Category: neoliberalism

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/

 

 

 

 

 

 

To the Guardian: A Political Manifesto for Nursing in unjust times

A Political Manifesto for Nursing in unjust times

 

Despite general satisfaction and support for nurses and the NHS by the public, there are continuing issues that threaten to undermine the trust given by the public, and to the health and wellbeing of the public. These issues include the health and social care needs of older people, care for people with mental health problems and inequalities in health as outlined in ‘The Spirit Level’. Junior Doctors are currently flexing their political muscles while public health professionals have been engaged in civic and political advocacy supported by such organisations as ‘The Equality Trust’.  The political ‘nursing voice’ has yet to be clearly heard.  To do this we propose an ‘Action Nursing’ which should:

 

  1. Equip all nurses with an understanding of the social, political and ecological determinants of health.
  2. Encourage and support nurses to confront vested interests through action at local, national and international level, by providing them with evidence, analysis, justification, critical concepts and theories and thus confidence to speak and to act.
  3. Create a network of clinical and academic nurses, and other co-opted health professionals, to argue and publicise the requirement to ‘speak truth to power’ and to engage in civic, academic and professional activity as part of a wider social movement from below.
  4. Seek and encourage research applications by nurses, alongside other academic colleagues, to continue to add to the body of scholarship on health inequalities and the politics of health care.
  5. To work with any of the Royal Colleges, and any interested parties, on political and civic action.

 

Acknowledging that many health professionals have been engaged in political action already, Action Nursing should encourage the wider body of nurses, and their health colleagues, into organised, confident civic and political action on their own working lives and the lives of the people they work with and for. Without this action, nursing and nurses may continue to be largely ignored, and thus relatively powerless, to change the experiences of vulnerable groups in society, i.e. most of us, the 99%, at some point in our lives.

Choose your parents

Alejandro Nieto.

Bernal Heights. San Francisco.

What has the death of a young man, shot by four police officers in a park in California got to do with with understanding health outcomes in the United Kingdom?

Mary Sue and Miriam. Two women born at similar times whose grandparents came from the same small town in the United States. One will be going to an Ivy League University while the other struggles with drugs and hopelessness writing on her Facebook page ‘Love hurts, Trust is dangerous’.

What links them is that Alejandro and Mary Sue ‘chose the wrong parents’, while Miriam chose wisely, a Harvard professor for a grandfather (Robert Putnam), and University educated parents.

Their cases illustrate that health and well being is ‘structured but not determined’, that to truly understand their life chances we have to consider the transformations in society that impact on the choices made and opportunities open to individuals and their families.

Alejandro was born to Mexican immigrants who came to San Francisco in the 1970’s. His mother worked all her life while his father took on most of the child care duties. San Francisco has a history of immigrants from other parts of the US as well as from elsewhere. Being Hispanic in California is ‘normal’ but not to the white, male, educated tech engineers from Silicon Valley who have moved to the area en mass ushering in gentrification and myopia. Alejandro was described to the Police as probably ‘foreign’ who had a gun, his red jacket marking him out as a gang member. All of this was supposition and assumption. Alejandro had lived in Bernal Heights all of his life, the gun was a taser, carried because he worked as a security guard. His red jacket was a sports jacket, the colour of the local sports team the 49’ers. Those doing the describing were white tech engineers making assumptions about behaviour. Indeed, Alejandro was holding a taser, but he had just been harassed by a dog barking and jumping up at him to get at his chips. The dog owner was 40 feet away, distracted by a ‘jogger’s butt’ and unable to keep his dog under control.

The police arrived, and shot him, one unloading over 20 bullets and had to reload.

Alejandro, Mary Sue and Miriam live at a time when the United States is experiencing growing inequalities in wealth, segregation in its communities, family instability and a collapse of both good working class jobs now being followed by a squeeze on middle class opportunities. While the wealth of the 1% has increased based on their increased share of wealth being created – they are getting an even bigger slice of the pie, working class incomes have stagnated. Mary Sue’s grandfather used to have a decent income from a solidly working class job, now gone leaving ‘flexible’, low paid insecure work.

As economies restructure, as cities adapt to new social conditions, people experience changing social structures that enhance or diminish their chances. The white Ivy League tech engineers are likely to know only other white Ivy Leaguers, to come from Ivy League parents, went to the same schools and know only their own kind in a networked bubble of privilege, social myopia and self satisfying smugness. They don’t know the ‘other’ and can thus label a sports fan as a gang member with in this case lethal consequences.

Perhaps representing their views:

“I know people are frustrated about gentrification happening in the city, but the reality is, we live in a free market society. The wealthy working people have earned their right to live in the city. They went out, got an education, work hard, and earned it. I shouldn’t have to worry about being accosted. I shouldn’t have to see the pain, struggle, and despair of homeless people to and from my way to work every day.”

 

So ‘free market society’ justifies the breakdown of community, segregation, inequality, fear and mistrust. Wealth is ‘earned’ rather than a result of circumstances (right time, right family, right ethnicity, right gender, right neighbourhood, right education, right opportunities and often the inheritance of not only financial but social and cultural capital). Indeed, no one should have be be accosted, no one should see pain and struggle and despair, but don’t blame the victims of unjust social, political and economic systems. Don’t blame the dog for barking when someone’s kicked it.

Alejandro’s ‘personal trouble’ (being shot) is now a public issue. When only one young man is shot by police, we might consider the character of the man and look to him as an individual for reasons and solutions. When hundreds of young men are being shot by police this individual analysis is no longer useful, we must look to social structures, to link personal stories to this point in time in this particular society.

Miriam can look forward to a bright future, she experienced great parenting, great education backed up of course by well resourced material assets. Mary Sue, is a single parent with no education, self harm, a drug habit and abusive partners. Her child will very probably not go to Harvard. Alejandro made the mistake of being born Hispanic and thus a potential threat to the White denizens of a newly gentrified neighbourhood.

If you are struggling to apply this to the UK context, you don’t know the truth and you lack the ‘sociological imagination’.

Alejandro’s story is in Rebecca Solnit ‘Death by Gentrification’. Opinion. The Guardian. March 22nd 2016.
Mary Sue and Miriam’s story is in a talk by Robert Putnam to the RSA in London, March 2015, on ‘Inequality and the Opportunity Gap’. https://www.thersa.org/discover/videos/event-videos/2015/10/robert-putnam-on-inequality-and-opportunity/#

The missing two C’s – commodity and critique

http://tinyurl.com/the-missingtwoCs   This is the link to the published article in the Journal of Research in Nursing.

This discussion paper argues for understanding nursing care as a commodity within capitalist relations of production, ultimately as a product of labour, whose use value far exceeds its exchange value and price. This under recognised commodification of care work obscures the social relationships involved in the contribution to the social reproduction of labour and to capital accumulation by nursing care work. This matters, because many care workers give of themselves and their unpaid overtime to provide care as if in a ‘gift economy’, but in doing so find themselves in subordinate subject positions as a part the social reproduction of labour in a ‘commodity economy’. Thus they are caught in the contradiction between the ‘appearance’ and reality. A focus on the individual moral character of nurses  (e.g. the UK’s 6Cs), may operate as a screen deflecting understanding of the reality of the lived experiences of thousands of care workers and supports the discourse of ‘care as a gift’. The commodification of care work also undermines social reproduction itself. Many nurses will not have tools of analysis to critique their subject positioning by power elites and have thus been largely ineffectual in creating change to the neoliberalist and managerialist context that characterise many healthcare and other public sector organisations. The implications of this analysis for health care policy and nursing practice is the need for a critical praxis (an ‘action nursing’) by nurses and nursing bodies, along with their allies which may include patient groups, to put care in all its guises and consequences central to the political agenda.

 

NHS Dissatisfaction levels are perhaps not yet high enough to embolden the political power elite to further uncouple NHS principles from actual delivery, but they might be going in the right direction.

How satisfied with the NHS are we? The British Social Attitudes Survey has been tracking satisfaction levels since 1983. In 2011 it reached the highest it had been (64%), much higher than the 39% recorded in 2001. In 2000 there was a large rise in funding and according to John Appleby (Kings’ Fund) the change upwards might reflect that extra funding. In 2010 the rate had hit 70%, while in 2015, 65% stated they were quite or very satisfied, with dissatisfaction at a low of 15%. Now, in 2016, dissatisfaction rates have hit a 23% ‘actively dissatisfied’.

 

For trends see the graph at:  http://www.bbc.co.uk/news/health-35527318)

 

 

So, should we read anything into these figures? The “NHS’ is a complex set of organisations and services, and is affected by such external factors such as social care. It is probably foolish to peg changes in attitudes to any one factor (such as funding or waiting times). The survey does provide some information as to why those who are dissatisfied say so:

 

The stand out reason is taking too long to see a GP (60%). Interestingly only less than 5% state ‘stories on TV or radio’. However, 6 reasons above that are also gained by reading the press, watching TV as well as being supplemented by actual experience of friends and family.

See reasons at http://www.bbc.co.uk/news/health-35527318)

 

The figures cannot be directly tracked to funding or political party. The background of the Health and Social Care Act 2012 has not on the face of it made a difference to people’s attitudes. The high rate of satisfaction in 2010 of 70% has dropped to around 60% since, while dissatisfaction has only just started to rise again from the 2011 level.

 

If you want to change the way the NHS is funded, this survey is still an issue. Too many people like it the way it is, “free at the point of delivery” is a possible reason. Social Care (means tested) ranks the lowest on these satisfaction scores and might indicate that funding is a real issue for people.

 

 

The context for this includes 4 assumptions held by governments over the past 25 years: Neena Modi in the Guardian writes:

 

  • Personal responsibility for health supersedes government responsibility.
  • Markets drive efficiency.
  • Universal healthcare is unaffordable.
  • Healthcare is a business.

 

For example, Christopher Smallwood wrote ‘Free at the point of use’ has had its day and argues for private health insurance.

 

Each one of these assumptions are questionable and draw upon a certain view of the role of the state vis a vis the private individual (neoliberalism). Alongside that there are profit making health care organisations looking for new business opportunities that the relatively closed NHS used to block. Graham Scambler’s ‘Greedy Bastards Hypothesis’ suggests that health inequalities are the unintended consequences of the actions of a core cabal of the ‘capitalist executive’ who, aided by the ‘political power elite’ engage in business activities aimed at capital accumulation which includes commercialisation of health services for profit. The Health and Social Care Act 2012 provided an opportunity for just such private sector involvement. A problem for the private sector is that much demand for services comes from an increasingly ageing population whose needs are difficult to make a profit from.

 

 

There are very real discussions to be had about the sort of health service we want and the principles that should underpin it. There is now increasing argument for a rolling back on its founding principles of universal access, comprehensive coverage, equity of service and free at the point of delivery all in the name of ‘affordability’ underpinned by an ideology that deplores public sector provision. Dissatisfaction levels are perhaps not yet high enough to embolden the political power elite to further uncouple NHS principles from actual delivery, but they might be going in the right direction.

 

 

 

For discussion on health services globally see:

 

  1. Which country has the best healthcare system?
  2. Britnall, M (2015) In Search of the Perfect Health System. Palgrave macmillan .

 

 

 

 

 

Has anything changed? The malefactors of great wealth.

I came across a quote in Oreskes and Conway’s (2014) ‘The Collapse of Western Civilization’ from a speech made by a national leader. At this point, I will not name or date the speechmaker. I thought it interesting as a view on the relationship between a nation state and its wealthy individuals and thus on the nature of democracy. What follows are parts of the speech with some commentary in bold. I think it speaks to us today.

 

“National sovereignty is to be upheld in so far as it means the sovereignty of the people used for the real and ultimate good of the people; and state’s rights are to be upheld in so far as they mean the people’s rights. Especially is this true in dealing with the relations of the people as a whole to the great corporations which are the distinguishing feature of modern business conditions”.

The democratic deficit in both the USA and in Europe is that increasingly voters’ rights are being increasingly limited and bound by the rights of corporations and through the actions of corporate lobbying and political influence. The Transatlantic Trade and Investment Partnership  (TTIP) further threatens nation state and citizen democracy by allowing corporations to sue governments if they implement social and environmental protection legislation that the corporation deems a barrier to trade. Thus, national sovereignty is being eroded by such new legislation that does not recognise the sovereignty of people. Globalised capital flows are also eroding national sovereignty through capital mobility and a lack of a globalised governance in such issues as tax evasion and climate protection.

“Experience has shown that it is necessary to exercise a far more efficient control than at present over the business use of those vast fortunes, chiefly corporate, which are used in interstate business”.

More efficient control is now seen as anti-business and anti-democratic by the corporate class executive and the political power elites within a neoliberal idiocy that wants smaller and smaller state interference.

“But there is a growing determination that no man shall amass a great fortune by special privilege, by chicanery and wrong doing, so far that it is in the power of legislation to prevent; and that a fortune, however amassed shall not have a business use that is antisocial”.

This determination has been somewhat diluted as exemplified in Peter Mandelson’s famous quote that new labour is “Intensely relaxed about people getting filthy rich” and Boris Johnson’s eulogy to the rich as an ‘oppressed minority’. In addition we have Tax laws favouring the 1% and their offshore havens and finance capital that rewards fancy financial products while being socially useless. They argue as an article of faith that if taxes on the rich go up, job creation go down to justify their snouts in trough. Nick Hanauer debunks this idea in this short Ted talk. The rich are not job creators.

“Almost every big business is in engaged in interstate commerce and…must not be allowed…to escape thereby all responsibility either to state or to nation”.

Globalisation. If you don’t like our employment practices and wage structures then we will take our investments elsewhere; we will take advantage of the weakness of global labour and call it flexibility. You should be grateful you even have a job.

“The…people became firmly convinced of the need of control over these great aggregations of capital, especially where they had a monopolistic tendency…”

The people have become blind and disorganised, many have been persuaded to vote against their class interests. Many wish there was greater control, but are unsure of how to do it.

“There is unfortunately a certain number of our fellow countrymen who seem to accept the view that unless a man can be proved guilty of some particular crime he shall be counted a good citizen no matter how infamous a life he has led, no matter how pernicious his doctrines or his practices”.

CEO’s of certain banks, some hedge fund managers, asset strippers, CEO’s in the fossil fuel lobby and industry, climate change deniers…..many who form part of the corporate class executive who view corporate social responsibility either as marketing ploy and as a façade to mask their antisocial and anti-environmental business practices. Their rewards are knighthoods, huge salaries and bonuses, because their activities are legal and increase shareholder value.

“There is a world-wide financial disturbance, it is felt in Paris and Berlin…on the New York stock exchange the disturbance has been particularly severe…it may well be the determination of the government…to punish certain malefactors of great wealth…”

They are conspicuous by their absence in criminal courts and yet no common thief has ever cost the country so much.

“….who shall rule this country – the people through their governmental agents or a few ruthless and domineering men, whose wealth makes them particularly formidable, because they hide behind breastworks of corporate  organisation”.

We know the answer now. Government agents are discredited, lobbied or have become representatives of capital, not the people.

“I…hope that the legislation that deals with the regulation of corporations engaged in interstate business will also deal with the rights and interest of the wageworkers…it will be highly disastrous if we permit ourselves to be misled by the pleas of those who see in an unrestricted individualism the all sufficient panacea for social evils…”

Hayek, Friedman, Reagan, Thatcher, Bush, Blair, Cameron. The high priests of neoliberal individualism who first philosophised and then preside and encourage low wage, part time, zero hours economies and call this ‘labour flexibility’.

“The rich man who with hard arrogance declines to consider the rights and the needs of those who are less well off, and the poor man who excites or indulges in envy and hatred of those who are better off, are alien to the spirit of our national life. There exists no more sordid and unlovely type of social development than a plutocracy for there is a peculiar unwholesomeness on a social and governmental idea where wealth by and of itself is held up as the greatest good. The materialism of such a view finds its expression in the life of a man who accumulates a vast fortune in ways that are repugnant to every instinct of generosity and fair dealing or whether it finds expression in the vapidly useless and self-indulgent life of the inheritor of that fortune…”

We now have demonization of the working class, poverty porn on our TVs and victim blaming focusing on immigrants, welfare claimants and benefit cheats as a way of deflecting public anger on the state of public finances and the accumulation of wealth in fewer and fewer hands. The 1% now blame the poor for their fecklessness and lack of hard work resulting in the poor man increasingly turning to such ‘tools’ as jihadist ideology in reprisals. Meanwhile the middle classes in the UK bleat on about inheritance tax that is set at such a level that most of them will not pay it in any case. Turkeys voting for Christmas, Lemmings searching for cliffs, donkeys asking for whips.

 

This speech was given by President Roosevelt 1907  – the words in bold are mine. There is nothing new under the sun, the same issues regarding wealth and its influence and practices exercised Roosevelt over a hundred years ago. Between then and now various policies and legislation were put in place to deal with those worries. However, we have now reverted back to a time when we can again speak of the ‘Malefactors of Great Wealth’. This time around Obama is aware of inequality as a ‘defining challenge of our time’ but is wary of raising it for fear of being accused of class warfare. Roosevelt had no qualms about calling these people out for what they are.

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.

 

 

 

Nurse -patient ratios – what is the evidence?

Peter Griffiths of Southampton University wrote on the researchgate site:

“…..this is an area with a massive literature. The positive association (between more nurses and better patient outcomes) has been demonstrated against a range of quality and safety measures – primarily safety. Linda Aiken is not the only researcher in the area but possibly the best known. 

Try : Kane, R.L., Shamliyan, T.A., Mueller, C., Duval, S., Wilt, T.J., 2007. The Association of Registered Nurse Staffing Levels and Patient Outcomes: Systematic Review and Meta-Analysis. Medical Care 45 (12), 1195-1204 1110.1097/MLR.1190b1013e3181468ca3181463.

…for a comprehensive if slightly dated overview of the safety literature.

Recent reports from the RN4CAST study show associations with other outcomes e.g.:

Ball, J.E., Murrells, T., Rafferty, A.M., Morrow, E., Griffiths, P., 2013. ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Quality & Safety.

Aiken, L.H., Sermeus, W., Van den Heede, K., Sloane, D.M., Busse, R., McKee, M., Bruyneel, L., Rafferty, A.M., Griffiths, P., Moreno-Casbas, M.T., Tishelman, C., Scott, A., Brzostek, T., Kinnunen, J., Schwendimann, R., Heinen, M., Zikos, D., Sjetne, I.S., Smith, H.L., Kutney-Lee, A., 2012. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. British Medical Journal 344.

Aiken, L.H., Sloane, D.M., Bruyneel, L., Van den Heede, K., Sermeus, W., 2013. Nurses’ reports of working conditions and hospital quality of care in 12 countries in Europe. International Journal of Nursing Studies 50 (2), 143-153.

…although limited as they are all self report.

The translation of this to specific ratios is difficult – largely for the reasons highlighted above and the evidence on that policy is less clear cut. Try

McHugh, M.D., Brooks Carthon, M., Sloane, D.M., Wu, E., Kelly, L., Aiken, L.H., 2012. Impact of Nurse Staffing Mandates on Safety-Net Hospitals: Lessons from California. Milbank Quarterly 90 (1), 160-186.

For a favourable gloss.

Some of the limitations are covered in:

Griffiths, P., 2009. RN+RN=better care? What do we know about the association between the number of nurses and patient outcomes? International Journal of Nursing Studies 46 (10), 1289-1290.

…one issue that is very germane for many health sectors is the absence of medical staffing from this literature. See

Griffiths, P., Jones, S., Bottle, A., 2013. Is “failure to rescue” derived from administrative data in England a nurse sensitive patient safety indicator for surgical care? Observational study. International Journal of Nursing Studies 50 (2), 292.

 

I would add:

This question is rooted within a wider context – that of managerialist control of care environments (Traynor 1999, Lees 2013) in which efficiency, effectiveness and economy are to the fore. This approach can militate against the consideration of qualitative, non measurable, outcomes which make a real difference to patients’ experience (Tadd et al 2011, Dixon-Woods et al 2013, Hillman et al 2013). The reality is that many health and social care sectors, in the UK, are under such financial pressure and managerialist control,  that the quality of the care experience is squeezed. Given current narratives of austerity, female undervalued labour and ‘private = good public = bad’, UK society has accepted that for example long term care of older people, and mental health, have to fight their corner for government and personal funding. I suspect that funders (e.g. DoH and FTs) ignore evidence, in any case, of staff-patient ratios, viewing it as idealistic and costly. However, they will not frame it in this way – the response will be that ratios are a blunt tool and should not be set down in terms of basic minimums. While I think it is imperative that evidence comes forth on this topic, we might need to consider that the translational model of evidence to policy is flawed. In the context of climate science,  Pielke (2010) describes the actual relationship between public policy and scientific research as problematic; it is not a linear ‘evidence to policy’ model.  The translational model, or ‘knowledge translation’ (Kerr and Wood 2008), in which scientists come up with answers which are then put into practice by policy makers (Wynne 2010) is contextualised within political and ideological frameworks such as that of neoliberalism and its adjutant, managerialism.  Naively we may think that the job of scientists, and their allies, is to improve the process of knowledge translation so that policy makers, guided by clear evidence, can make the right decisions. Drugs policy research is another example of the failure of this model. In nursing, even if we had irrefutable evidence, there is no necessary link to this and health policy on nurse staffing. The UK’s NHS is a ‘highly politicized setting’ (Traynor 2013), staffing of wards is as much a political as an empirical question.

Dixon-Woods, M., Baker, R., Charles, K., et al (2013) Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Quality and Safety (published online) http://www.ncbi.nlm.nih.gov/pubmed/240195079th September 2013 accessed February 25th 2014
Hillman, A., Tadd, W., Calnan, S., Calnan, M., Bayer, A., and Read, S. (2013) Risk, Governance and the experience of Care. Sociology of Health and Illness. 35 (6) pp 939-955
Kerr, T., and Wood, E. (2008) Closing the gap between evidence and action: the need for knowledge translation in the field of drug policy. International Journal of Drug Policy 19 (3) pp 223-234
Lees, A., Meyer, E., and Rafferty, J. (2013) From Menzies Lyth to Munro: The problem of Manageralism. British Journal of Social Work. 43 (3) 542-558
Pielke, R. (2010) The Climate Fix. Basic Books. New York.
Tadd, W., Hillman, A., Calnan, S., Calnan, M., Bayer, T., and Read, S. (2011) Dignity in Practice: An exploration of the care of older adults in acute NHS Trusts. NIHR Service Delivery and Organisation Programme. Project 08/1819/218. NETSCC – SDO: Southampton
Traynor, M. (1999) Managerialism and Nursing: beyond profession and oppression. Routledge. London
Traynor, M. (2013) Nursing in Context. Policy, Politics, Profession. Palgrave Macmillan.
Wynne, B. (2010) Strange Weather, Again. Climate Science as political art. Theory Culture and Society 27 (2-3): 289-305

Planetary and Public Health – its in our hands ?

From public to planetary health: a manifesto.

The Lancet (Horton et al, 2014) has just published  a manifesto for transforming public health.

You can read the full one page easy to read manifesto here.

This is a call for a social movement at all levels, from individual to the global, to support collective action for public health. Public Health has been widely defined in this manifesto and draws upon the ideas of Barton and Grant’s health map which has climate change, biodiversity and global ecosystems as the outer ring of the determinants of health.

The current definitions of public health, for example from the Faculty of Public Health,  draw upon Acheson’s 1998 definition “The science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society”.  However this definition may now be outdated as there is no mention of environmental or ecological determinants of health and no express action on planetary health at all.

Therefore this manifesto is an implicit call to redefine what public health means. Currently you can read the FPH’s approach to public health and fail to consider issues around climate change, biodiversity loss or the crossing of planetary boundaries which delineate a ‘safe operating space for humanity‘. This needs changing.

The main points within this manifesto  include a definition of ‘planetary’ , rather than ‘public’ health which they argue is an “attitude towards life and a philosophy for living… emphasising people not diseases, and equity not the creation of unjust societies”.  There is a strong focus in the manifesto on the unsustainability of current consumption patterns of living, based on the harms this has on planetary systems. They argue “overconsumption…will cause the collapse of civilisation”. Jared Diamond is worth a read on the collapse of civilisations,  and this argument is in line with his analysis.

Interestingly, an overt political statement is introduced: “We have created an unjust global economic system that favours a small wealthy elite over the many who have so little”. They attack the idea of progress, and of neoliberalism  including ‘transnational forces”, for deepening this ecological crisis and for being socially unjust. There is also a hint of the ‘democratic deficit‘ in which trust between the public and political leaders is breaking down.

The call is for an urgent transformation in values and practices based on recognizing our interdependence and interconnectedness, a new vision of democratic action and cooperation.  A principle of ‘planetism’ is invoked which requires us to conserve and sustain ecosystems upon which we rely.

Finally they suggest that public health and medicine can be independent voices of conscience who along with ’empowered communities’ can confront entrenched interests.

So far so good, and in a one page document the detail is necessarily missing.  The principles outlined in this manifesto and the analysis focusing on neoliberalism and ‘entrenched interests’ point us in a direction. However, there is now a need for a map.

I am not convinced that public health, medicine and certainly not nursing, is sufficiently politically aware of the scale of the issue and the sheer force and dynamic of capitalism to even begin constructing the map. That may be an unfair criticism because the education of health care professionals is ‘ahistoric’ and ‘apolitical’ by nature,  they simply lack a sociological or political imagination underpinned by a critical theory of capitalism. And for good reasons.

However, if doctors and nurses are to engage with this manifesto and to debate and argue for an alternative world view, then there is an urgent need to understand the forces railed against them. This manifesto rightly points out the political nature of the issue and the authors no doubt have a clear idea what they mean, however I doubt very much if the majority of healthcare professionals really understand, or even perhaps care about,  the concept of neoliberalism.

In the UK we will be having an election in 2015, in which we will be offered similar versions of the system that is causing the mess. There will be little in the way of mainstream reporting or argument on radical alternatives to consumption or finance capitalism. Indeed parties will be arguing over who can best manage the system.  The only exception will be the Green party who are a fringe party, in terms of votes.

As an example of the scale of the problem, consider Bill McKibbens’  ‘three numbers‘ argument: 2 for two degrees, the threshold beyond which we should fear to tread; 565 gigatons of CO2 we might be able to put into the atmosphere and have some hope of staying below or around 2 degrees; 2795 gigatons which is the amount of carbon in current reserves, but is the the amount of carbon we are planning to burn!  Further, the wealth of investors is tied up in this number and would evaporate like petrol in a hot day should we globally decide that this reserve should stay in the ground. This is an example of an entrenched interest backed by neoliberal politics which is antithetical to global and governmental regulations. The current TTIP negotiations which is trying to establish a free trade area between the US and the EU,  possibly exemplifies the powerlessness of states in the face of lawsuits by corporations if George Monbiot is correct. TTIP is a public health issue and forms part of the backdrop to this manifesto.

I welcome this manifesto, and would urge public health bodies to become overtly political in their statements about public health, perhaps revisiting Acheson and redefining public health to include planetary health.

Following that observation, a new publication published in February 2014, appears to address the politics in an overt way. The Lancet – University of Oslo Commission on Global Governance for Health argues in a document called ‘The political origins of health inequity: prospects for change’ : “Although the health sector has a crucial role in addressing health inequalities, its efforts often come into conflict with powerful global actors in pursuit of other interests such as protection of national security, safeguarding of sovereignty, or economic goals.”

This then sets up political determinants of health which sit alongside the social determinants of health. Whether it goes as far as critiquing the underlying dynamic of various forms of capitalism remains to be seen.

How much is enough?

Robert and Edward Skidelsky, father and son, address the question ‘How much is enough’, in their recently published book (2012). Robert Skidelsky, professor of political economy, and Edward, lecturer in philosophy, wish to suggest what might the elements of a ‘good life’ accepting that this indeed can be known. Following on from this they suggest that the goals of economic policy should be directed to foster the good life, if we can know what that is, rather then directed towards encouraging mindless GDP growth for growth’s sake. They do this through briefly exploring the work of the renowned economist John Maynard Keynes and through examining the long traditions of philosophical thought. They critique current economic thinking, measurements of happiness and examine some weaknesses of environmentalism.

Underpinning their argument throughout is the notion that wealth is not the ends of a good life, it is merely a means, and not the only or exclusive means at that. In addition to this failure to identify what the ends of economic policy should be, current economics and culture conflates needs and wants thus failing to make the distinction between the two. Policies aimed at the relentless pursuit of money, are then counterproductive because they fail to direct us into asking when we have enough and what a good life is.

Wealth is not what they would classify as a ‘basic good, and is not automatically an element of ‘the good life’. This might seem counterintuitive and goes against the grain of a ‘euromillions lottery, celebrity-obsessed, consumerist culture’. However, many already know that the ‘love of money is the root of evil’ even if they often fall victim to its lures.

 

The argument is of course highly relevant in cultures which have elevated money making and economic growth as ends in themselves. The results of so doing are environmental damage, social division and a diminution of human flourishing, or as Skidelsky and Skidelsky say eudaimonia’.

They leave it until chapter 6 to outline what they consider are the ‘elements of the good life’, which they say could apply across cultures and across time.

So what are these elements (the basic goods) and how do they go about deciding what they should be? Accepting that the choice of these goods could be arbitrary, they argue for inclusion criteria to prevent this. There are thus 4 inclusion criteria to use to choose the ‘basic goods’.

1.    Universality. Basic goods apply across time, cultures, and not just from a localised, time-bound definition of them.

2.    Finality. They are goods in themselves and not a means to an end. Keep asking the ‘what is it for’ question. Money, what is it for? To buy food. Food, what is it for? For life. Life, what is it for? Well, life is not ‘for’ anything, it is not a means to an end, it is an end.

3.    Sui Generis. That means it exists on its own and is not part of anything else. So, ‘freedom from cancer’ is part of larger whole, the good of ‘health’ generally.

4.    Indispensable. Anyone who lacks a basic good can be deemed to have suffered serious harm or loss. Another way is to think of basic goods as needs.

In establishing these criteria of sufficiency, the task is to treat a ‘good’ as basic only if its lack constitutes serious harm or loss, for it is “…only such goods whose possession could be thought to constitute ‘enough’ ” (p153).

In choosing these basic goods they acknowledge that there is fuzziness, room for argument and overlap, but in such matters as this they argue for “honest roughness is better than spurious precision”. (p 154).

The seven basic goods:

1.    Health.

2.    Security.

3.    Respect.

4.    Personality.

5.    Harmony with nature.

6.    Friendship.

7.    Leisure.

Of course each of these need defining and argument, but maybe that is the point. However tempting it may be to descend into a hermeneutic vortex of relativist definition seeking, and as much fun as that might be in academic discourse, this list could be used as a basis for some universal agreement about how much is enough for a ‘good life’. An interesting exercise would be to gather people of faith and those of no faith to discuss the criteria and the seven basic goods. This would highlight subjective definitions of what for example ‘respect’ means. The list itself is difficult to argue with, who does not want health and security?

Herein lies a problem and that is ‘Politics’. The political class, the capitalist class, have yet to show any signs of social solidarity and thus a desire for the development of these basic goods. The marketisation of society, the commodification of all things, continues apace while the main political parties bow down to the God of growth. The Skidelskys resurrect  Keynes who thought that capitalism was a necessary if nasty route to prosperity and well being. He thought increased GDP would provide ‘enough’ and would usher in a shorter 15 hour working week. Yet despite increased national wealth we are now working longer hours. It is however the spirit of Hayek and the triumph of neoliberal free market ideology which has been unleashed upon Western economies. Hayek would want governments to go even further in their attempts to wither away the State. However without a strong civil society and a strong state, the 7 basic goods have no chance of being realized. They are just too vague and do not serve the interests of capital which requires the increase of profit, driven by competitive advantage.

Skidelsky, R., and Skidelsky, E. (2012) How much is enough? The love of money, and the case for the good life. Allen Lane, London.

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