Month: April 2016

Hunt’s agenda

The ideology of health care provision.

 

 

Amid the junior doctors strike of 2016, the health secretary Jeremy Hunt was embroiled in a conflict with the BMA over doctors’ contracts designed to address a 7day NHS. This is the surface issue but sits upon a deeper ideological conflict, one that many of the doctors will be unaware of but will suspect, especially if they have read Alysson Pollock’s works on the privatisation and corporatisation of the NHS. Hunt argued he has a ‘mandate’ to introduce a 7 day NHS and perhaps realises that if this policy cannot be introduced, the balance of power over the future of the NHS will swing back towards the BMA and other health professional groups. The irony is that the BMA opposed the introduction of the NHS back in 1948 but now is one of the strongest supporters. Since 2012 however, the NHS has been dismantled and been replaced with privatised and corporatized service provision, with ‘patient choice’ and ‘patient safety’ being used as the ideological veil which masks the corporate face. People have not noticed this detail because so far ‘free at the point of delivery’ is still in place, but this principle, along with universal and comprehensive cover, is under threat. The government remain the almost monopoly purchaser of health services on our behalf but for how long? The care home crisis points in the direction of travel. This will be withdrawal of state funding and reliance on private provision which will not be ‘free at the point of delivery’.

 

 

 

In 2005 ‘Direct Democracy – an agenda for a new model party’ was published, the authors include the current health secretary Jeremy Hunt. It is not government policy and does not represent the full range of conservative views. The Tory party itself is home to those of a ‘one nation’ persuasion who mix ideas of ‘noblesse oblige’ with a modicum of a social welfare, safety net, public service ethos. It is also home to ‘neoliberalism’ rooted in anti State sentiment based on freedom of the individual and free market economics. This ideology can be clearly seen in the 2012 book ‘Britannia Unchained – Global lessons for growth and prosperity’ which argues for further free market economics based on a bonfire of employment laws. The book suggests:

 

“The British are among the worst idlers in the world. We work among the lowest hours, we retire early and our productivity is poor. Whereas Indian children aspire to be doctors or businessmen, the British are more interested in football and pop music.”

 

This one quote conveys the disdain neoliberals have in general for those less well paid, less “successful” and less powerful than themselves. Boris Johnson’s speech in 2013 on the impossibility of equality being based on differences in IQ, implied some people are too stupid to get ahead. This individualises issues, while ignoring structures of class, gender, ethnicity and privilege. He said:

 

And for one reason or another – boardroom greed or, as I am assured, the natural and god-given talent of boardroom inhabitants – the income gap between the top cornflakes and the bottom cornflakes is getting wider than ever. I stress: I don’t believe that economic equality is possible; indeed, some measure of inequality is essential for the spirit of envy and keeping up with the Joneses that is, like greed, a valuable spur to economic activity.”

 

Two ideas are core here: that the working class and the poor are so because they are more lazy and stupid than the ruling class, and that the answer to this is to increase competition and to use inequality as incentives for personal improvement. Of course said like that to the electorate, it would seriously threaten voter support. Instead the discourse of market efficiency, effectiveness and choice is used to justify privatization and corporatization of public services. The message to the public is clear: take responsibility for education, health, social care and housing. It is down to individuals and families to provide by working hard and being prudent.

 

The arguments over the NHS have to be seen within this wider context. At heart, many in the current Tory party viewed the state run NHS as anathema. As such they have succeeded in dismantling the post war structure of the NHS following the Health and Social Care Act 2012. This allowed for private providers to bid for the provision of health services but keeps in place, for now, principles such as ‘free at the point of delivery’.

 

According to Alysson Pollock, the Health and Social Care Act 2012:

 

  1. Removed the duty of the Secretary of State for health to secure and provide health care for all.
  2. Introduced US style insurance schemes.
  3. Gives the secretary of state legal powers to create a market, allows providers to pick and choose which patients will get care, services to be provided and what will be charged for.

 

A market has been introduced into health service delivery, and markets operate through risk selection and appraisal resulting in fragmentation of provision. That is to say a market provider needs to pick and choose which patients are profitable in competition with other providers. We now have clinical commissioning groups modelled on insurance based lines. Those with high risk or multiple needs will be expensive to provide care for.

 

The ‘NHS’ is now fragmented in which:

 

  1. Services are broken up and put out to tender to commercial companies.
  2. Commercial shareholders have new legal powers to decide who gets care, what the get and what they pay for.

 

This current state of affairs is not enough for neoliberal thought. So what is the vision of this group of neoliberal Tories? How did this happen?

 

Direct Democracy argues:

 

“Several other countries operate political systems based on localism and direct democracy. Two outstanding examples – one much smaller than the United Kingdom and one many times larger – are Switzerland and the United States. In their different ways, both states respect the principles of the dispersal of power, the direct election of public officials and the use of the referendum as a legislative tool. Our proposals for the devolution of power directly to the citizen – notably in the fields of education and health care – have also been successfully trialled abroad, often in unlikely places. No less corporatist a state than Sweden has introduced a form of school voucher, while almost every state in Europe, at least since the fall of the Berlin Wall, now provides for an element of health insurance”.

 

This goes to the heart of the matter, note how the US and the Swiss are held up as models. The principles of localism and direct democracy are invoked as justifications hiding their argument and belief about market mechanisms. The United States is a beacon for the dispersal of power? One cannot expect anything other than this nonsense from neoliberals, wilfully ignorant as they surely must be of the work of C Wright Mills, Herbert Marcuse, Jurgen Habermas, David Harvey, Thomas Picketty, Graham Scambler, and Yanis Varoufakis? This also ignores the literature on social inequalities and inequalities in health and the social and political determinants of health. At this point we must also point to the wealth of feminist and post-colonial literature on ‘power’. In short it is an invocation of bourgeois patriarchal perspective on the exercise of power which blinds them to actuality.

 

As for Switzerland, the OECD reports that compared to the UK’s 9.3 % of GDP, the Swiss pay 11.4%. The UK used to pay under 6% but has seen a rise, not totally due to actual health spending but to cater for administration and profit for private companies. The US spends 16.9% (OECD 2014) and has introduced ‘Obama care’ to address the plight of uninsured americans. Obama care is an outcome of class struggle which has been hotly contested in the ‘land of the free’.

 

 

 

‘Direct Democracy’ claims to hold to three principles:

 

  1. Decisions should be taken as closely to the people they affect.
  2. Law makers should be directly accountable.
  3. The citizen should enjoy maximum freedom from state control.

 

 

On the face of it who would argue with that? Certainly not anarchists, socialists or libertarians. The problem is that these principles exist within a social and historical context, one characterised by imbalances of power along class, gender and ethnic lines and this cannot deal with the reality on the ground. Hunt et al are blind to the context in which ‘men of wealth buy men of power’, a world in which the capitalist class executive and the political power elite exercise a new class/command dynamic which neoliberal ‘reforms’ ushered in since about the 1980’s especially in the US and UK.

 

Yanis Varoufakis (2016) clearly discusses the effects of such things as the “Nixon Shock’ on the post war global financial settlement, the outcome being that the ‘strong do what they can and the weak suffer what they must’. Global health corporations need new markets and looked to the UK’s NHS as a source of rich pickings. This is the context in which Hunt’s bourgeois democracy operates.

 

  • Decisions about who provides health care, what health care looks like and where it is provided are taken by unelected clinical commissioning groups operating within a profit driven market context.
  • Patients do not have an electable secretary of state who has a statutory obligation to provide health care services.
  • Freedom from state control for health service provision has morphed into control via corporate decision making.

 

 

Direct Democracy (2005) argues:

 

‘The problem with the NHS is not one of resources. Rather it is the system remains centrally run, state monopoly designed over half a century ago’ (p74).

 

Clearly this is a statement that ‘the system’ needs to go. The resource issue in the context of increasing demands and costs is brushed aside. This remark now looks questionable at best in 2016.

 

“We should fund patients either through the tax system or by way of universal insurance, to purchase health care from the provider of their choice. Those without means would have their contributions supplemented or paid for by the State.” (p74).

 

Holding on to a notion of ‘free at the point of delivery’ implied here, it is clear that private provision is to be introduced. The language is anodyne, context free, taking no notice of what private provision might look like, who would provide it and what the consequences of the inevitability of a market might be. The State at least has a role in providing for the poor. The writers of this document are part of the political power elite, or may wish to be, and the coherence of interests with the corporate/capitalist class executive are hidden. Those who sell insurance have not been lobbying for this change then? A bit of research into who benefits from this change might prove insightful. Are there links between corporate interest and the politicians who are driving the changes?

 

Hunt et al feared the NHS would only be second to the US in terms of % of GDP spent. This has not occurred. They report a study ranking the UK 18 of 19 countries. This is selective in the extreme, and is now way out of date.

 

Many of the critiques they evoke of the NHS are a result of the rise of new public management, or ‘managerialism, introduced into the system by previous governments both New Labour and Tory. For about three decades managerial control, targets and distrust of professionals have eroded the ability of the NHS to be the best in the world.  The judgment about the efficiency and effectiveness of health services partly depends on what criteria are being used to judge them. The % spend of GDP is a crude figure as it hides a plethora of costs and profits.

 

Other measures of success could include universality of access, comprehensiveness of cover, mortality and morbidity outcomes, and the publics’ safety and satisfaction.

 

Mark Britnall has written ‘In search of the Perfect Health System’ (2015) of the complexity of comparing health systems. Britnall is no Tory ideologue and describes his approach as more brown mud than blue sky thinking:

 

He also wrote in 2011 before the 2012 Act:

 

“[o]f course, the vast majority of care – quite rightly in the UK context – will always be provided by public sector organisations (currently, about 95% of it) and will be paid out of taxation” and “[t]he issue of competition, which now seems to be conflated with privatisation, is unhelpful and misleading and, at best, only a small part of reform. Competition can exist without privatisation and the NHS can maintain its historic role in funding care while dealing with a richer variety of providers – public sector, social enterprise and private organisations”.

 

This 2011 comment predated the 2012 Act and can be seen as a statement of intent than actuality on his part. In 2010 there was some controversy over his statements in the US about private provision.

 

One area in which private provision is facing severe challenges is the care home sector.

 

Roy Lilley, writes a daily blog, and has considerable experience in the health service and with private sector organisations. He is no left wing radical. He writes in ‘They don’t matter’ (3rd May 2016) that success in private provision in the community has been ‘patchy’, citing Circle’s loss of £5 million and the paying of another £2 million to get out of the Hinchinbrooke contract, while SERCO and Bupa ‘bailed out’ of provision leaving Virgin clinging on. He argues that the private sector can be nimble and quick to adapt, but of course needs to make a profit.

 

However, the largest care home provider, Four Seasons, is in talks to ‘restructure its debt’ as they face a 39% drop in profits. Most of their ‘customers’ have their fees paid by social services. This amounts to some local authorities paying £385 per week which is just not enough. The living wage is also an issue for them, they have over 30,000 staff but with no way of adjusting prices to pay for the increase and with no operating surplus. It has a debt of £510 million. If Four Seasons go broke they have 450 care homes at risk.

 

The bottom line is that health and social care costs money. There is not enough money in the system to pay for the care required. Some private families are paying £1,250 per week. Company Watch data which covers 20,000 homes, indicates that there is a funding black hole of half a billion pounds. This is market failure due to inadequate funding by design. It is almost as if the government is deliberately forcing people to find the money themselves either through savings, insurance or property while state funding through local authorities is slowly wound down.

 

Mark Britnall’s approach is scholarly, based in experience managing health care organisations and a deep knowledge and overview of many health systems. However, is Britnall sufficiently aware of the political economy of neoliberalism and its agenda for health?  Roy Lilley’s highlighting of the care home crisis clearly shows the political, austerity driven nature of the issue.

 

‘Direct Democracy’ and ‘Britannia Unchained’ are ideological approaches to health and social care. Whether Hunt has the temper for addressing Britnall’s insights or whether he still stands by the document he co-wrote is anyone’s guess. However, I know where the smart money would go. His face down of the doctors is more to do with power and who exercises it rather than the future of the health service as we knew it. If the neoliberals can get away with it, then free at the point of delivery will be severely challenged perhaps using spurious arguments stigmatising drug users, alcoholics, smokers, the obese, self harmers, self inflicted sports injuries, prostitutes, the promiscuous and Johnson’s ‘stupid’ as a wedge driven between the deserving and the undeserving ill. The care home crisis indicates that older people are ignored and the costs increasingly privatised as the state withdraws, or should we say abdicates, support. The NHS was to socialise risk, to spread its cost across the whole population. Instead we are rapidly moving towards individualising risk and private insurance based provision as the state withers away.

 

The neoliberal revolution and Health

Neoliberalism has various meanings, but many commonalities (Hall, 2011). Nurses in the UK’s NHS, alongside their colleagues elsewhere, may not be familiar with the term but they will be familiar with its effects on service delivery, patient care and of course their own working conditions (Abramovitz & Zelnick, 2010; Gonçalves et al., 2015; Horton, 2007; Reiger & Lane, 2013; Wright, 2014).  Stuart Hall outlines the main ideas underpinning what he calls the ‘neoliberal revolution’ (Hall, 2011). This is useful for nurses in order to first understand and then to act.

 

The main ideas according to Hall (2011) are:

  1. It is grounded in the idea of the ‘free, possessive, individual’; a concept understood in classical economics as ‘homo economicus’ – the rational actor in a market weighing up costs and benefits of consuming decisions according to price signals. Therefore:
  2. The State must not govern society or dictate to individuals how to dispose of their private property.
  3. The State must not regulate the free market.
  4. The State must not interfere with ‘God Given’ rights to make profits or to amass personal wealth.
  5. The State is tyrannical and oppressive.

 

In the health service it means:

 

  • The State should not really be running hospitals. Instead private sector companies, and health care professionals should offer their services for a fee. These providers should compete in a market
  • Patients are not really patients but consumers of health care services and so should decide what they want, when they want it and where they want it.
  • The State should not tax the public to pay for health services, instead there should be private health insurance or provision by family, charity and friends.
  • The NHS gets in the way pf private sector companies money making services by distorting the market.
  • There should not be any national pay and conditions for service providers, that should be decided by the market, so where demand outstrips supply the price (wages) should go up.

 

 

 

Abramovitz, M. & Zelnick, J. (2010) ‘Double jeopardy: the impact of neoliberalism on care workers in the United States and South Africa’. International journal of health services : planning, administration, evaluation, 40 (1). pp 97.

 

Gonçalves, F., Oliviera-Souza, S., Gollner-Zeitoune, R., Leite-Adame, G. & Pereira do Nascomento, S. (2015) ‘Impacts of neoliberalism on hospital nursing work’. Texto contexto – enferm., 24 (3). pp 646-653.

 

Hall, S. (2011) ‘The neoliberal revolution’. Cultural Studies, 25 (6).

 

Horton, E. (2007) ‘Neoliberalism and the Australian Healthcare System (factory)’. Proceedings 2007 Conference of the Philsophy of Education Society of Australasia. Wellington. Available at: http://eprints.qut.edu.au/14444/1/14444.pdf (Accessed: 7th December 2015).

 

Reiger, K. & Lane, K. (2013) ”How can we go on caring when nobody here cares about us?’ Australian public maternity units as contested care sites.(Report)’. Women and Birth, 26 (2). pp 133.

 

Wright, S. (2014) ‘Cash v compassion: underpaid care workers expose the battle between the profit and the service ethos, says Stephen Wright.(Reflections)’. Nursing Standard, 29 (1). pp 26.

 

Inequality, the Gini coefficient, does it matter?

Inequality (Income) and the Gini Coefficient.

(picture of global GC by Kurzon (Own work) [CC0], via Wikimedia Commons)

On 16th April 2016 The RSA held a discussion called the ‘Inequality debate’ which posed the question ‘is growing Inequality a price worth paying for London’s continued economic success?’ The panel largely answered in the negative but Mark Littlewood, Director of the Institute of Economic Affairs, questioned the accepted fact of inequality arguing that income inequality as measured by the gini coefficient (GC) has not increased in the UK.

This was an interesting point because it challenges much of the debate around social inequalities and health inequalities. Littlewood’s point is correct, but irrelevant, due to issues with the sensitivity of the GC, other measures of inequality and other dimensions of inequality for example  of health (Marmot 2010).

 

Gini Coefficient and the Palma ratio

The coefficient is between 0, where everyone earns the same, and 1, where one person earns all the money.

 

In 2012-13, the UK’s Gini score for income inequality was 0.332, as measured by the Office for National Statistics (Figure 1). Individual cities vary in their equality – London is the most unequal, as measured by the Joseph Rowntree Foundation, while Sunderland is the most equal.

 

However, it has been critiqued for not being sensitive enough at the extreme ends of the scale. It does not capture changes in the top 10% or the bottom 40% where most of the poverty lies. Sumner and Cobham have put forward the Palma ratio. If the top 10% has 5 times the income of the bottom 40% the ratio is 5.

 

Larry Elliot (2017 see link below) argues: “The ONS’s estimate of the Gini coefficient comes from its annual publication The Effects of Taxes and Benefits on Household Income (ETB). This shows that inequality peaked at around 0.37 at the end of the 1980s, was still at around 0.35 in the mid-2000s, and has fallen to around 0.32, according to the latest available data.Turn to the DWP and it is a different story. The Gini coefficient is higher than it is according to the ONS (0.35 before housing costs) and on an upward trend.”

In 2013 David Cameron also suggested that inequality was at its lowest level since the 1980’s again supported by the ONS measure of the GC.

 

So we both the prime minister and a director of a think-tank (the IEA) downplaying inequality in public.

 

The IEA published a blog Almost everything the left tells you about inequality is wrong by Ryan Bourne (12th April 2016). Bourne uses the ONS “Effects of taxes and incomes on household income” to argue that the gini coefficient has not exceeded its 1990 level. Income inequality went down largely due to the stagnation of incomes while the rich got relatively poorer than the poor. This indeed indicates an issue with using income inequality as measured by the GC to say much about inequality itself. Income inequality would fall if the top become poorer relative to the bottom but of course in absolute terms would remain far richer. Bourne then points out that it was the top 1% who experienced an income rise, especially the top 0.01%, a point noted by Danny Dorling who argues that it is the 0.01% we should be examining. This is the weakness of the gini coefficient in that it is not sensitive enough to address the 0.01%. Although the income of the top 10% remained unchanged, it is those in the 10% but outside the 1% who saw income fall.

 

As for incomes, Gabriel Palma argues that 50% of gross national income is captured by deciles 5-9, the other 50% is shared between the top 1 decile and the bottom 1-4. He used a data set from the World Development Indicators (135 countries) to argue that there are two forces at work: centrifugal meaning increasing diversity between the top 10% and the bottom 40% and centripetal meaning a growing uniformity of income share within the middle 50%.

The Institute for Fiscal Studies produced a more nuanced discussion than that presented by Littlewood of the IEA and pointed out that the GC was only one measure. Others include the 50/10, 90/50 and 99/90 ratios (figure 3). These are decile ratios so for example 90/50 is the ratio of income at the 90th percentile divided by the level of income at the 50th percentile, the higher the number the greater the inequality. The IFS confirms that within the 1% the incomes of the richest has grown fastest with income growth at 99.9th percentile even higher than at the 99th.

Reasons, say the IFS include:

  • Increases in the financial returns of education ( a wage premium of higher education).
  • Trade liberalisation.
  • Tax and Welfare policy
  • Employment patterns.

 

Top incomes are racing away, which might reflect globalisation and international labour mobility for ‘global stars’ coupled with the erosion of social norms regarding the acceptability of pay differentials. The IFS argue that evidence for these assertions is not yet forthcoming. Nonetheless the top 0.01% are racing away for whatever reason.

Fedirico Cingano (OECD 2014) reports in Trends in income Inequality and its Impact on economic growth that the gap between rich and poor in most OECD countries is at its highest level for 30 years. The top 10% earn 9.5 times the income of the bottom 10%. In the 1980s this ratio was 7:1. He writes;

“econometric analysis suggests that income inequality has a negative and statistically significant impact on subsequent growth” in the OECD. Also:

“In particular, what matters most is the gap between low income households and the rest of the population. In contrast, no evidence is found that those with high incomes pulling away from the rest of the population harms growth”.

Income of course is not the only inequality, we also need to consider:

  • Health
  • Educational attainment
  • Wealth
  • Land ownership
  • CEO pay and employee pay
  • Housing
  • Consumption

 

Inequality is a complex concept and care has to be taken when discussing it. There is a mass of data on the subject for example the equality trust publish data from several sources, but there is no doubt about the scale of inequality in the UK. Does it matter? For those of a neoliberal persuasion, no it does not. In fact, inequality is good because for them it provides incentives and rewards hard work. The rich should be lauded as tax heroes. For others, such as Wilkinson and Pickett, inequality not only harms those at the bottom, it harms everyone in society by eroding trust, increasing anxiety and illness and encouraging excessive consumption.

 

 

Update 2017: Income inequality is getting wider. If the stats count what counts.

https://www.theguardian.com/inequality/2017/dec/03/income-inequality-is-getting-wider-if-the-stats-count-what-counts

 

 

 

 

How responsible am I for my health 2

How responsible am I for my health?

 

The answer to that question from the dominant discourse is an overwhelming “very”.

This response sits alongside more scholarly understandings of the social determinants of health.  This ‘upstream’ understanding is open to ‘Lifestyle Drift’ , ‘downstream’, responses to health. Lifestyle Drift is:

“the tendency for policy to start off recognizing the need for action on upstream social determinants of health inequalities only to drift downstream to focus largely on individual lifestyle factors” (Popay et al 2010)

McKenzie et al (2016) argue:

“Although policy documents may state that the causes of poor health or inequalities in health are to do with poverty and deprivation, the interventions which actually operate on the ground focus much less (if at all) on changing people’s material circumstances and rather more on trying to change behaviours (which are in fact heavily shaped by material circumstances)”.

Nurses might understand the concept of the social gradient in health inequalities but drift into advocating lifestyle changes for the individual, centring around smoking, diet, and exercise messages.

So why is this happening? Why resort to lifestyle approaches to health when we know health is largely socially and politically determined?

 

One answer is that lifestyle answers fit within the neoliberal social imaginary which individualises health and social problems and seeks market solutions to those problems. Neoliberalism is a doctrine well known to many scholars and academics but is hardly mentioned in popular discourse.  To understand responses to health inequalities and poverty , we need to understand the tenets of neoliberalism underpinning much of current thinking:

 

  • Neoliberalism sees competition as the defining characteristic of human relations. Therefore competition between service providers should be introduced into the NHS.
  • It redefines citizens as consumers, whose democratic choices are best exercised by buying and selling, a process that rewards merit and punishes inefficiency. So patients can and should choose between hospitals and GP practices as consumers of health care using their purchasing power (not yet realised in the NHS). This way, poor service providers should go out of business.
  • It maintains that “the market” delivers benefits that could never be achieved by planning. Therefore NHS = bad, US private health insurance = good; BBC = bad,  SKY/Fox = good;  British Rail = bad, Great Western/Virgin = good; Royal Mail (state owned) = bad, Royal Mail (privately owned) = good.
  • Attempts to limit competition are treated as inimical to liberty. Thus socialised NHS service provision must be broken up to allow freedom in the market. The BBC must be sold off because it is unfair competition for Sky.
  • Tax and regulation should be minimised, thus the use of offshore tax havens, reduction in top rate of tax, mistrust of EU environmental standards and hatred of health and safety regulations.
  • Public services should be privatised. The Health and Social Care Act 2012 facilitates this, there may well be more to come for the NHS.
  • The organisation of labour and collective bargaining by trade unions are portrayed as market distortions, that impede the formation of a natural hierarchy of winners and losers. Unison, RCN, BMA etc, must have their power curtailed. The Junior doctors cannot be allowed to win or else it will be a victory for organised labour.
  • Inequality is recast as virtuous: a reward for utility and a generator of wealth, which trickles down to enrich everyone. Those at the bottom require incentives to better themselves, therefore benefits need cutting, those in the middle will benefit from wealth creation.
  • Efforts to create a more equal society are both counter-productive and morally corrosive. The market ensures that everyone gets what they deserve. The arguments from books such as ‘The Spirit Level’ are therefore irrelevant. If there is a social gradient in health then this is the natural outcome of people’s decisions and choices and any attempt to change this invokes  ‘moral hazard’ arguments; that is if people know they have a safety net (someone else takes the risk) they will not try to avoid poor choices.

(Monbiot 2016 The Zombie Doctrine)

 

 

 

Tory Rituals on poverty:

 

 

·         Blame the individual for their illness and poverty.

·         Benefits cause dependency , repeat this ad nauseam.

·         Deny any political responsibility for ill health, emphasise culture as causative.

·         Divide population into:  skivers v strivers, deserving v undeserving poor, low achievers v high achievers.

·         Deny the ‘social’ exists, there are only individuals

·         Privilege wealth through tax breaks and preferential treatment.

·         Deny one’s own privilege as a white affluent male.

 

 

These attitudes underpin the ideology of neoliberalism.

 

For a statement about what the Conservative Party should be about see:Direct Democracy – an agenda for a new model party’ (2005) especially the chapter on health:

 

 

“The problem with the NHS is not one of resources. Rather, it is that the system remains a centrally run, state monopoly, designed over half a century ago”.

 

 

 

All of this results in the politics of blame and shifting responsibility for health fully onto individuals.

If material health assets are paramount, poverty and our response to it is a foundation for understanding health in society. Poverty can be defined as 60% of the median income or using the ‘consensual method’  it is “enforced lack of necessities determined by public opinion”.

However, the UK government’s position is that poverty is not caused by lack of income. Based on Charles Murray’s idea of the ‘Culture of Poverty’, poverty is a result of individual deficits, as Kitty Jones writes:

“the poor have earned their position in society, the poor deserve to be poor because this is a reflection of their lack of qualities, poor character and level of abilities”.

Kitty Jones has written clearly on this issue in 3 blogs, which can be found here.

The alternative view, expressed in for example the ‘Greedy Bastards Hypothesis’ is that poverty, and health inequalities, is caused by the rich, often through unintended consequences of their actions but also through design. It results from structural socio economic conditions that neoliberal governments encourage: for example, low wages, withdrawal of benefit provision and the use of offshore tax regimes. Osborne’s ‘living wage’ is a cynical political manoeuvre designed to woo middling swing voters rather than to address structural economic issues such as under and unemployment , lack of investment in a green economy, deficits in the housing stock and affordability and a zero hours, self employed precarious job structure.

 

Nurses offering health advice, are not immune to this dominant discourse. It suffuses health advice on such sites as NHS choices and is supported by health campaigns which focus on changing individual habits. Action on social inequalities as root causes for ill health sits within specialised public health literature, for example ‘Fair Society,  Healthy Lives’, and unless nurses are exposed to an alternative perspective they will naturally draw upon dominant explanations for health inequalities. These are often either biologically/hereditarian explanations* or a ‘moral underclass discourse’ (Ruth Levitas) or a mix of the two. The politics of neoliberalism encourages the latter perspective.

 

 

Benny Goodman 2016

 

*See Chapter 4 in Psychology and Sociology in Nursing  Goodman 2015 for explanations.

Watch Richard Wilkinson discuss inequalities at a TED talk.

https://www.facebook.com/groups/Sociologyhealthnursing/

 

 

 

 

 

 

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