This book is a collective project drawing on the work of numerous individuals and organisations who have been campaigning to ensure that the National Health Service envisioned by Aneurin Bevan remains a reality. The contributors to this volume are:
Jacky Davis
Oliver Huitson
John Lister
Stewart Player
Allyson M. Pollock
David Price
Raymond Tallis
Charles West
David Wrigley
Keep Our NHS Public
London Health Emergency
NHS Consultants’ Association
openDemocracy
A Oneworld Book
First published by Oneworld Publications 2013
Foreword copyright © 2013 Ken Loach
Introduction copyright © 2013 Raymond Tallis
‘Breaking the Public Trust’ copyright © 2013 John Lister
‘Ready for Market’ copyright © 2013 Stewart Player
‘Parliamentary Bombshell’ copyright © 2013 David Wrigley
‘The Silence of the Lambs’ copyright © 2013 Jacky Davis and David Wrigley
‘The Failure of Politics’ copyright © 2013 Charles West
‘Hidden in Plain Sight’ copyright © 2013 Oliver Huitson
‘From Cradle to Grave’ copyright © 2013 Allyson Pollock and David Price
‘Stop Press: The Final Betrayal’ copyright © 2013 David Wrigley and Jacky Davis
Afterword copyright © 2013 Jacky Davis and Raymond Tallis
All rights reserved
The moral rights of the contributors to be identified as the Authors of this book has been asserted by them in accordance with the Copyright, Designs and Patent Act 1988
Copyright under Berne Convention
A CIP record for this title is available from the British Library
ISBN: 978-1-78074-328-8
Ebook ISBN: 978-1-78074-329-5
Cover design by www.rooted-design.co.uk
Typeset by Tetragon, London
Printed and bound by CPI Mackays, Croydon, UK
Oneworld Publications
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For Aneurin Bevan and all those who continue the fight for the NHS
Danger of abuse in the health service is not in the way that ordinary people use the service. Abuse is always at the point where private commercialism impinges on the service – where an attempt is made to marry the incompatible principles of private profit with public service.
The solution is to decrease the dependence on private enterprise.
A free health service is a triumphant example of the superiority of the principles of collective action and public initiative against the commercial principle of profit and greed.
Aneurin Bevan, In Place of Fear
The first guiding principle is this: maximise competition ... which is the primary objective.
Andrew Lansley
Ken Loach
The reform of the National Health Service is, of course, to bring it back into the marketplace and degrade it back into making health care a commodity – so it’s not reform at all.
If we don’t understand that we’ve got to do everything, up to and including breaking the law, to defend the National Health Service, then we’re finished.
First the words of a distinguished GP, then those of a former Liverpool dock worker. Across society, there is a realisation that the National Health Service is one of our greatest social achievements and that to keep it is an enormous political challenge.
This book is a weapon in that struggle. It shows how politicians of all parties, to a greater or lesser extent, have prepared the way for privatisation. It is a familiar pattern. The process in the health service began in the early 1980s, with the subcontracting of cleaning services. Why have we taken so long to respond? Are we so gullible that we believe politicians who say that the National Health Service is ‘safe in their hands’ when all the evidence is to the contrary?
In order to fight back, we need to understand the reasons for the attack on the NHS. This is an ideological issue. If it were simply a matter of finance, there are solutions to hand. There are billions of pounds in unpaid and uncollected taxes. Trillions, we are told, are kept off shore, beyond the reach of national governments. The wealth that is created by the work of ordinary people is siphoned off so that it cannot be used for the common good. If the political will to sustain a publicly funded health service existed, a way would be found.
It is a battle for ideas. To some, the drive for profit is a necessary discipline. Private business will see a need, provide the service in the most cost-effective way and make money in the process. Greed is good. When everyone pursues their own self-interest, so the theory goes, we all benefit.
Except that we don’t. When the need can’t yield a profit, the need goes unanswered. The health service and care services are full of examples of where people’s requirements are not met. All who work there could fill many pages with stories. Further privatisation will widen the care gap and the so-called austerity programme diminishes every aspect of our life.
The resistance to this has been very weak. Those organisations that should be our first line of defence have let us down. The trades unions, crippled by Thatcher’s government and abandoned by the Labour Party, have barely made an intervention. The Labour Party itself has followed the same path as its Tory predecessor in government. While trying to present a more humane face, it has continued the policies of privatisation and deregulation. When Labour adopted the slogan ‘Labour Means Business’ it was not immediately apparent that it was meant literally.
This has left a political vacuum. Who puts forward the idea of working together for the common good? That we should be our brother’s and sister’s keeper? That we have the technology and the knowledge to provide a decent life for all but we are in the grip of an economic ideology that makes that impossible?
There is a fight-back taking place across Europe. Strikes and direct actions are seen in the countries hit hardest by mass unemployment and other consequences of economic failure. In Greece, France and Germany there are new political movements on the Left, putting forward alternatives. It has not happened yet in Britain. When people ask who they can vote for to defend the NHS, what do we tell them?
This book explains how current politicians have betrayed the principles of the NHS. In my view they are not worthy of our vote. If ever there was a time for there to be a broadly based movement, democratic and principled, which stood for the interests of the people against the demands of business and the politicians who speak for them, that moment is now.
ACEVO Association of Chief Executives of Voluntary Organisations
APMS Alternative Provider Medical Services
ARM Annual Representative Meeting
BMA British Medical Association
BMJ British Medical Journal
CQC Care Quality Commission
CCG Clinical Commissioning Group
CCP Co-operation and Competition Panel
DoH Department of Health
EGM Extraordinary General Meeting
FESC Framework for Procuring External Support for Commissioners
FT Foundation Trust
GPC General Practitioners Committee (of the BMA)
GPCos GP Provider Companies
HMO Health Maintenance Organisation
ICO Integrated Care Organisation
IPA Independent Practitioner Association
ISTC Independent Sector Treatment Centre
KONP Keep Our NHS Public
LHE London Health Emergency
LIFT Local Improvement Finance Trust
MCO Managed Care Organisation
NAPC National Association of Primary Care
NHSCB NHS Commissioning Board
NLN National Leadership Network
OFT Office of Fair Trading
PCT Primary Care Trust
PFI Private Finance Initiative
PHO Physician Hospital Organisation
PPG Patient Participation Group
QIPP Quality, Innovation, Productivity and Prevention
RGCP Royal College of Psychiatrists
RCGP Royal College of General Practitioners
RCM Royal College of Midwives
RCN Royal College of Nursing
RCP Royal College of Physicians
RCOG Royal College of Obstetricians and Gynaecologists
RCS Royal College of Surgeons
SHA Strategic Health Authority
Raymond Tallis
The only thing necessary for the triumph of evil is that good men do nothing.
Edmund Burke
This book was conceived in desperate circumstances. In the summer of 2012 I attended the British Medical Association (BMA) Annual Representative Meeting (ARM) for the first time, in order to put forward a motion related to legislation of assisted dying. Three months earlier, Andrew Lansley’s Health and Social Care Act had been passed in the House of Commons after a very protracted and bumpy ride (as Dr David Wrigley will describe). In the packed hall there was an attempt by one or two brave souls, including my co-editor, Dr Jacky Davis, to hold the BMA to account for its ‘too little, too late’ gestures towards opposing Lansley’s bill. The debate was largely procedural, intended to make sure that no one was held responsible, and to deflect attention from the main issues. It was worse than uninspiring. Is this the best that the profession could do, I thought, when required to respond to the greatest threat to the health and well-being of the patients they are supposed to serve since the birth of the NHS?
On the second evening of the ARM, in deep despair, I decided to follow Jacky’s advice to attend a fringe meeting at a pub near the conference centre. The contrast with the main event could not have been greater. There were about twenty people (half a dozen of them speakers) in a little back room, as opposed to the many hundreds in a beautifully appointed hall. The atmosphere was informal as opposed to the highly choreographed, closely scripted and minutely regulated show I had been sitting through earlier in the day. However, there was a more profound contrast. First, it was obvious that those who were present cared for the NHS and were enraged at what was going to happen to it. Second, the speeches, often given with the minimum of notes, were searching, well informed and impassioned. I had moved into another world, a world of which the medical profession was once a part.
The two hours I spent listening to the speakers was a crash course in what remained of principled medical politics. For the first time, I was able to see clearly how a toxic bill that few had foreseen and no one other than its proponents saw as desirable, even less necessary, had got on to the statute book. I felt that what I had learned in that small room should be more widely publicised. It seemed as if there were the makings of a book. I arranged for a few people to meet together for an early breakfast a couple of days later. And so began the process that led to NHS SOS.
This book is about the betrayal of the NHS – and of the people who depend on it for health and health care – by politicians, journalists, the unions and, perhaps most culpably, the leaders of the medical profession. Without the active collusion, passive acquiescence or incompetence of all of these players it would hardly have been possible for the Tories – who did not command a majority in Parliament – to have succeeded in getting Andrew Lansley’s nightmare vision for the NHS enshrined in law. After all, prior to the 2010 election, the Tories had promised to defend the NHS not only from cuts to its budget but from the continuous redisorganisation that successive governments had inflicted on it over the preceding decades. This had been reaffirmed in the Coalition agreement: ‘we will stop the top-down reorganisations of the NHS that have got in the way of patient care’.1 Within a few months, the Coalition was boasting of the most radical shake-up of the service since 1948, the mother of all top-down reorganisations. This would be hugely destabilising and expensive,2 at a time when, according to Sir David Nicholson, the NHS chief executive, the service would have to make £20 billion of efficiency savings in four years. Nor had any of the political parties given a hint in their manifestos that they would open up the NHS to wholesale privatisation. The impression from the Tory manifesto had been that the NHS would be financially protected – with increased spending year on year (a promise broken) – and otherwise left well alone. It was evident, however, that the plans had been in preparation a long time, though, as Nicholas Timmins has discovered, Lansley was banned from talking about them ahead of the election.3
Such blatant deception, such chutzpah, such contempt for the electorate, should have meant that the bill was doomed. While its passage to the statute book required (as Edmund Burke might have said) that good men should do nothing (or, with a few exceptions, very little), many other conditions were required, as described in the pages of this book. While each of these conditions was individually outrageous, the fact that they were able to come together to deliver the planned destruction of the NHS says something shocking – about the condition of the nation, the pervasiveness of corruption, the debased state of the national conversation about matters of supreme importance, and the marginalisation of professionals who, when faced with the greatest threat for generations to the institution and the values for which they claimed to stand, in most cases preferred appeasement to confrontation, insisting that the latter would be pointless.
While much of NHS SOS is about the failure of those who should have sunk the bill – their failure to oppose it effectively, or even with conviction – it is important not to forget that Andrew Lansley’s vision had its advocates. There have always been those to whom the very idea of universal health care publicly funded, publicly delivered and publicly accountable is repugnant, and would remain so, even if it were shown that such services were the most effective, cost-effective and popular mode of delivery. While attachment to the NHS has often been described as ‘religious’, hatred of state-provided and state-funded services qualifies more fully for the status of an article of passionate faith. The recent release of the 1982 Cabinet papers shows how the ‘mild-mannered, courteous’ Geoffrey Howe and his leader Margaret Thatcher dreamed of ‘dismantling the welfare state’, accepting that this would be ‘the end of the NHS’.4 This caused a near riot in the Cabinet, not because it was a wicked plan – which it was – but because it was deemed ‘politically toxic’. It took another thirty years of neoliberal consensus thinking, as described by Stewart Player, for this to become thinkable. As Ken Clarke said in 2008:
Labour secretaries of state have got away with introducing private sector providers into the NHS on a scale which would have led the Labour Party onto the streets in demonstration if a Conservative government had ever tried it. In the later 1980s I would have said it is politically impossible to do what we are now doing. I strongly approve.5
It was still unacceptable to the vast majority of those who provided and used public services. Moreover, in 2009 Andy Burnham, Secretary of State for Health before the Coalition, made up for some of the sins of his predecessors in the Labour administration by making the NHS the service’s ‘preferred provider’. Consequently, deceit was still necessary and, when the Lansley plan was eventually brought into the open, it had to be spun. Doctors and patients were to be reassured by politicians presenting the key aim of the bill as putting the clinicians, notably GPs, in charge of health service budgets and what they were to be spent on, and, naturally, to ‘increase patient choice’. Just how far this is from the truth is set out in terrifying detail in chapter 1 (Breaking the Public Trust) by John Lister, and in chapter 7 (From Cradle to Grave) by Allyson M. Pollock and David Price. That this spin was not adequately challenged, or even critically examined, in the mass media is an outrage, as discussed by Oliver Huitson in chapter 6 (Hidden in Plain Sight).
There were several potential sources of opposition to Lansley’s bill which, if fully mobilised, would have prevented its passage. These were the medical profession, non-Tory politicians and the media.
The health care professions were best placed not only to understand the true implications of Lansley’s Health and Social Care Bill but to influence public and parliamentary opinion against it. The Royal College of Nursing made its hostility very clear but it was the doctors whose views would carry most authority in the public mind. After all, Lansley’s assertion that his bill would put clinicians in the driving seat would look rather strange if the majority of doctors said either that they didn’t believe him, or that they didn’t want to be running NHS budgets and were unqualified to commission services for populations. Unfortunately they, or at least their leaders, failed abjectly to oppose the bill effectively until it was too late, as Jacky Davis and David Wrigley reveal in chapter 4 (The Silence of the Lambs).
As Davis and Wrigley discuss, of the doctors who very much liked the idea of a service where they had control of the budget, some were motivated by altruism and others by self-interest. For some, to be blunt, the blatant systemic conflict of interest in providing services that they would themselves commission was embraced as an opportunity for personal enrichment. Greed was the spur. They were in a minority but they had disproportionate influence because they were pro-market and pro-GP commissioning and so had the government’s ear. It would be interesting to know how much gold had been promised to stuff in the insatiable mouths of certain doctors. The rewards would come quickly. A survey in Pulse – the GPs’ magazine – reported that by December 2012 over one-fifth of board members on clinical commissioning groups had financial interests in private health care providers; the BMJ put the number at more than one-third in March 2013.6 Things are looking good for Dr Fat Cat.
Greed was not the main reason for the failure of many to question Lansley’s bill before it was too late. After all, as I shall discuss, the most powerful, articulate and sustained opposition came from the Royal College of General Practitioners (RCGP), who looked at first as having the most to gain. No, there was a deeper malaise in the medical profession.
The political class has, over the last few decades, regarded doctors with increasingly open contempt. Instead of being respected as patients’ advocates, and as having unique expertise in the best ways to care for patients and the best context in which that care might be delivered, they are portrayed as instinctively conservative, irrationally opposed to change, unable to see the need for it and obsessed by their own perceived self-interest. This has resulted in a progressive marginalisation of the role of doctors in the process of reshaping the services within which they work. Of course, each administration has found a sufficiency of useful idiots within the profession to act as cheerleaders for whatever idea crosses the mind of an ambitious Secretary of State. They are rewarded by flattery, first-class fares, gongs,7 elevated office and financial opportunities. But the majority of doctors have gradually drifted to the margins of decision making, doing their best to work with whatever ill-thought-out ideas are foisted upon them by Whitehall.
I discussed the first twenty years of the marginalisation of the medical profession in Hippocratic Oaths: Medicine and Its Discontents, published just under a decade ago. Successive redisorganisations have further reduced the influence of the medical profession. In the late 1990s and early 2000s the opportunistic exploitation by politicians, most notably Alan Milburn, of medical scandals such as the problems with heart surgery in Bristol, the retention of organs at Alder Hey hospital and the mass murders by Harold Shipman, placed the profession on the back foot. Treating these episodes as symptomatic of a profession that was arrogant, dangerous and unaccountable was very damaging to its reputation.
Not everyone bought that image of the profession carefully fostered by politicians. As shown in poll after poll, doctors remain highly trusted – in contrast to politicians. Even so, the ‘managerialism’ in the NHS, which has progressed remorselessly since the first steps were taken in 1983 with the recommendations made by Roy Griffiths, has reduced many doctors to mere sessional functionaries. They are concerned to deliver on contracts narrowly defined, and less exercised by larger issues such as the context in which care is delivered and the health of the nation. Brian Jarman, in a recent article,8 which should be required reading for anyone concerned about the health of the NHS, has examined the long-term effects of ‘managerialism’, most notably an imbalance of power between doctors and managers. Managers have considerable influence on the funding of hospital and other units, appointments to posts within hospitals and pay rises through the clinical excellence awards. They can refer doctors to the General Medical Council and there is no redress for groundless referral. Whistle-blowing doctors may be dismissed and, with their cards marked as troublemakers, they may find it difficult to obtain further employment in the NHS. (The Francis Report identified this as an important factor in the silence of doctors in the face of the wholesale abuse of patients in the Mid Staffordshire NHS Foundation Trust.) The Department of Health has spent very large sums of money on ‘gagging agreements’ for individuals dismissed from the service. A ‘culture more of fear and of compliance, than of learning, innovation and enthusiastic participation in improvement’ was identified in a report commissioned from Joint Commission International (an authoritative body on accrediting health care institutions).9 Needless to say, this report was dismissed and deep-sixed by the Department of Health. David Nicholson regarded it as ‘insignificant’, which makes his very long tenure as CEO of the NHS easier to understand. It was exhumed only in response to a request under the Freedom of Information Act. Managers on the ground – many of whom are deeply committed to patient care – are themselves equally the victims of the ‘top-down and bullying culture’.10
These trends have been exacerbated by the casualisation of the medical workforce and those pressures that Colin Leys identifies to make them become businessmen and -women, and which are described by Stewart Player in chapter 2 (Ready for Market).11 ‘Corporatising the NHS’ requires instilling the corporate ethos into its workforce and replacing the fundamental idea (or at least ideal) of the professional as one who is bound by covenant to those he or she serves with versus a contract mediated through an ever-lengthening chain of intermediaries, each taking its cut. You are no longer the servant of the people who come to you for help or of the population from which they come, or answerable to the ideals of your profession. Your immediate loyalty is to a body whose primary oath is ‘First Balance Your Books’ or ‘First Meet Your Targets’ or ‘First Satisfy Your Shareholders’. No wonder the Hippocratic Oath seems to have ‘First Cover Your Ass’ as the most important of its contemporary clauses. Troublemakers make trouble only for themselves. Gone is the consultant body that was the ‘glue’ that held hospitals together and defined their mission. And GPs who feel personal responsibility for the patients on his or her list are becoming less common. Stewart Player describes how the relationship between GPs and individual patients has been deliberately unpicked by health care policies over the last decade or more. Not everything is lost, however. Lord Owen is still correct when he asserts:
The NHS is … a vocational service. It needs to retain within it a generosity of purpose, philosophical commitment and a one-to-one relationship with the individual patient.12
Nevertheless, the doctor as advocate for the vulnerable is in danger of becoming a thing of the past. This is excellent news for politicians for whom the professions, as an alternative source of authority, have always represented a threat13 – second only to patients as a source of trouble. No wonder politicians like to spin advocacy for patients by the medical profession as self-interested. And, of course, there have been striking examples of such self-interest, most notably the BMA’s opposition to the foundation of the NHS in 1948 and, more recently, the negotiation by its general practitioner body of a vastly enhanced salary, while handing over out-of-hours care to private providers.
Jacky Davis and David Wrigley’s account (chapter 4) of the lamentable failure of the medical establishment to oppose Lansley’s bill deals with the BMA’s policy of ‘critical engagement’ with the Coalition – an overly generous description of what amounted to appeasement, which was maintained until it was far too late. The policy betrayed either a fatal political naivety or a cynical decision to back the bill while pretending otherwise. While this was pathetic, it was less shocking than the way in which the BMA acted with little regard to the views of its members. What is more, it failed to work together with other professional bodies such as the medical royal colleges to put up a united front. It seems unlikely that the bill would have survived the opposition of a united profession.
The royal colleges’ performance individually and collectively (in the feeble body the Academy of Medical Royal Colleges) was also dismal. Indeed, the Royal College of Physicians (RCP) was stung into action only by the determined efforts of a few activists who called for an Extraordinary General Meeting (EGM) at which the bill was rejected. The leaders of the RCP found this so traumatic that one of their first subsequent actions was to propose an increase in the number of fellows necessary to call an EGM in future!14 In the light of Davis and Wrigley’s account of the muted response of the Academy of Medical Royal Colleges in early 2012, it was exasperating to be told of the Academy’s concerns about the implications of the Health and Social Care Act a year after it had been passed, as if they had suddenly discovered the plans for mass privatisation of the NHS.15
The impotence of the profession, or its representative bodies, and the feebleness of its leadership (with one or two extraordinary exceptions) should not occasion surprise. The medical establishment had scarcely noticed – or if they had, done nothing to oppose – the trends over the previous decades that I have just described, which were making it easier for politicians to ignore them. The failure to see that Lansley’s bill was a threat to their fundamental purpose was myopia as usual. They seem not to have grasped that their mission to improve the quality of doctoring and maintain the highest standards of patient care is not deliverable within a political framework that undermines it. It is unlikely that the royal colleges’ well-meaning reports would attract much attention from the senior executives of UnitedHealthcare, Serco or Virgin Care.16 The image that comes to mind is of a series of ridge tents pitched on an avalanche.
The inspiring exception to the mild-mannered protests of the royal colleges (concerned not to upset anyone or threaten their charitable status by being accused of being ‘political’) and the BMA’s advocacy of ‘critical engagement’ (not exactly an adequate response to threatened destruction of everything you are supposed to stand for) was the Royal College of General Practitioners. Their courageous leader Dr Clare Gerada maintained to the very end that the bill would ‘cause irreparable damage to patient care and jeopardise the NHS’.17 The story of Gerada’s lonely opposition should shame those who kept mum, whatever their reason. Had she been supported by the other powerful medical bodies in her call for the bill to be dropped, then ‘Dr Lansley’s Monster’ (as the British Medical Journal called it18) might well have assumed its rightful place in the dustbin of history.
I have focused on the betrayal by the medical profession but there were other parties who failed to mount an effective opposition to Lansley’s bill. The other health care unions – which would be an interesting study in themselves – while they were clearly opposed to the bill, did not manage to make themselves heard. They were, of course, in a weaker position than the royal colleges because their clearly expressed views could more easily be dismissed as self-interested. But there were two other players: the media and the politicians. I want to say something briefly about each.
First, the media. As Oliver Huitson demonstrates, with a few honourable exceptions (most notably Polly Toynbee and her colleagues at the Guardian, the online openDemocracy and, from time to time, the Mail group of newspapers), there was a failure in many print and broadcast media to grasp and communicate the implications of Lansley’s proposed changes. The mantras of ‘putting the patient at the heart of the NHS’ and placing most of the NHS budget (variously quantified as £60 billion and £80 billion annual expenditure) in the hands of GPs was reported and repeated endlessly. In fact, as Pollock and Price make clear in chapter 7, the most important budgetary consequence of the bill would be to place both commissioning and provision of services in the hands of private providers, concealing from public scrutiny the way the health care budget was being spent and, of course, distancing the Secretary of State from responsibility for an increasingly privatised service. Just how little awareness there was of the serious implications of Lansley’s bill is reflected in the findings of an Ipsos MORI poll conducted in February 2012, just as the battles in the House of Lords were reaching their climax, in that only 22 per cent of those surveyed regarded the NHS as the most important issue facing Britain – a long way behind immigration.19
Second, the politicians. The Tories in opposition deceived the public about their plans for the NHS but at least their aims were in accordance with their ideological preference for private over public provision or, failing that, marketised public services. They were being true to their unprincipled principles. As Stewart Player shows in chapter 2, Labour were most culpable; in particular Alan Milburn, whose ultimate ambition – not made clear to those who had elected him – was to make the NHS ‘a kitemark attached to the institutions and activities of purely private providers’.20 The Tories were entirely justified in claiming (when they were not describing the bill as ‘revolutionary’) that their proposals were a realisation of a plan dreamed up by the neoliberal wing of the Labour Party; that they were finishing Labour’s dirty work for it. Lansley’s destruction of the NHS has been a long time in the making.
This left the Lib Dems, who are the focus of Charles West’s insider account in chapter 5 (A Failure of Politics). Without their support it is inconceivable that a minority Conservative government could have got the bill through. What is more, that support was in the face of opposition from their own grassroots membership, who, as West makes clear, were deceived and outmanoeuvred by their leaders. Nick Clegg’s wavering and confusion – due in part to his initial careless inattention to the bill and its implications – is shocking. It was probably not a symptom of the corruption that comes from power – it was too quick for that – but perhaps the equally dangerous corrupting effect of impotence, not too different from that which had been seen in the Labour Party’s reinvention of itself, and betrayal of its principles, in the years out of office.
One of the great mysteries that West tries to make sense of is Shirley Williams’s defence of the bill at a crucial moment, having earlier made plain her opposition to its core features. It is tragic that Williams’s capitulation, which would have such malign consequences, might be the most important decision in her distinguished career of public service.
Let me end this overture by addressing several questions that may be crossing the reader’s mind.
First, is the bill really as destructive as some have painted it? Does it matter who provides health care, so long as it is of a high standard and is free at the point of need? The answers to these questions are to be found in chapter 7 in particular, where Allyson M. Pollock and David Price spell out the consequences of an unravelling NHS. It will take some time for these consequences to unfold but once they have done so, and it is realised that something catastrophic has happened, it will be more difficult to reverse the changes. No administration will be able to buy out the private sector and return the NHS to public ownership or recreate a coherent service from the fragments in the hands of dozens of private providers. Think how, after many years of chaos, renationalising the railways was a financial impossibility. We must act urgently.
Second, is the NHS worth saving? On the most disinterested assessments, the NHS is both efficient and effective and is currently enjoying a very high level of approval ratings – over 90 per cent – by those who use it. A report by The Commonwealth Fund assessing quality, efficiency, access to care, equity and healthy lives in different health systems in seven industrialised countries, was published in June 2010, just before Lansley’s plans were sprung on the nation. It rated the NHS very highly on quality of, and access to, care; it was top (above, for example, Australia and the Netherlands) on efficiency.21 By contrast the US – the inspiration for much of Lansley’s thinking – was a dismal last in all measures. Even more tellingly, a report published in January 2013 found that the US, which devotes a staggering 18 per cent of its economy to health spending (double the percentage of the UK), is at or near the bottom in measures of health and life expectancy in sixteen economically wealthy countries.22
The NHS, however, does have its problems. The shocking findings of the Francis Inquiry into the neglect of patients at the Mid Staffordshire NHS Foundation Trust indicate the scale of such problems in some places.23 But the Health and Social Care Act 2012 will not solve them; rather it will make them worse. We may anticipate resources siphoned off into the pockets of private providers, and the atomisation of services. This will be associated with the fragmentation of health care into discrete functions provided by individuals whose primary loyalty must be to the company. Those who blow the whistle on bad, negligent, dangerous and unethical practice in a privatised NHS will face even greater risks to their personal prospects. Indeed, it is the quasi-marketisation of the NHS, with desperately competitive management and ‘de-professionalised’ professionals, and the introduction of much-lauded ‘private sector disciplines’ and ‘private sector values’ that lay behind much of the awfulness of what went on in the Mid Staffordshire Trust. And the events at Winterbourne (hidden from) View, where patients were abused at the per capita cost to the taxpayer of £150,000 a year, hardly demonstrate the humanising influence of the market in health care.
Third, why rake over the past? The answer is straightforward. If we do not examine and come to understand the context that led to Lansley’s act, we shall not be able to reverse the most toxic parts of it. Most of this book focuses on that context: deceitful politicians with their weasel words; a demoralised, supine or ‘de-professionalised’ profession; and failings of the media in their duty to inform. It is not enough to be tough on Lansley: we need to be tough on the causes of Lansley so that what happened in 2012, for which the way was prepared in the preceding decades, can never be repeated. NHS SOS has been written in the belief that effective opposition requires clear diagnosis of the pathological background and aetiology of the Health and Social Care Act 2012, in particular the corruption of the political process that permitted a drive towards universal privatisation without a political mandate.
Fourth, can there be effective opposition? Isn’t it all too late? We believe that there is room for hope. The most pernicious parts of Lansley’s act can be removed without yet a further reorganisation. Reinstatement of the duties of the Secretary of State for Health and of the NHS as the preferred provider for services would limit many of the damaging effects of Lansley’s dream. It is heartening, and reassuring, that this view is shared with as astute and experienced a politician as Lord Owen, who has tabled a bill to this effect.24
Fifth and finally, what can we do to create effective opposition? This is the theme of the Afterword by Jacky Davis and myself. It is based on the collective wisdom of many of our contributors and we hope it will motivate readers to act.
So, the battle is engaged. It is of supreme importance. The NHS was created at a time of great austerity (much more severe than that which the bankers and their neoliberal friends have inflicted on the people of this country) and belongs to an era in which each of us recognises that we share the vulnerability of all. We must not allow this jewel in the crown of the welfare state to be destroyed by those whose rapacious self-interest has rendered them unable to comprehend any notion of the public good or public service. If the corporate raiders succeed, some of us will die from lack of care, many more will undergo unnecessary suffering due to ill health,25 and more still will experience financial ruin. This seems a high price to pay for making the world pleasing to hedge fund managers and multinational companies, whose interests are increasingly dominant in the corrupted parliamentary processes shaping every aspect of our lives.
If Percy Shelley were alive today, he would have to admit that it is not the poets but the Fortune 500 who are the ‘unacknowledged legislators of the world’. It is perhaps more than a little ambitious to hope that we might be able to change this. However, foiling politicians’ plans to turn the NHS into a lucrative industry – something for which there is no political mandate – that will provide fewer and worse services at greater cost is something that lies within our powers.26