The Sustainability of the NHS
The neoliberal ideology of health care provision.
‘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”
(Direct Democracy p74).
Amid the junior doctors’ strike of 2016, the health secretary at that time, Jeremy Hunt, was embroiled in a conflict with the BMA over doctors’ contracts designed to address a 7 day NHS. This was the surface issue that 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 ongoing project of privatisation and corporatisation of the NHS.
Since 2012, Pollock argues, the NHS has been dismantled and been replaced with privatised and corporatized service provision. ‘Patient Choice’ and ‘Patient Safety’ as laudable aims, are being used as the veils to mask the ideological 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 access and comprehensive cover, is under threat. Daniel Hannan may say that this has long been a complaint of certain interest groups that has yet to materialise. The Government still remains the almost monopoly purchaser of health services on our behalf, but for how long? The social care home crisis points in the direction of travel. The future is further withdrawal of state funding and more reliance on private provision which will not be ‘free at the point of delivery.’ Hannan’s complaint that threats of privatisation have not materialised, is undermined a little by his realisation that the public are very wary of changes to the NHS and therefore any politician wishing to rush this process has to take into account voter feeling. So, to say that it has not fully happened merely reflects the softly, softly approach required to dismantle a much loved institution.
There is a history to this process.
In 2005 ‘Direct Democracy– an agenda for a new model party’ was published, the authors include the past and current (2018) health secretaries Jeremy Hunt and Daniel Hannan. It is not yet 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, and the ‘good that government can do‘ 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.
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. This is known as the ‘Moral Underclass Discourse’. The answer to those making poor lifestyle choices and thus keeping themselves poor, 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’.
Daniel Hannan in 2018 has argued for United States healthcare companies to compete with the NHS to run hospitals as part of a free trade pact after Brexit. There is a story to be told here of the links and visits made to the United States by UK ministers such as Liam Fox and the ‘dark money’ that funds it. This is part of a blueprint for a free trade deal between the US and the UK to open up the NHS to competition from the US, along with reducing consumer and environmental regulations.
Hannan has denied back in 2015 that privatisation is going on.
According to Alysson Pollock, the Health and Social Care Act 2012:
- Removed the duty of the Secretary of State for health to secure and provide health care for all.
- Introduced US style insurance schemes.
- 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:
- Services are broken up and put out to tender to commercial companies.
- 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 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).
‘Direct Democracy’ claims to hold to three principles:
- Decisions should be taken as closely to the people they affect.
- Law makers should be directly accountable.
- 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) discusses with clarity thee 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 and Hannan’s neoliberal 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 2018.
“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?
Many of the critiques evoked 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.
The Perfect Health System?
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.
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?
‘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 as a wedge driven between the deserving and the undeserving ill. The NHS was to socialise risk, to spread its cost across the whole population. Instead we are moving towards individualising risk and private insurance based provision as the state withers away.
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:
- 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:
- The State must not govern society or dictate to individuals how to dispose of their private property.
- The State must not regulate the free market.
- The State must not interfere with ‘God Given’ rights to make profits or to amass personal wealth.
- 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.