By Dr Bob Gill @drbobgill
The latest assault on the NHS involves the imposition of a new contract for junior doctors that will see their salaries slashed by 30% with requirement for evening and Saturday work (1). The excuse used to justify this change is to provide a 7 day service and improve patient outcomes on weekends. The reality is that more qualified staff are being driven out in preparation for the deskilling that is always part of healthcare privatisation and corporate takeover. For the UK this is mapped out in ex-UnitedHealth executive and now head of NHS England Simon Stevens’ Five Year Forward View (2). Many junior medics (which means all doctors not senior enough to work in consultant positions) have been stirred into action but it is crucial for them to understand the context of their current predicament to mount an effective campaign to protect patients, restore decent treatment of staff and block the completion of the privatisation of the NHS.
Conversion from the NHS model, a publicly funded, provided and universal system, to a private insurance model has been proposed for decades. In 1968 Arthur Seldon, later Margaret Thatcher’s privatisation policy adviser, produced a pamphlet for the Institute of Economic Affairs titled ‘After the NHS’, explaining the aspiration to “improve the NHS” by abolishing it so as to build profit opportunities insurance industry(3). Further incarnations of this same plan to enable the insurance industry to increase its profits in the UK by destroying the NHS surfaced in the 1980s. This included Health of Nations by the Adam Smith Institute (4) and a version articulated by current Conservative Minister of State for Government Policy, Oliver Letwin MP in the NHS privatisation he wrote with John Redwood MP, published by another Thatcherite think-tank(5). The stealth privatisation of the NHS had quietly begun under the Thatcher administration and has continued unabated ever since. The sole attempt to bring the plan out of the shadows, its presentation to a Conservative cabinet in 1983, was so roundly rejected that the decision was taken to complete the privatisation by covert means, under a series of false narratives to distract the public from what was really taking place. From outsourcing of non-clinical services, introduction of market bureaucracy, splitting up of the hospital network into independent Trusts and usurious Private Finance Initiative (PFI) for creating an opportunity to gouge the public purse through inflating the costs of funding new hospital building.
Blair’s US-sponsored New Labour governments continued with the privatisation project whilst maintaining the deceptions contained within successive ‘pointless top-down reorganisations’ which in reality all took the NHS further down the privatisation road precisely following the steps laid out in Health of Nations’ NHS privatisation plan. Consecutive governments diligently disguised health reform debate with spin and misdirection, while energetically outsourcing all the financially and legally qualified NHS posts whose incumbents would be likely to point out these lies to their medical colleagues and the lay public. The success of the project depended on public ignorance and distracting attention with myth creation. The propaganda agents include large sections of the media in particular the BBC (6). Our public service broadcaster has avoided scrutinising health reforms choosing to simply regurgitate government spin, myth peddling and presenting pro-privatisation think tanks as the independent. Growing public and professional protest conveniently ignored – censorship by omission.
The British Medical Association has spent the last two decades gently nodding through marketization and privatisation under the guise of ‘critical engagement’. In this they have provided no effective challenge to government policy, and they have kept members in the dark to a degree that suggests complicity at leadership level. Genuine opposition by BMA leaders to the Health and Social Care Act 2012 could have prevented the NHS being carved up for profiteers (7). Unfortunately it seems that while the BMA ostensibly represents doctors, and is funded by them, in fact it seems to have been dancing to some different tune where the NHS privatisation is concerned.
The NHS has been fundamentally transformed in the last 20 years. Our nationally-integrated hospital network has been split up into distinct business units (“foundation trusts”), which were deliberately burdened with PFI millstones which would throw them into insolvency as soon as a funding squeeze was applied to trigger this at the right time for the privatisation(8). Services are since 2013 funded through clinical commissioning groups (CCGs). Designed by John Redwood MP to be self-collapsing state-funded insurance pools (4) (9). Though many CCG boards are fronted by GPs, the commissioning decisions they take are ultimately shaped by a set of rules which incentivise outsourcing to private healthcare companies with administrative support provided by yet more private companies. CCG boards have great discretion over which services they will pay for and NHS funded care will be increasingly restricted, damaging universal and comprehensive care. A rump of NHS services will lead to patients paying charges for care, out of pocket or through private health insurance. Or as Letwin and Redwood pointed out in 1988 (5)
“Another avenue which has been tentatively explored by the Government is charging. In principle, this could be extended to the point of universality — a charge for every service.” page 16
CCGs were designed as transitional bodies to be taken over by private insurers, accountancy firms and management consultants, an army of unnecessary intermediaries siphoning away money from delivery of healthcare. GPs have been set up to be the scapegoats for the demise of the NHS (10).
Disempowerment, corruption and scapegoating of health professionals
In order to repurpose the NHS from a health service to a business the traditional medical leadership had to be replaced with a general management structure (11). Hospitals and health boards had their small clinically dominated and patient focused members replaced by functionaries less inclined and equipped to protest about damaging patient services and quality of care. Introduction of the internal market, targets and performance management necessitated an explosion in numbers of administrators and managers required to implement market reforms. The purchaser-provider split divide and rule manoeuvre set up GPs against hospital doctors, handing GPs the axe to take to hospital services, contrary to the patients’ interest and in the face of opposition from hospital colleagues.
New Public Management facilitated the blurring between public and private sector and provided the infrastructure for siphoning money away from the delivery of care to patients (12). This bloated administrative structure imposed government policy irrespective of outcome for patients’, the most infamous example of this was at Mid Staffordshire NHS Trust. Priority was given to achieving financial performance targets to qualify for Foundation Trust status over ensuring adequate staff levels to run the hospital safely. Spinmeisters carefully crafted messages for officials and politicians to redirect responsibility away from management and predictable government policy failings, and instead to blame staff for lacking compassion or commitment (13).
A culture of fear and intimidation for those who dare speak out about preventable patient harm has been exposed repeatedly over recent years. The perpetrators escape sanction and many are promoted in contrast this with the career destruction and psychological torment for the whistle-blowers (14). There is also the waste of public money on cover-ups of malpractice linked to the privatising leadership clique in hospitals. Some whistle-blowers are banned from coming into work, and this costs money. Dr Kim Holt told her superiors of the risks that later led to the death of Baby P, and their reaction was to send her home from work and hire locums to do her job, at a cost to the public purse of around £1 million.
Clinical autonomy is severely restricted due to lack of resources, so doctors may no longer be allowed to do what is right for patients because of bureaucratic restrictions introduced as part of the reshaping for privatisation. The NHS has lost over 50% of acute beds since 1979 leaving us with some of the most meagre hospital provision in Europe. The UK has just 2.8 beds per 1000 population compared to 6.3 and 8.3 for France and Germany respectively (15). Doctors have to discharge patients prematurely to make space for sicker patients, but that can hamper recovery, or worse. Outpatient clinic appointments are also being cut, and the market prevents patients being referred directly between specialists without first being sent back to their GP’s who has to make the referral. This frustrating, inefficient additional bureaucratic hurdle created to fit the suit the marketization not patient or doctor. The costs for administration for the NHS have increased from 5% (before the privatisation process started in the 1970s) to 14% by 2005 (16), amounting to over £10 billion per year additional cost without patient benefit. And the American system to which we aspire spent 31% by 2003 (17).
The cost of repayment of £11 billion in PFI loans will be over £80 billion. Doctors anguish over patients being denied a bed or other essential care, whilst extortionate sums of money are squandered on market administration, outsourcing and PFI payments.
A significant minority of doctors have assisted in betraying the public and their colleagues motivated by self-interest, realised through promotion, performance related pay and bonuses. They have been busy downplaying and distracting from others’ concerns over privatisation; ensuring the BMA remains a feeble representative body; and colluding with management and politicians in promoting hospital cuts and closures which will endanger patients’ lives. Paid advocates for reconfigurations of NHS services expensively concocted by management consultants and accountancy firms whose glaring conflicts of interest barely get a mention in public discourse.
In this environment of constant flux, confusion and stress, most NHS workers rarely delve into the detail of what is going on around them but remain preoccupied with dealing with the consequences. Apathy, ignorance, fear, disempowerment and sense of futility combine to make a powerful disincentive to push back. Instead NHS staff just keep their heads down and get on with the day (and night) job.
This is so far from the idealised vision most would have had of being a doctor in a civilised, open and accountable democracy. Working in the NHS has been transformed from feeling like part of a large family working for the common good to resembling a totalitarian state where survival is dependent on wilful blindness to all that fails our patients and colleagues. No wonder more than two-thirds employees are seriously considering leaving the NHS (18).
The blueprint for the final stage of the NHS privatisation and conversion to a private insurance system is to be found in ex UnitedHealth Vice-President and NHS England Chief Simon Stevens’ Five Year Forward View (2). Proposals that will profoundly alter the NHS in favour of his former employer have escaped exposure and scrutiny (19). Like many policy documents before it, the true intent is coded within harmless sounding text. No mention of ‘privatisation’ ‘competition’, ‘market’ or the growing role of commercial insurance in the NHS. Instead we see code words like ‘innovation’, ‘choice’, ‘modernisation’, ‘integration’, ‘partnership’ and ‘prime contracting’. The introduction claims a strong commitment to the NHS and then goes on to promote its carve-up. The proposals will replace the last vestiges of the NHS with ‘New Models of Care’ (NMC) which reformat the internal structure of the NHS to less flexible, more costly arrangements which better suit the commercial insurers destined to take over the system (see Seldon, Letwin & Redwood, Pirie & Butler, etc). A further £20 billion shortfall in funding is celebrated as ‘efficiency savings’.
This masterpiece in spin and deception hides the reality of further hospital closures, GP surgery closures, staff reductions, pay cuts and reduction in qualified staff. Patients’ medical needs will be serviced by non-existent community services. The same con trick was pulled off with mental health services under the ‘care in the community’ narrative in the 1990s. Publicly owned psychiatric institutions shut down and flogged off with insufficient replacement services to support patients. Access to competent life-saving emergency care will be drastically reduced. Specialist hospital services cut and concentrated in fewer larger centres. This, according to Stevens
“could avoid the need for another 17,000 hospital beds – equivalent to opening 34 extra 500-bedded hospitals over the next five years” page 36
Or put another way NMC will enable the closure of another 34 district general hospitals.
“More generally….NHS employers and staff and their representatives will need to consider how working patterns and pay and terms and conditions can best evolve to fully reward high performance, support job and service redesign …” page 31
Some of the investment required for the NMC will come from the sale of NHS land and assets and by 2020 the NMC could be put out to tender for international corporations to make ‘productive investment’ i.e. extract profit. Junior doctors’ loss of income and increased hours performing routine work in previously defined unsocial hours will increase profitability for the new players providing healthcare.
The ‘modern workforce’ created through the ‘Shape of Training Review’ for medical students and ‘Shape of Care review’ for nurses and creation of ‘transitional roles’ is designed to produce a cheaper and quicker to train, less qualified workforce. We are told that they will be performing new roles ‘across organisational and sector boundaries’, i.e. doing things they aren’t qualified to do. This represents a wholescale deskilling of the workforce with nurses and Physicians Assistants doing doctors work, health care assistants doing nurses work and volunteers doing HCAs work. No qualifications whatsoever are needed to enter an NHS hospital as a paid HCA, to do work formerly reserved for qualified nurses (20). We are starting to be softened up for the ‘HealthForce’ of volunteers (21): we won’t even be paying the unskilled people we get to do nurses jobs! This is about to start becoming really dangerous for patients – just as the monitoring of NHS performance is in the process of being privatised.
What now for Junior Doctors?
The prospect of a 30% reduction in pay through restriction of unsocial hours payment and increased working week has been the prompt for protest and a potential spark for a brain drain with thousands preparing documentation to emigrate (22). Leaving the NHS for pastures new is an entirely justified response but will do nothing to defend the NHS for the relatives and friends left behind who may need to rely on it for care. Those that leave now in the hope of coming back later when the dust has settled may find that the NHS has dwindled to a threadbare remnant in their absence, and the country will be a worse place for it. We are collectively faced with one of the greatest political betrayal of the public interest in destroying the best healthcare system in the industrialised world and replacing with a model resembling the worst (23).
Medics are highly trusted by the public and could prove a powerful voice against Stevens, Hunt and Letwin. NHS activists have been desperately hoping more medical leaders joined their ranks and help break the silence. Your local community would welcome your contribution in defending the NHS. No doubt the stakes are high as serious consideration has to be given to personal and professional damage. Pressure may come from employers and unexpected quarters to stay in the shadows (24).
It is crucial to understand the scale of the privatisation industry and their broad influence over our politics and media, and the fact that they are now presiding over the discontinuation of the welfare state. They are well funded and cunning, but they are lying. We must educate ourselves and the wider public on the truth of the threat to the NHS to mount a defence. The documentary ‘Sell-Off’ (25) gives a summary of what has happened in England. Michael Moore’s ‘Sicko’ film exposes how the American system fails private healthcare insurance policy holders (26).
The privatisation project is well planned and effective. Many of the potential defenders have been effectively neutralised by privatisation sympathisers at leadership level including the BMA and Royal Colleges. Resistance from these quarters has been more symbolic than genuinely designed to succeed.
In the UK it was essential to have New Labour as a controlled opposition (27) to then carry the privatisation baton between 1997 and 2010. Since back in opposition providing tokenistic resistance and diverting genuine grassroots activism whilst simultaneously promoting the massive corporate power grab in the form of the Transatlantic Trade and Investment Partnership (28).
What shall we do?
Junior doctors’ have overwhelming public support for industrial action (29) but must be vigilant to avoid being impeded in their struggle by hidden traps. With vast sums of money up for grabs, the privatisation lobby will stop at nothing to permanently and irreversibly break open the NHS for exploitation and profiteering at the expense of patients, staff and the taxpayer. It is essential that techniques successfully deployed by the health insurance industry in America for decades to neutralise attempts to improve healthcare for Americans including the use of front groups, third party advocates, think tanks and other propaganda channels (30) are recognised and avoided or counteracted.
Join or support local NHS campaigns and network with health activists to learn about the local issues and share your experience. Cross fertilisation of knowledge is vital for maximising impact of future activity.
Clear and simple messaging is important to influence the widest audience. The treatment of Junior Doctors is inextricably linked to the privatisation agenda. Attempts to separate these issues will squander opportunity to alert the public at large to the major heist that is under way. Advice to uncouple these issues should be rejected and recognised as counterproductive or duplicitous.
Campaign for an end to privatisation, restoration of the NHS THROUGH RENATIONALISATION as a publicly funded and provided universal health service with reinstatement of the Secretary of State for Health’s must legal duty to provide. It will only be possible to protect patient care and improve terms and conditions for staff in a RENATIONALISED publicly run, not for profit system. Anything less will not escape corporate capture through EU-US co-called trade deal – TTIP.
Speak out about what is going on in your workplace taking care not to put your career on the line. That said, there will be few places for doctors in the Five-Year Plan’s deskilled NHS unless you are willing to work for clerk’s wages using computer packages rather than clinical judgement, just in order to be able to help patients in the NHS.
Exposing the damage inflicted by frontline services cuts is powerful evidence against the privatisation. Spread the word to your friends, family and to your patients. Cultivate trusted local journalists and activists to be the conduit for your voice, and write and present the material yourself to the extent that you are able to learn how to do this effectively. Use every available platform from talking to people on the street to broadcast and social media. The greater the public awareness and understanding about what is happening to their health service the harder the privatisation becomes.
Pleading and petitioning of our politicians has failed to hinder the privatisation. There remain many already engaged in this approach. Both Conservative Party and the Labour opposition support Stevens’ final solution for the NHS, the control of which currently remains in the firm grip of the corporate raiders. Doctors, nurses, patients, campaigners and everyone they can get to join in must help build a mass movement to expose what is going on and fight for our NHS.
- Junior Doctors descend on Westminster in protest at ‘unsafe’ working contracts
- After the NHS 1968 Arthur Seldon
- BRITAIN’S BIGGEST ENTERPRISEideas for radical reform of the NHS. (1988) Oliver Letwin and John Redwood. CENTRE FOR POLICY STUDIES.
- ‘NHS SOS’ (2013) Dr Jacky Davis and Dr David Wrigley – Silence of the Lambs Chapter 4,
- ‘The Plot Against the NHS’ (2011) by Colin Leys and Stewart Player
- GP commissioning and the NHS reforms: what lies behind the hard sell? Lucy Reynolds, Martin McKee http://jrs.sagepub.com/content/105/1/7
- Griffiths Report 1983 http://www.nhshistory.net/griffiths.html
- ‘How Corrupt is Britain’ (2015) edited by Prof David Whyte – Private sector giveaway p11-16
- Private Eye Special (2011) Shoot The Messenger: How NHS whistleblowers are silenced and sacked. Dr Phil Hammond and Andrew Bousfield http://drphilhammond.com/blog/2011/11/28/private-eye/shoot-the-messenger/
- N Engl J Med 2003;349:768-75. Costs of Health Care Administration in the United States and Canada Steffie Woolhandler, M.D., M.P.H., Terry Campbell, M.H.A.,and David U. Himmelstein, M.D. http://www.pnhp.org/publications/nejmadmin.pdf
- Thousands of NHS doctors apply to be able to work abroad amid contract changes
- Medical schools accused of stifling protest against junior doctors contract
- ‘Sell-Off’ https://www.youtube.com/watch?v=ultKvnw2h3Q
- ‘Sicko’ trailer http://www.nytimes.com/video/movies/100000003373846/sicko.html?playlistId=100000003277281
- ‘Deadly Spin’ (2010) by Wendell Potter