01.10.2015
At the behest of capital
Youssef El-Gingihy How to dismantle the NHS in 10 easy steps Zero Books, 2015, pp82, £9.99
Margaret Thatcher was famously said to have considered the national health service as the one untouchable British industry - she feared the consequences of openly applying her neoliberal blitz to it, due to its unique place in the consciousness of the working class.
It turns out there is more than one way to skin the NHS, and you have to admire the present-day Tory strategy which has allowed the Conservatives, in a few short years, to nearly complete its dismantling - in a more sophisticated way than a Thatcherite-style head-on attack. Yet there is nothing original about the tactics: through misinformation (aka lies), division, impenetrable bureaucracy and by utilising the helping hand of their old ally, the bourgeois press, the Conservatives have very successfully opened the veins of the NHS for the circling corporate vultures. Yet, although the NHS has been set on a journey towards full privatisation at the behest of capital, there has not been the mass mobilisation to defend it that Tony Benn once predicted.
Youssef El-Gingihy’s book is a timely summary of the dire situation the NHS is currently facing. This is not the first such book: there have been several in the past few years - mostly also written, like this one, by doctors (Youssef El-Gingihy is a GP in Tower Hamlets) - Allyson Pollock’s NHS plc and The plot against the NHS by Leys and Player are notable others. Youssef El-Gingihy borrows quite a bit from these preceding titles, but the information here is presented in the form of 10 short chapters, which are roughly a chronological summary of the changes forced on the NHS since John Major’s reign, bringing us to the present day. Well, nearly to the present day: the book was written just before the last general election, when, interestingly, El-Gingihy was rather optimistically pinning his hopes on a potential Miliband-led Labour Party:
We are on the eve of an epoch-defining general election in 2015. Put simply, this election is likely to define whether the NHS continues to exist as a cherished institution or whether it is gradually dismantled into a privatised, insurance-based system (p1).
What El-Gingihy could not predict was that from the ashes of Labour’s defeat would rise an openly leftwing leadership, offering the NHS a beacon of hope on an otherwise depressingly bleak horizon.
Internal market
The first few chapters of the book cover the introduction of the internal market into the NHS by Major’s government - but it was New Labour that extended this process and introduced some of the most destructive public-private partnerships. By the end of the 1990s hospitals were being run like businesses, selling their services to primary care trusts (PCTs), which were at the time the bodies in control of the NHS budget. This purchaser-provider split was highly damaging - despite the claims that competition would increase efficiency, it actually discouraged collaboration and led to greater waste. As El-Gingihy points out, “administrative costs rose from 5% in the mid-1970s to 14% in 2003 mainly due to internal market operations” (p6).
Then came the infamous introduction of New Labour’s ‘independent sector treatment centres’ (ITSCs) and ‘private finance initiatives’ (PFIs). ITSCs meant that huge sums of NHS money were syphoned to private health firms, which were able to cherry-pick lucrative, low risk, planned surgical procedures. Patients were often left in the dark about when they would be treated by these private companies - unless, of course, there were surgical complications and they needed (far more expensive) urgent treatment. In which case, they were simply transferred back to an NHS hospital. PFIs were (and still are) an even more devastating economic drain on the NHS. They were sold as a win-win partnership between the NHS and private construction firms, which would build new hospitals and rent them back to the health service - what was not made clear was that the NHS would be tied into contracts lasting up to 30 years at massively inflated prices - the legacy of which is the bankruptcy that so many hospitals are currently facing. As pointed out by Youssef El-Gingihy, “the PFI tab … stands at £301 billion for infrastructure projects worth £54 billion … [this] would pay for all the nurses, plus consultants, plus GPs, for 10 years, with £67 billion still to burn” (p10).
The next stage towards the dismantling of the NHS covers the familiar story of the revolving door between corporations and government, bringing to mind the comment made by Jim Hightower, former US agriculture commissioner: “The corporations don’t have to lobby the government any more: they are the government.” El-Gingihy lists several leading government figures who have worked for private healthcare firms. For example Nick Seddon, Cameron’s special health advisor and former head of communications at the healthcare firm, Circle, who has openly called for the ending of the NHS in favour of an insurance-based system. Circle, by coincidence, has been one of the biggest beneficiaries of the NHS sell-off: in 2011 it was awarded two contracts (including running Hichingbrooke Hospital) worth £285 million.1
The fall of New Labour gave the Tories the confidence they needed to unleash their doomsday device for NHS destruction - or, as it is more commonly known, the 2012 Health and Social Care Act. El-Gingihy dedicates his longest chapter to explaining the impact that this legislation has had on the way healthcare is delivered in the UK. The department of health justifies the act as providing much needed modernisation (privatisation), which is more realistically affordable (heavily cut). Two crucial elements of the act, subtly buried amongst the 473 pages of jargon, are that it removes the legal duty for the government to provide key NHS services and it introduces the requirement to allow “any qualified provider” to bid for those services. This represents the opening of the floodgates to the private healthcare companies, allowing them to easily undercut the NHS, to provide an ever-growing range of services, from carrying out blood tests and X-rays to running hospitals. El-Gingihy highlights the extent of this big sell off, stating: “… an estimated £2.6 billion worth of contracts have been awarded to profit-driven companies, such as Bupa, Virgin and Care UK.”
The act also abolished the PCTs and replaced them with clinical commissioning groups (CCGs), made up of a collection of GP surgeries in a given locality. As a newly qualified GP I have attended several of my local CCG meetings and I can confirm they are a thoroughly demoralising affair. Instead of giving GPs the power to make decisions in the best interest of their patients, as the government claimed, they actually add several extra layers of dumbfounding bureaucracy and are run as a vehicle for implementing vast cuts. I have attended meetings where the CCG leadership presented us with the extent of “efficiency savings” required as a fait accompli and asked the GPs to brainstorm on services that can be reclassified as ‘non-essential’ and therefore restricted. This has led to cataract, hip and knee operations being severely rationed … apparently it is no longer deemed essential to be able to see or walk properly.
Smear campaign
As El-Gingihy points out, all this has taken place alongside a relentless, media-led anti-NHS smear campaign. In 2014 the Commonwealth Fund ranked the NHS as the leading world health service for quality, access and efficiency. Yet not a week goes by without another story about poor standards of care in hospitals or the unaffordability of the ever growing demand on an NHS “at breaking point”. But the media are careful not to link this to the Tory cuts, the burden of PFIs and the loss of revenue to private firms - all of which has led to a massively underfunded and thinly spread workforce. This rightwing media-Tory collaboration is the invisible hand attempting to guide us towards the conclusion that the NHS cannot survive as it is. And that brings us towards the final step in its dismantling: the introduction of universal health insurance.
Part of the reason why there has no mass uprising against the 2012 Health and Social Care Act lies in the way Cameron has labelled it ‘modernisation’ - he has been clever enough not to refer to ‘privatisation’. The collaboration of the media has meant that as of yet the public are, on the whole, unaware of the full significance of the act. Like a boxer who has taken repeated blows to the body, but defended their face well, outwardly they look unscathed, but there are clues that all is not well; legs have started to wobble and eyes have a glazed look … in fact it will only be a matter of time before they are beaten. In a way this is currently the situation with the privatisation of the NHS. Outwardly, to the majority of the population, it seems much the same as it always has been - free at the point of need. However, you do not have to look too deeply to realise that, as with the boxer, the NHS is on the ropes and facing a knockout blow.
‘Personal health budgets’ are one early sign of the end of the NHS as we know it. These schemes provide certain amounts of money to patients to buy their services directly. As El-Gingihy says,
… it’s all about empowerment, right? Wrong. They represent the end point of the journey with the self-paying consumer in the market for healthcare … what happens when your personal health budget runs out? Easy - you top it up.
Which is where private insurance comes in. The idea is that the NHS will remain - but only in name: a useful logo for the insurance companies to exploit.
For all its useful summation of the devastating journey towards privatisation, How to dismantle the NHS offers little towards any type strategy for reversing the changes. The book ends with a short chapter encouraging ‘resistance’. We are asked to support the Campaign for an NHS Reinstatement Bill2 - Jeremy Corbyn and John McDonnell are listed among its supporters. The aim of this campaign is basically to reverse the 2012 act and allow “private companies to provide NHS services as an exception”.
I believe we should support defensive campaigns such as this one: a reversal of the act would have immediate benefits for NHS workers and users alike. But at the same time we should be trying to drag this and other campaigns like it - not to mention the Labour Party’s NHS policies - to the left. As communists we need to be leading the fight for an NHS that is freed from its bureaucratic and capitalist market chains. We do not simply want to return to a pre-2011 or indeed pre-1970s NHS.
We should instead call for a health service that provides the highest quality of care, democratically run by the staff and the community. We also need to be calling for the nationalisation of the pharmaceutical industry; drugs should be produced to help treat people, not generate profit. Ultimately this is linked to our struggle for a new global order - hopefully one day we will be able to look back with pride at the dismantling of the NHS in favour of an International Health Service l
James Linney
Notes
1. See ‘Private firms on course to net £9 billion of NHS contracts’ The Guardian November 19 2014.