Month: June 2014

The NHS in ruins: Small state private medical care is the future?

You would have to have been living on a desert island, celebrity obsessed or just plain ‘not interested’ to know there is an issue with NHS funding. The issue at stake is not that there is a funding gap between demand and provision, although that is certainly the case. The issue is the dismantling of the NHS as a publically funded service based on core principles. These principles are based on progressive, socialist/collectivist values rooted in social democracy. In short, the larger political project currently underway is the shrinking of the state by transferring its core functions of empowerment and protection of the public, to private, often global, corporations. The ‘moral mission’ of government is being eroded in favour of profit and individualising risk and responsibility.

 

Before we briefly examine this claim, it might be a good idea to remind ourselves of the current basis for the NHS:

 

The NHS was a political project founded in 1948 on the following guiding principles to address inequalities in access to medical services. The 3 core principles were:

1. that it meets everyone’s needs.

2. free at the point of delivery.

3. based on clinical need, not the ability to pay.

Since then these 3 have been developed into 7 principles underpinning the NHS constitution.

1. The NHS provides a comprehensive service available to all.

2. Access to NHS services is based on clinical need, not an individual’s ability to pay.

3. The NHS aspires to the highest standards of excellence and professionalism.

4. The NHS aspires to put patients at the heart of everything it does.

5. The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population.

6. The NHS is committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources.

7. The NHS is accountable to the public, communities and patients that it serves.

NHS Core principles

 

These principles derive from a social democratic root, instigated initially by the post war labour government under the guidance of Aneurin Bevan , Minister for Health in the Attlee government of 1945 to 1951 at a time when the UK owed far more as a % of GDP than it does now. Despite this national debt, the Attlee government still found the money to set up the NHS. So from the outset, this was a political project based on collectivist principles and for this reason is now seen by free market conservatives, neoliberals and small state conservatives, as undesirable. However, as the NHS has huge public support, these critics of collectivism use the language of ‘affordability in austere times’ to frame the debate rather than outright argue for the wholesale privateering of the NHS and a move to individual responsibility for health based on health insurance. As part of this process, there appears an almost deliberate softening up of the public for this privateering and abdication of government responsibility for the protection of the public’s health and medical services. As a result of government policy we are being exposed to stories about NHS funding such as:

The Royal College of General Practitioners asks patients to petition the government on the issue of funding cuts”. This was reported by Neil Roberts in May 2014, who writes that a poster showing queues outside a GP surgery, and a claim that up to 100 practices face closure, is being sent to GP practices. Roberts states:

“The poster and petition, which the college is asking patients to sign, are part of the Put Patients First: Back General Practice campaign, run with the National Association for Patient Participation. The campaign calls for an increase in general practice’s share of NHS funding to 11% by 2017”.

Is this a case of special pleading? I don’t think so, the health service is facing a funding issue, including the £20 billion Nicholson challenge. In the context of rising demand, and an increasing gap in the budget to meet that demand, the NHS requires some radical changes or faces a ‘productivity challenge too far’ (Appleby, J. (2013) A productivity challenge too far? BMJ 344 e2416). One report from the parliamentary Public Accounts Committee, suggested that 1 in 5  NHS Trusts were in financial trouble and bankruptcy was a real option, this despite the NHS having an overall surplus of £2.1 billion in 2012-13. This surplus may not last, and the seemingly disorganised, costly management and inspection schemes alongside the disintegration of the providers into an ‘any willing provider’ mix of public and private do not bode well for the financial future of the service. The Private Finance Initiative (PFI) schemes have also locked some NHS organisations into costly long term contractual agreements.

So, yes the NHS is facing many challenging issues that some argue require a solution not yet fully implemented, although started, by the Health and Social Care Act 2012. This solution is to reduce public provision and encourage private sector organizations to tender and compete for services, they would be known as ‘any willing provider’. In theory this means Tesco as well as small social enterprises.

To get to this position, the NHS has to be seen to be not working and the current pressure on reducing public spending assists this process. Lack of funding, allied to poor services, paves the way for further privateering. The argument is that the state cannot provide the funds and also should not provide the funds, but it is the former argument – ‘austerity’ that is being used as a shield for the latter.

David Cameron, in a speech at the Lord Mayor’s (of London) Banquet on November 11th 2013, outlined the strategic objective: ‘austerity is here to stay’, he said:

“The biggest threat to the cost of living in this country is if our budget deficit and debts get out of control again…we have a plan…it means building a leaner, more efficient state. We have to do more with less”.

Debt reduction as an imperative, masks the ideological position for a smaller state.

Let us not forget, for this government will have you do so, that the debt rose as a result of the bank bail out rather than out of control state spending. The successful narrative is that the debt is all Labour’s fault and that big state spending cannot go on. The global financial crash of 2007-8 is a very useful smokescreen hiding conservative wishes to reduce the state’s functions.

Health and medical services in this worldview is not a public good, it is a commodity to be bought and sold in the market. If the NHS can be seen to be failing, to be expensive, then you have a narrative which states that the answer is selling off the services to private companies and introducing competition. So, why not privatise the NHS?

We already have a model for this; it is childcare, the costs for which is seen primarily as the responsibility of the individual and the family, with just a little state support. The private sector is paying so little for so many families with children, and private sector landlords have private rents so high, that the state is subsidizing low pay with benefits. The idea that the whole of society benefits from well educated, healthy children, and thus has an interest in supporting their development, is sidelined when it comes to paying for that care. Childcare costs are largely picked up by individuals and families. The state supports families with tax credits, child allowance and is introducing some measure of support for childcare for parents who are working. This support derives from a collectivist, not an individualist, political philosophy, and as yet has not been fully withdrawn. This is partly meeting the government’s moral mission to empower and protect its citizens. Conservatives argue however that benefits should be cut, and wonder why those who choose to have children are not fully paying for them, after all it was their choice!

We do not know how far Cameron wants to push competition and more private provision for medical services, we don’t yet know how much of the more expensive US health insurance system he wants to copy. We do know that corporate lobbying for state contracts from companies such as Serco, Capita and GE occur for the more profitable services. See this short film on NHS lobbying .

The Free University argues:

The UK government is proposing to privatise yet more public services including Ministry of Defence procurement and the Fire Services. Other institutions such as the Met Office are also being considered for sale. Privatisation of NHS services has been underway for some time and will accelerate under the secret US/EU Free Trade Agreement currently in negotiation. These are all a manifestation of “Liberalisation“.

Linda Kaucher in 2013 stated:

“Liberalisation means offering investment opportunities transnationally and since the 1980’s, successive UK governments have prioritised liberalisation in both private and public sectors. Private sector liberalisation has resulted in overseas ownership of most UK enterprise. Privatisations in the public sector have been simultaneously liberalised, so overseas investors are involved in the public sector sell-offs (e.g. water, rail), private contracting (e.g. waste collection, hospital cleaning) and PFI schemes. Right now, it is the NHS that is at stake, as it is divided up, privatised and liberalised – potentially forever: once overseas companies are involved, it is very difficult to reverse liberalisations, and, inherently, also the privatisations underpinning them. This is even more the case as liberalisations are committed to international trade agreements –  which is precisely the purpose of trade agreements.”.

The drift is towards more privateering of medical services. Will we get a better health service with improved outcomes? Lets not confuse health with medical services; health is largely socially and politically determined, so even if the NHS is fully publically owned, health outcomes are determined elsewhere (socio-economic status, ethnicity, gender….). The NHS is providing medical services to treat illness and disease and to manage chronic long term conditions. So, will private provision improve medical outcomes, will it improve services for dementia, mental health, elderly care?

Nurses for Reform.

A free market nurse think tank:

“NFR has long argued that the NHS is an essentially Stalinist, nationalised abhorrence and that Britain can do much better without its so called ‘principles’ ”. (2008).

 

Health care is part of the ‘moral mission’ of government (Lakoff 2008 ‘The Political Mind p141) to empower and protect citizens. Lakoff argues that other forms of protection, such as the Police and the Fire services, don’t require insurance and health security likewise should be a function of government. Conservatives do not believe this, they feel that you should have health care only if you are willing and able to pay for it. If you are not making enough money then you probably do not deserve it. For conservatives, health is a commodity that should come with a price in the market. The post war consensus between conservatives and socialists in the UK held back this belief. This is now breaking down and conservatives are emboldened and empowered not only to make this argument, but to enact it.

 

Lakoff poses a simple question…will the privateering of the NHS serve the overall moral mission of protection and empowerment, will protection and empowerment be best served or undermined?

 

Those who argue it will not undermine this moral mission are also set to make a very large profit out of it.

 

 

 

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