Who cares?

I very nearly didn’t write this post at all, because I am reading a book on the Spanish Civil War (entitled, imaginatively The Spanish Civil War) by Paul Preston.

It’s so shocking, in its deadpan description of the atrocities of the ‘rehearsal for WWII’ (not a direct quote) that I genuinely began to think ‘compared to this, what’s the point in talking about anything else?’

On the other hand, nothing in the entire course of human history stands alone, and today is a product of every day which preceded it. It’s also worth remembering that things being worse in some other place, or at some other time, is no reason to ignore what’s where you are.

After all, if my leg was on fire, I probably wouldn’t say to myself ‘that guy over there’s head’s ablaze, so rather than complaining I’ll just sit tight and count my blessings…’

So, after that insightful metaphor, I feel I have definitely justified what’s to follow. Any disagreements to the usual address, and I promise I’ll print them out and pin them to my bedroom wall, as usual.

(As a sideline, one thing I learned about the Spanish Civil War was that a popular fascist slogan read ‘Franco – Austerity’. So it’s comforting to know that the Conservatives and Lib Dems are both fully aware of and paying the appropriate respects to the world’s glorious political history…)

Mandate

So a couple of weeks ago, I got into a conversation about the Eurozone (bear with me). I complained that our glorious leader, man of the people ‘Dave’, had told the Greeks to form a government ‘as quickly as possible’.

I can only imagine that before this piece of political gold, the politicians of Greece were chillaxing in togas, eating moussaka and dashing plates to the ground, without a care for the future.

Alternatively, our PM was deliberately commenting on a crisis situation which could affect the entire global economy solely in order to justify his own decision to form a coalition government.

I fear that with just three years until the next General Election, Mr Cameron’s belief that any occasion, no matter how serious, should be used by him to justify his own actions is set to grow, however glaringly stupid the statement he makes to do so.

I am particularly looking forward to hearing him draw a comparison between a cease-fire in Somalia and his own choice to end the ‘years of bitter struggle between my party and that of the deputy Prime Minister, call me Nick’.

Anyway, I got away with this. So I also criticised his statement that the EU must ‘act fast’ to sort out its debt crisis.

In many ways, it’s hard to imagine why no-one had thought of this sooner. I guess it must be because everyone knows about the Germans’ notorious laid-back ‘why do today what can be left to next week?’ approach, and refused, through sheer cowardice, to take the bull by the horns and make the Germans just jolly well sit up and do something for once…

I added that the only thing which let down the new Churchill, undisputed leader of global insight, was that he had refused a package proposed to do exactly that, several weeks earlier.

This, apparently, was a step too far. My Lib Dem-supporting friend asked ‘what mandate did he have to support that deal?’

I magnanimously set aside the argument that it would have been impossible for the Conservatives to have gained a mandate from the people on the Eurozone crisis because they had spent the entire election campaign (not to mention the 25 sundrenched, pleasure-filled months since) telling everyone the UK’s financial position was far worse than everyone else’s (we will DEFINITELY be looking at this another time) and it was all ‘Gordon’s fault’.

Instead, I responded that I wasn’t sure Cameron had received a mandate to do anything at all.

After the police had left, the broken glass had been cleared away and the blood hidden with mats and cushions, I decided I should make sure I hadn’t just invented a definition of ‘mandate’ with which no-one in their right mind could possibly agree.

thefreedictionary.com, who I can only assume will be paying me handsomely for this plug, describes a mandate as: A command or an authorization given by a political electorate to its representative.’, a definition which I’m sure is as exciting to you as it is to me.

The Oxford English Dictionary, meanwhile, probably winking as it touches the rim of its Homburg, prefers the rakish: ‘Political authority given by electors to party in parliament.’

Now. The Conservatives received slightly more than one third of the votes cast in the last election. Which equates to very little more than one fifth of the total number of votes which could have been cast if everyone old enough to vote had done so (the Conservatives are by no means alone in being at fault for the damning indictment of the UK political system that led to two fifths of the electorate not bothering to vote during a global crisis, but they certainly share some of the blame).

It’s true that no political party has won a majority of the popular vote since Baldwin’s coalition of 1935 (the coalition had been formed in 1931, as a result of the Wall Street Crash and Great Depression), but the Conservatives failed to secure a high enough vote share to form a majority government (this has happened once before, in 1974, though Callaghan’s Labour government later that decade relied on a ‘Lib/Lab’ pact. When it fell apart, Labour was removed by losing a vote of no confidence by one vote).

Added to that, the Conservatives stood at the last election as the only major Right-wing party, with the Lib Dems and Labour regarded as Left-of-Centre. The latter parties took a total of 15.4m votes, against the 10.7m the Conservatives won. Despite the coalition, the fact is that after the population of the UK voted overwhelmingly in favour of Left-of-Centre policies, the nation has Right-wing politicians as PM, Chancellor, Foreign Secretary, Home Secretary and in 14 of the remaining 19 cabinet positions.

For the record, the cabinet contains 23 members. Eighteen are Conservatives, with five Lib Dem MPs making up the numbers. The Conservatives won 10.7m votes at the last election, the Lib Dems 6.8m.

Cameron undeniably has permission to govern, given to him by the Queen, but given the above, the idea that the Conservatives have a mandate from the people is stretching things beyond any kind of credibility.

On the other hand, he DOES lead the government. And it’s perfectly reasonable to say he can’t just sit on his hands for five years, waiting for another election.

So what should he do? Well, perhaps he could respond to emergencies, and assist the country to recover from the global recession. Or maybe he could stick, scrupulously, to his pre-election promises, and those made in the coalition agreement. That way, no-one could whinge that he has no mandate, because he would at least be able to point to the fact that his is the largest party in the House of Commons, and he’s doing what his voters requested, with the support of his partners in crime. Sorry, government. His partners in the government.

But Dave is a man of action. A man who likes to keep the nation guessing. A man who thinks what the UK needs in its hour of need is a towering colossus, who will dedicate himself to dismantling the state so his new, ‘improved’ version can start on the worst possible foot –with no cash, the unadulterated loathing of most of the people within it and the blank incomprehension of the rest of the world.

Logically, he chose to start with the NHS.

Health of nations

The NHS has a rather unusual place in the UK’s political system. Introduced in the last period of ‘austerity’ (the one caused by a world war in which more than 50m people died, as opposed to the one we’re in now, caused by the inability of a few expensively-dressed men to behave themselves with other people’s cash, combined with a government which perhaps feels put out it didn’t experience it the first time around. Austerity, by the way, is defined by the Oxford English Dictionary, breathing softly as it runs its finger, lightly, against your cheek, as ‘harsh, severely simple.’ Far be it from me to extend the description to its greatest fans) it has run for 64 years, providing life-saving treatment costing nothing at the point of delivery.

It’s the envy of the rest of the world – a genuinely trailblazing idea (at least in the capitalist world) – and one which has operated with spectacular success throughout its history.

As recently as 2010, an American report (it’s here: http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2010/Jun/1400_Davis_Mirror_Mirror_on_the_wall_2010.pdf go, look at it!) analysed the health-care systems of seven nations; the USA, the UK, Australia, Canada, Germany, the Netherlands and New Zealand.

The NHS was rated first in terms of ‘efficiency’ and second overall. The USA was last. (the Netherlands finished first. No, me neither.). Not only that, the NHS did this on the second lowest ‘spend per capita’, at $2,992. New Zealand spent less, at $2,454. But I’m pretty sure that’s where hobbits live, and they’re smaller than us, so…

Fortunately, though, we have Andrew Lansley as Health Secretary. He is a man who is certainly not just a chap in a suit who holds a position not because of his knowledge of health, but because he happens to be in government. In fact, he is a man who knows more than those who are paid to rate health services. He is more knowledgeable than health workers and specialists around the world. And he has made it his business to let YOU know that the NHS IS inefficient, no matter what so-called ‘experts’ with decades of ‘experience’, ‘learning’  and ‘knowledge’ say.

We are really very lucky to have someone as intelligent and dedicated as him. And we are even more lucky to have Dave and Nick, both of whom have backed him up with their OWN assertion that the NHS is ‘inefficient’.

If you can be bothered, type ‘Lansley, NHS, inefficient’ into Google. I must admit I was going to count the number of different speeches which came up, but I lost count twice. In any case, Lansley, Dave and Nick have been making speeches claiming – or mentioning in other speeches – that the NHS is ‘inefficient’ since early 2009. (in fairness, this is pretty good going on Mr Lansley’s behalf, as the rest of his party didn’t really start making any policy announcements until November that year. And Nick was pretty quiet about the NHS’ inefficiency until about, ooooh, June 2010. I’m really not sure why).

And up and down the country, people agree. Even those who say they support the NHS will come out with the phrase ‘…but it IS very inefficient…’ at some point.

Why?

Well, in part, it’s because of the efforts of Right-leaning newspapers – particularly the Sun, the Daily Mail and the Express.

Weirdly, their own criticisms of the NHS seem to have begun in the 1980s, just after Margaret Thatcher’s introduction of monetarism – a doctrine which claims that the ‘interference of the state in the lives of the people’ is the worst of all possible activities.

Now, to be fair, I CAN see areas in which state interference could be a bad thing. In a bar, for example, chatting to my mates about the football, I’d rather not have Vince Cable popping up to make sure I don’t say something silly about the Brazil side of 1970 as opposed to today’s Spain.

But as lovely as liberty is, I’m not sure I want it to extend to the freedom to die because I can’t afford to have a gaping wound taped up, or pay for a polio jab.

And of course, newspapers LIKE the odd story here and there about a hospital mix-up. It’s their job to hold politicians and service providers to account.

But in every case, there’s a reason why that’s news. Because it’s unusual.

To put it another way, the NHS employs more than 1.7m people. That includes cleaners (numbers cut because of successive – three – governments’ cuts in its budgets), cooks and other support staff, but it also includes thousands of GPs, surgeons, specialists, nurses and therapists.

It treats more than one million people every 36 hours. And in fact, roughly 98 per cent of people born in the UK have experienced at least one successful NHS treatment process and operation. Including you. (I’m assuming you HAVE been born. If not, well… I might stick around where you are for a bit. You know, see how things turn out…)

Compared to that, the maybe ten stories per year that actually turn out to be true AND down to NHS malpractice seem rather a small amount.

But anyway. I know nothing. Lansley’s your man.

Because it appears the NHS IS inefficient, despite all the so-called ‘evidence’ and ‘facts’ which prove the exact opposite.

And he’s driven a solution through Parliament.

There’s a lot that’s been thrown at the Health and Social Care Act, which was passed by the House of Commons by 328 votes to 246 on March 20 2012, and received royal assent from Dave’s fifth cousin, Queen Elizabeth II, seven days later.

One of the major accusations is that it will ‘privatise’ the NHS. I’d like to make it clear that that’s not my view. But it IS very close to the view of Kingsley Manning, director of Tribal Newchurch, a private healthcare ‘provider’, who said he ‘welcomed (the Act’s) denationalisation’ of the NHS.

In fairness to Kingsley, and the opponents of the Act, who include the Labour Party, some Lib Dems (not one of whom voted against it) and all the assorted halfwits you’d expect, like GPs, nurses, surgeons, midwives, you know, people who actually know what the NHS is and how it works, AND the 52 per cent of the public who opposed the Act in an ICM poll in February this year (just 33 per cent said it should become law, which I suppose explains why Dave felt he had national approval), it’s quite easy to see how someone could make that mistake.

See, what the Act actually says is that all hospitals can now raise 49 per cent of their income through private health care, through ‘renting out’ bed and hospital space to private healthcare companies, or, perhaps, by charging for treatments themselves. The cap at present is just below two per cent.

So it’s obviously not privatisation. Just a 25-fold increase in the amount of private health care provided in hospitals up and down the country.

So why would this be a good idea? Well, it’s pretty clear that hospitals can benefit financially from charging more people for healthcare (though this is NOT what the NHS exists to do). And the government fears, with some justification, that the overall cost of healthcare provision will increase massively in the next two decades, as the number of older people, who generally need more regular, and more intensive, health and fitness care, increases.

At its simplest, given that the NHS budget in 2010-11 was £106bn, this could effectively see the service benefit from an extra income of £51.94bn.

But there is, perhaps, a potential problem. See, when Labour introduced the idea that some hospitals could make money by charging for some treatments (with that two per cent cap), it was also involved in a massive building project, in which 157 new hospitals were built, or construction was begun, between 1997 and 2010 (this was, of course, performed under PFI contracts, a disastrously expensive idea. Ironically, one introduced by the previous Conservative government, and OPPOSED by Labour when they were in opposition. But they WERE at least built. The number built in the 18 years of Thatcher and Major was roughly 35). So if there was an impulse for hospitals to fill more beds with private patients (and there was) at least there WERE more beds to be filled.

Under this plan, up to 49 per cent of beds will be filled with private patients. And no new hospitals are planned. So where do the NHS patients get treated?

The debate about whether this is ‘privatisation’, sadly, is one it’s too easy for the government to bat back. It CAN deny it, with some justification, although whatever way you look at it, telling the NHS it can make almost half of its money from charging the population for treatment IS a massive step towards the FULL privatisation of the service. And it is no accident that 49 per cent was the figure chosen. After all, if the financing of ‘demographic change’ is the reason, why not say 60 or 75 per cent of NHS cash-raising can come from private care? One per cent less than half is a thin screen behind which the government can hide.

A far better argument is about WHY levels of privately-charged treatment are a bad thing, and it comes down to a very simple fact: if the NHS is as inefficient as the government wrongly claims, then where will people who can’t pay be treated? Why remove bed space, if your interest is ensuring the public can continue to benefit from free healthcare?

In the end, what is the point of a public healthcare service, which is free to use at the point of delivery (never forget that all of us, you and I included, pay for the NHS out of taxes. It is OURS. We pay for it and we are the ones who are supposed to benefit from it) if the only way to guarantee being treated is if you pay for it?

It is worth here revisiting the ‘mandate’ issue we started with. Because in the run-up to the election, Call Me Dave was pretty clear about his plans for the NHS, or more accurately, about what his government would NOT do.

Speaking to the Royal College of Nursing in 2009, for example, he said: ‘First, let me tell you what we are not going to do. There will be no more of those pointless re-organisations that aim for change, but instead bring chaos.’

As the election campaign, in which ‘Change’ was the Conservatives’ watchword, got underway, he promised: ‘No more top-down reorganisation of the NHS.’

And this promise was repeated in the May 2010 coalition agreement, the document which ensured, after an election in which his party failed to win enough seats to govern, that Cameron could lead a Tory government, the first in 13 years.

The promise reads, simply: ‘We will stop the top-down reorganisation of the NHS.’

Lansley’s bill came just two months later.

A second controversial section of the Act is its proposals for the commissioning of care.

The Conservative Party, and the Lib Dems, at least have some justification here in terms of delivering what they promised. Indeed, when I interviewed Nick Clegg in the 2010 election campaign, he repeated his belief that Primary Care Trusts should be abolished four times, perhaps fearing that otherwise I might focus more on his plan to abolish tuition fees.

Primary Care Trusts are seen by many as a layer of pointless bureaucracy and management in the NHS. Their role included commissioning healthcare in the region they operated, and they had responsibility for spending  roughly 80 per cent of the NHS annual budget.

They were pretty unpopular, among NHS staff, but particularly among the Daily Mail, The Sun and The Express’ ranks of editorial heroes, who claimed this was no more than the pointless introduction of managers to ‘meddle’ in the operations of public healthcare.

I have some sympathy with this view, but it would be remiss of me not to point out that a) the NHS does NEED managers. They are not ALL parasites, attempting to steal from you, the Great British Public, and b) there is a certain disjunct between the view that the NHS is terribly, hopelessly inefficient and that measures to reign in its ‘terrible inefficiency’ (Blair’s Labour Party was always a sucker for making policy based on the outlook of Lord Rothemere, Richard Desmond and good old Rupert Murdoch) were somehow an affront to the very foundations on which the NHS rests.

Either way, there were 152 PCTs, and they were pretty unpopular.

So, Lansley proposed to scrap them.

Astonishingly, he appeared to expect that this would win him unquestioning praise. But there WERE questions. Namely, who on Earth would commission services instead, particularly given his idea that 49 per cent of services should be allowed to be provided by non-NHS providers.

His plan was to replace them with Clinical Commissioning Groups. But surely these would just be the same as PCTs?

Not so, he countered. Because they would be run by GPs (in fact, they won’t JUST be run by GPs, but because of the way Lansley announced the idea, aiming to get as much popular support before revealing the rather murkier elements of the proposal we will return to that in a moment).

Lansley said that scrapping PCTs would save £5bn per year (not counting slightly more than £1bn to be paid out in redundancy deals for those who lose their jobs as a result), and that his plans would instead see GPs, who after all know their patients and so can judge best what treatments are most appropriate for them, commission services.

He said the proposal would: ‘Give patients and health staff more power.’

Savings of £5bn, the scrapping of an unpopular layer of management and more power to GPs and patients? It all sounds too good to be true.

And the problem is, it is.

First of all, GPs don’t want these new powers. The Royal College of General Practitioners joined the Royal College of Nursing, the Royal College of Midwives and the British Medical Association in outright opposition to the Act.

Some medical staff have had a slightly bad press in recent weeks, after their decision to strike over pensions. The Conservatives, hoping they had at last found an issue on which many thinking human beings could agree with them, seized upon this, pointing out that GPs are already very well paid, and why should they withhold services when we are, after all, ‘All in this together’?

But let’s not fool about. These are people who are often well paid, but they also work very very hard indeed, and without them focussing properly on their jobs – to make the rest of us better if we’re sick – we’d be in a much worse place.

And they pointed out, not unreasonably, that if they were to treat patients properly, they wouldn’t have time to chase ‘healthcare providers’ to ‘commission’ their services. It is just about possible, I’d suggest, that when Nye Bevan created the NHS, he considered that IT would provide healthcare services, thus removing the pointless ‘commissioning’ process altogether, but then what do I know?

But this is how £5bn is to be saved: sack the PCT employees and make other people – in this case the people on whom we rely for our health – do their jobs as well as their own.

In effect, then, Lansley was telling GPs ‘you will have the power – whether you want it or not!’

The second problem is that there were 152 PCTs, packed to the rafters with time-serving, money-leeching managers, brutally commissioning services as if it wasn’t tantamount to the biggest fraud ever committed against the UK population.

This number had to be slashed. Because it was wasteful. And probably evil.

Unfortunately, there are now 240 CCGs.

So, there are more commissioning bodies than before, and the GPs who run them fear they won’t have time to treat patients and commission care for them.

Not to worry, though. Because almost as if he’d anticipated this exact eventuality (not that he told anyone. Remember he said he would give ‘patients and health care staff more power’?) Lansley had also made it possible for company directors, including, of course, the directors of the very private health care providers who stood to benefit directly from the increase in the levels of private health care provision within NHS hospitals, to be part of these CCGs.

Even more helpfully, he also made it possible for CCGs to ‘outsource’ the commissioning of healthcare services, and the decisions as to which treatments should be provided by private firms, to, er, the private firms which would earn cash by providing them. Which, I’m sure you will agree, clears that little problem up with no potential ‘conflict of interest’ whatsoever.

Combined with the ‘autonomy clause’, which allows CCGs (or the firms which perform the role instead of them) to decide which services should be provided by the NHS, and which must be paid for, the claim that ‘patients’ are to receive more control looks difficult to justify.

Max Pemberton, a doctor who writes for the Telegraph, used his column in that revolutionary, anti-establishment publication to highlight his concerns about this process.

In an article which began with him saying he is not a supporter of the NHS for ‘ideological’ reasons, but because it does its job well, he said: Services such as mental health provision, facilities for pregnant women, preventive medicine, aftercare and services for children could be substantially reduced by this power to save money, generate revenue or redirect patients into the for-profit sector.’

There are many other concerns raised by, well, more or less everyone outside of Lansley and his closest friends, all of whom know more, but this is a very long piece by now, so we’ll take a brief look at just two of them.

First, the Act changes the law on healthcare provision as applied to the Secretary of State for Health, or ‘Andrew Lansley’ as he is also known.

Previously, the law stated that the Secretary of State, and other Ministers in the Department of Health have a ‘duty’ to ‘provide a national health service’. Under the Act, Mr Lansley’s duty is to ‘promote’ a national health service.

You may argue that there is very little difference between the two. In which case, one may ask why make the change at all? In an Act designed to ‘reduce inefficiency’ (though which has actually caused the number of NHS statutory organisations – those not directly involved in providing care and treatment to patients – from 163 to 521 ‘health and wellbeing committees’, ‘clinical networks’ ‘clinical senates’ etc) of the NHS, why add a change in the status of the Secretary of State for Health?

Provision of a national health service certainly suggests the Health Secretary must provide such a service. That it is his/her responsibility and any failures within it are his/her responsibility. Promotion sounds rather more like a duty to make sure a health service exists and that people are aware of it. If this isn’t a move towards privatisation, it certainly sounds like it.

Connected to this, the Act also removes responsibility for public health campaigns from the NHS.

One justification for this is that, for example, local authorities have responsibility for many things which impact on health, including housing. So, the argument goes, local authorities can set out ‘joined-up’ campaigns to improve public health.

But local authorities only cover small areas of the country. So, depending on where you live, different aspects of health may be focussed upon, rather than the ‘catch-all’ approach practised at present.

Just as importantly, where will the money come from for this? With their budgets slashed by the government, local authorities are already laying off hundreds of thousands of employees and are having to choose between shallow fripperies such as ‘children’s homes’ or ‘care for the elderly’. What would have to be dropped so Manchester City Council could tell Mancunians not to smoke?

Finally, a note on the Lib Dems.

At the party’s Spring Conference, the Bill was discussed. Much to party leaders’ dismay, delegates voted in favour of an emergency motion to ‘kill the bill’.

This meant that not only had the party’s voters never voted for the comprehensive alteration of the NHS, the party membership, at a Conference where policy is set, specifically voted against it.

Many Lib Dem MPs spoke out against the Act in the House, and the party’s response was perhaps the most outrageous in its history.

Senior Lib Dem MPs briefed their party members in the House that the party voting to drop the bill would be ‘a Labour win’. That’s ‘a Labour win’. Not ‘missing an important opportunity to improve the NHS’, or ‘blocking the provision of better healthcare for the population of England’. The party told its MPs to vote against the wishes of their voters, and against the democratically expressed wishes of their own party members, because otherwise it might appear that Labour had won.

A less understanding man than me might ask exactly what Nick Clegg had been talking about in April 2011, when he criticised ‘the old politics of tribalism backed by dinosaurs on all sides of the political spectrum.’

But I might instead simply suggest that the Lib Dems have lost the only thing which made them attractive to voters – the possibility to change the way politics is prosecuted by those within it.

And repeat doctor and journalist Ben Goldacre’s judgement on the briefings.

On March 20, when the final votes were to be cast, and the senior Lib Dems spread their ‘Labour win’ warning, he tweeted: ‘is this a FUCKING PLAYGROUND?’

Of course, some Lib Dem MPs abstained. None, however, voted against the Bill.

The future

As we know, the Health and Social Care Act became law, officially, on March 27 this year. Originally, it was hoped that the policies within it would be in full operation by April 2013, though in recent weeks, Call Me Dave has admitted this is ‘unlikely’.

So what, if anything, can be done?

The BMA’s Annual Representative Meeting voted on June 25 to campaign for the repeal of the Act, while other groups, including campaign group 38degrees, have set up petitions to show public opposition to the Act (38degrees’ petition currently has more than 600,000 signatures, while David Cameron has promised ‘any e-petition which gains more than 100,000 signatures will have its topic debated in Parliament’).

Meanwhile, Labour Shadow Health Secretary Andy Burnham has pledged to repeal the Act ‘at the first opportunity’. It is unlikely his party will be alone in campaigning on the NHS at the next election.

Finally, on April 29 2009, David Cameron told the nation that if elected, he would ensure that politicians were accountable to the public. That if they went back on pre-election promises, or acted irresponsibly, the public would be able to call for a by-election to replace them. He repeated the promise several times, both before and after the election, and the idea was repeated often by Nick Clegg.

Perhaps now is the time to put that pledge to the test?

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2 thoughts on “Who cares?

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