Monkey and organ grinder

Monkey and organ grinder

One of David Cameron’s favourite sayings is apparently, “It’s not where you’ve come from, it’s where you going to.” That’s right, the same David Cameron who went to Eton and Brasenose College, Oxford, and who is now leading a Cabinet full of millionaires. The grain of truth in the NHS being a ‘national religion’ might be that the polls consistently return the verdict that the public generally like the idea of a national well-run state NHS. They likewise oppose the notion of its privatisation.

A state-run NHS, funded out of general taxation, free-at-the-point of use is of course critical to the NHS, as is the fundamental duty of the Secretary of State having a duty for the provision of universal healthcare. Conversely, Ed Miliband is terrified of the voters rejecting him. That was of course Tony Blair’s fear too (and his second fear, for the record, was a failure to get re-elected). The purpose of a ‘loyal opposition’ is to provide sharp, constructive criticism of HM Government’s policies, but it seems perhaps at present that the Government is going overboard on the ‘loyal’ bit with not with much opposition. Tony Blair’s vision of the National Health Service can perhaps be for autonomous units in the National Health Service have clinical and financial independence, with more ‘accountability’. PFI was hailed as giving an infrastructure boost to the NHS, but was a natural progression of Conservative policies under John Major.

Because of the bungling nature of the Labour opposition, we can see an ‘extension’ of this “motherhood and apple pie”. Nobody can inherently object to the NHS being run ‘efficiently’, in that nobody aspires the NHS to be run ‘inefficiently’. However, the view of the NHS as a conglomerate of failing businesses is an inaccurate one, and lends itself to a malignant caricature of the uncritical media. There is not so much evidence that introducing a market into the National Health Service improves ‘efficiency’, and yet conversely there are bucketloads of evidence that implementing a market into healthcare reduplicates transactions unnecessarily, introduces various sources of waste and efficiency, and generally can increase the wastage of the order of fifteen fold.

Ed Miliband is a card-carrying social democrat. Whether he is simultaneously a socialist is a matter for his conscience, and to some extent to his own ballot box in Dartmouth Park. Recent mutterings from Ed Miliband have suggested that he, and his partner in crime Lord Stewart Wood, are reluctant to touch taxation with a bargepole, as Miliband is petrified of Labour being tarred with the taxation brush. Of course, apparently Blair is the ‘most successful election winning machine’ Labour ever had, but he was also a man who lacked any socialist principles. As a card-carrying social democrat, however, Ed Miliband can purport to have more than a trivial interest in solidarity. He can also have an interest in social justice, despite the fact that his opposition has presided over one of the most clinical murders of English legal aid in recent times.

The concern is how far Ed Miliband wishes to pursue ‘equality of opportunity’. The Conservatives and Liberal Democrats have prioritised liberalising the market for competing private providers to have a slice of the action. ‘Equality of opportunity’ may have a rather mamby-pamby meaning of Prof Michael Sandel when it comes to social mobility or other society-based issues, but for free market fanatics it literally means a ‘free-for-all’ where you pursue the reduction of barriers-to-entry. The present Coalition have successfully implemented the outsourcing part of the privatised market, but the lack of proven effective regulation could yet prove to be its comeuppance.

The failure of regulation of the new NHS is already being seen on a number of different fronts. The corporate acquisition of Plasma Resources UK raises patient safety implications for blood products being produced as an output of  a business model seeking a quick return on investment. Secondly, a lack of a safe staffing level of nursing staff, coupled with PFI NHS Foundation Trusts hiding from data disclosure requirements under the Freedom of Information Act, is a recipe for disaster while NHS FTs try to implement the “McKinsey efficiency savings”. Thirdly, despite all the tack of ‘greater accountabiltiy’ in the ‘prime contractor’ model of private providers providing “integrated care” (however defined), contractors and subcontractors are subject to the legal doctrine of “privity of contract”, meaning that anybody who is not party to a contract cannot enforce any rights within it.

Being a social democrat, Ed Miliband might also have a fundamentally different definition of ‘redistribution’ to socialists, again reverting to the issue of avoidance of taxation (not “tax avoidance”) to fund the fabric of society. This is illustrated in Ed Miliband’s flagship policy of ‘predistribution’, originally introduced by Professor Jacob Hacker. However, under a liberal market, redistribution could mean instead easily transfer of funds between CCGs, as is already happening. In this neoliberal market, seen already through sporadic national closures of A&E departments not directly protected by PFI funding, this can mean some CCGs will literally wither, and ultimately could leave themselves open to acquisition themselves from the private sector. This is literally an elaboration of the “money following the patient” policy which has been bobbing on the surface for a few years now, with money literally following the money out of the public sector into the private sector.

The effect of this neoliberal ‘survival of the fittest’ CCG architecture, seen by some as providing the infrastructure for full integration with the private insurance industry, will mean that there are some losers and winners. If one wished to ensure an excellent NHS throughout, you would pump money into underperforming Trusts to bring them up to a level of safety and throughput acceptable to the general public. The consequence of members of the public not going to Trusts with longer than average waiting lists could mean that those Trusts get starved of the money they need to function well, and so their performance further deteriorates. And yet nobody wishes openly to have a NHS where, if you can pay, you get special treatment, but surely there are less guards against this type of behaviour in a social democratic NHS.

The opposition led by Ed Miliband is currently full of inherent paradoxes. It sets to repeal the Health and Social Care Act (2012), without a coherent explanation of what it wishes to do about PFI-funded trusts or the McKinsey Efficiency Savings. On the latter two points, it appears it even agrees with the Conservatives (and the Liberal Democrats). It says it wants to reverse competition, but a significant part of introducing the competitive market was achieved in the dying days of the Blair/Brown government. Ed Miliband has promised to restore ‘the duty of the Secretary of State to provide a universal National Health Service’, and yet some members of the Labour health front bench seem more quiet on this issue. One prominent Labour member is reputed to have said recently that he or she would not like to talk about re-nationalising the NHS as this would be ‘political suicide’ for his or her career. There is clearly a lack of political philosophy ability amongst some current influential members of Labour: is it beyond the wit of man to wonder why ‘efficiency savings’ have not been adjusted to take account of the dire performance of the economy, as measured in the last three years?

With monkeys such as this alleged one, one can only look to the organ grinder for clues about where the NHS is heading to. To that extent, where it has come from may in fact be quite irrelevant.

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  1. Martin Rathfelder says:

    I dont think you explain what you think a socialist NHS would look like.

    Does the idea of individual State owned health providers being financially autonomous and liable to fail conflict with your idea of Socialism?

    If it does then perhaps we should abandon the whole idea of an internal market. But enen without it surely individual organisations need to be run in a business like way?

    1. what is a “businesslike way”? i wish people would not conflate “businesslike” with “efficient” or “good” (didn’t this start with Thatcher?). i have worked in extremely large businesses and they were unbelievably inefficient. forms had to be filled in triplicate to get stationery out of the cupboard (seriously).

  2. Shibley says:

    both very good questions Martin. I will have a think along with others I hope.

  3. Des Halestrap says:

    Ok Then lets start work on “What a Socialist health service should look like” At the moment I believe we are just floundering around

  4. Martin Rathfelder says:

    The most obvious point is surely that a socialist health service should focus on preventing ill health, from which disadvantaged people suffer more.

  5. I was Born one month after the second world war ended, I grew up with the NHS although My mother paid £7 per week when I was born in a privately run hospital, as there were no NHS hospitals at that time.

    To say what a Socialist Health service should look like, is ask how long is a piece of string. Martin you are clearly not a socialist, otherwise you would realise that that everything encompassing health needs; is a socialist priority.

    From the cradle to the grave.

    What you are espousing is a neo-liberal system of care, which looks at how we pay for that system. I suspect you do understand how money is created but like Miliband you would rather serve the interests of the Banks than take control of the country.

    If you do not have control of finance you can’t control the economy, which is why the Banking and financial sector rule with an iron fist.

    Because I know you understand that no country with it’s own currency can ever go broke, the question of what we need from the NHS is not how much money do we have to pay for it but what resources we have to provide it.

    This link will explain how the economy works and how we have been duped by the political system for hundreds of years.


    This other Link is a much longer lecture given by Professor Mark Blyth, but fundamentally is about the same thing.


  6. Val Hudson says:

    Martin I do not agree with this argument you always put that the nature of our National Health Service depends primarily on the prevention of ill health. That’s what happened at the beginning of the last century, but people live longer and often then have a number of co morbidities which need a good national health and social care services to be able to respond. Why as a socialist organisation are we afraid to say that? The other issue with preventing ill health is that the evidence shows the biggest determinant of preventable diseases that cause health inequality is poverty. And yet even under 13years of a Neo-Liberal New Labour Government the gap between rich and poor widened not narrowed. Let’s be bold and agree the message We want a socialist health and social care service meaning free at the point of use provided publicly funded through general taxation

  7. Martin Rathfelder says:

    If Mervyn thinks he is providing an explanation of socialist principles by saying they encompass everything related to health, I don’t think that is either helpful or convincing. Nor is it terribly helpful to accuse me of being a neoliberal. I am asking a question. Abuse is not an answer.

  8. Richard Bourne SHA Chair says:

    Its a good question. Since we do not live in a socialist society and assume change will come through our democratic processes (not revolution or direct action) what are the limits on what sort of healthcare system we can get? We have raised this many times with those who advocate various forms of publicly owned, publicly provided and publicly accountable system – which may, or may not, make it socialist. Many rightly argue for a change in society not simply a change in how we deliver healthcare.
    The SHA collectively has set out the best answer it can find but continues to develop the position since new ideas come along all the time.

  9. Martin Rathfelder says:

    Socialism is not about wasting money. Providing healthcare efficiently does not conflict with our principles. But health is not something you can buy. You can only buy treatment. Of course some people need treatment, but treatment is not a good thing in itself.

  10. Martin Rathfelder says:

    I dont disagree with anything Val says except that I think we can and should put more effort into prevention. Many of the chronic conditions on which we spend most money are preventable. And reducing economic inequality would do more to prevent them than individualised life style intervention. But my impression is that the Labour Party thinks that talking about inequality would scare the voters.

    I dont see primary prevention of most chronic diseases as a job for the NHS. Its more to do with planning, transport, food and education.

  11. Shibley says:

    Two things to say here

    1. Nobody reasonable can inherently wish to ask for an inefficient health system inadvertently. It’s motherhood and apple pie stuff as I said originally in my blogpost. However, anyone with an ounce of knowledge about private markets will have qualms about being a silent bystander to a policy which knowingly introduces a source of massive waste and inefficiency. The issue of multiple private providers, repeating transactions needlessly, poorly communicating with one another, is well known across the pond. Most voters that I know wish money to go into frontline doctors and nurses than ‘bad’ managers. I don’t wish to pursue this Aunt Sally argument here though. This does mean also not knowingly using public funds as an easy cash cow for shareholder dividends, however.

    2. Nobody can object to a public health slant to prevention of illness. However, we should have a clear understanding of the limitations of this.

    A wholly prevention-driven approach (e.g. eat less fat) will not particularly help prevent sudden death in someone with a rare cardiomyopathy, such as right ventricular dysplasia, causing a near-fatal heart rhythm disturbance like an arrythmogenic venticular tachycardia. If you think this is pie-in-the-sky, I suggest you look up recent news stories about some well known athletes, and indeed Andy Burnham’s own campaign to make defibrillators more widely available. Targeted health screening is open to abuse by rent seeking private healthcare providers. Here, of course, I give you one example, but there are countless others in general medicine and the medical specialties.

  12. Shibley says:

    @Martin’s original comment

    “If it does then perhaps we should abandon the whole idea of an internal market?”
    August 17, 2013 at 07:19

    Martin, you are absolutely right that we ideally have to remove the internal market.

    Market-related administration in the new NHS system will be above 30% of the total budget, as in its US model (e.g. calculations by Woolhandler & Himmelstein 2007).

    Before Thatcher, we spent 3.5% to 5% of the NHS budget on admin. Scotland and Wales have grasped that the internal market wastes a lot of money and provides gains only for private providers. The market in the NHS is a wasteful nonsense which is going to involve throwing away a quarter of all the NHS funding available on paying for a portal to let private providers be paid from the NHS budget.

    This sleazy leeching of public sector funds to the private sector is utterly contemptible – this ready ‘money siphon’ simply ought to be got rid of, at the first available opportunity, I feel.

  13. i may be misquoting nye bevan when i say that the language of socialism is the language of priorities – but i think it was something like that.

    public health and inequality and the nature of our society and how much we can change it without a radically different system are huge, perennial, evergreen concerns.

    but right now, we have a government who loves the nhs so much they want to break it up into little pieces and sell it off to their friends.

    we have a labour party that hasn’t yet got a clear enough position on what to do about this, or whether its expansion of the market was a mistake.

    we have polls saying this is a hugely important issue for people, that people are crying out for the nhs to be saved in a way they are NOT crying out for lots of worthy public health measures.

    maybe the public are smart and realistic enough to know that we need all sorts of stuff to change in our society before it is a “good” one but that the NHS is one of the best things in it, and it is under immediate attack from the corporate beast.

    priorities, folks.

  14. a properly impartial reading of polls makes it crystal clear that the public want a publicly owned nhs. they see that outsourcing hasn’t worked. they aren’t particularly clamouring for more cycle routes and community farms, much as “we” love these things. they are clamouring to keep their local hospitals.

    we might not like this, but it is the way it is.

    we need to heed it, as democrats, as people who care about elections, and also as people who believe in evidence based medicine (EBM).

    the latter term was severely debased by the blairite school of health management but in fact EBM (as originally conceptualised) is about lots of things you can’t quantify into a managers tick box or put a cost on, including a very strong emphasis patients (and potential patients, i’d argue) wishes.

    too many seem to love the idea of patient ‘choice’ when it is posited as a bulwark to overcome those nasty vested interests (by which they always seem to mean doctors and nurses, not corporations), until those patients choose to keep their local hospital open or have it run by the NHS.

    it is at that point that many including some in SHA seem to revert to a weird tory paternalism or fabianism or new managerialism. tsk tsk. silly patient! what do you mean you’d be willing to pay more taxes, even? lalala not listening!

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