilities, which they then leased back to the NHS at often exorbitant rates on the back of 20-30 year deals. It was a convenient arrangement for the political elite since PFI building and refurbishment did not appear on government books (they represented an investment of private not public capital). Blair and Brown lovingly embraced PFIs from 1997 to 2010. As Alyson Pollock presciently noted, one day the chickens would come home to roost. And they have: PFIs are a major contributor to the indebtedness of many an NHS Trust, the more so given the cuts or austerity measures following the financial crash.
The 2010 election resulted in a Cameron/Clegg coalition that backtracked on a (Tory) pre-election promise not to engage in a top-down reorganization of the NHS. Health Minister Lansley published a White Paper ‘Liberating the NHS’ a mere 60 days after the election. It was the product of protracted and insistent pre-election private sector lobbying. This was followed by the Health and Social Care Bill that opened the door for a root-and-branch privatisation of health care in England. It was a long, complex and devious Bill. There were five main ‘rhetorical’ themes: strengthening commissioning services; increasing democratic accountability and public voice; liberating provision of health services; strengthening public health services; and reforming health and social care’s arm’s length bodies. Five organizational changes were mooted: by April of 2013 the existing192 primary care trusts to be abolished and GPs to join commissioning consortia; consortia to control 80% of NHS budget; services to be purchased from ‘any willing provider’; all NHS hospitals to be foundation trusts by 2014; and commissioning to be overseen by an NHS ‘financial regulator’, Monitor. Like many others, critics like Wendy Savage and I were not fooled. Why would the new commissioning consortia be better than primary care trust commissioning? What would the role of private companies be with regard to commissioning criteria? What would be the role of Monitor in European law? How would patients have ‘more choice’? Where would the efficiency savings come from? Would the pursuit of efficiency savings be at the expense of quality?
A period of ‘consultation’ and debate was extended. The medical profession, a reluctant recruit to the original concept of an NHS, questioned and subsequently opposed the Bill. Then it folded. They were ready to take industrial action to defend their pay and conditions but not to safeguard a public NHS. Public protests were similarly ineffective and the Bill became an Act in March of 2013. Later in 2013 the coalition pushed a (strategically re-written but equivalent) ‘regulation 75’ through the Houses of Parliament, removing residual obstacles to the unfettered promotion of for-profit health care.
A number of comments are in order here. Neither the Tories nor the coalition had a mandate to ‘reform’ the NHS in the way they did. Moreover it was a reform carried out against the background of Brown’s efficiency savings announced in mid-2009 and amounting to £15-20bn in three years starting April 2011. The reform was opposed by the medical, nursing and other health professions; polls showed widespread public concern; and a series of campaigns and protests were sidelined and ignored. Although a small number of health professionals and academics were recruited to the coalition cause, there is no doubt that ‘best evidence’ on comparative health care bore testimony to the regressive nature of the Health and Social Care Bill/Act: this was ‘policy-based evidence, not evidence-based policy. Finally, it emerged later that for-profit providers were not only lobbying the Tories before the election, but were intimately involved in the thrust and composition of the Bill (e.g. via the Future Forum). They were lining up to takeover NHS services. The leading private providers – H5, accounting for 80% of private hospitals and 85% of private beds – formed an alliance as early as December 2010. Much of this ‘secret’ activity was portrayed as ‘internal to the NHS’ rather than as external lobbying.
We are already experiencing the predictable short-term effects of the Health and Social Care Act, with ill-equipped and predatory for-profit providers taking over services and benefitting from the NHS ‘brand’. The ‘revolving door’ is also well oiled. Alex Scott-Samuel has taken a medium to long-term view, anticipating that: the NHS will become a subcontracting operation privileging competing private providers; that services of ‘low clinical priority’ will cease to be free; that a market for health insurance will emerge, affordable for the affluent, which will drive up costs (administrative, fees, private profits); and that the development of personal health budgets will lead to personal charges as commissioning groups come to operate on an individual basis in order to be compatible with the insurance companies (i.e. an end to ‘population-based pooling of risk’).
In short, the Health and Social Care Act was always going to be and is an unmitigated disaster for which the BMA in particular was a shameful accomplice. PFI debt, cuts and privatisation are destroying perhaps the most just, efficient and effective – ‘imperfect’ – health care system in the world.
The point of this blog is to ask why. It seems clear enough. The super-rich greedy bastards who fuel our governing elite or plutocracy – that is, those who buy, hold and use power to their advantage – now have sufficient sway in financial capitalism to open up (even) the NHS for profiteering. Follow the career trajectories of Lansley and his successor Hunt (and a few Blairites). The privatisation of the NHS, and the future commodification of health care, might have been halted by a BMA-led campaign provoking a crisis of legtimation for the power elite, but that opportunity was lost. We need to recognise that if capital can purchase enough power, it will pursue accumulation via, to borrow Wallerstein’s phrasing, ‘the commodification of everything’. It’s a class/command issue. If we ignore this sociological/structural dimension, we become ideological co-optees and deny ourselves the theoretical and practical capacity to explain and counter regressive policies. To paraphrase Bill Clinton, ‘it’s class warfare, stupid’. Maybe the EU referendum will provoke a legitimation crisis?
Scambler,G, Scambler,S & Speed,E (2014) Civil society and the Health and Social Care Act in England and Wales: theory and praxis for the twenty-first century. Social Science and Medicine 123 210-216.