Best of times, worst of times
Saving the NHS will undoubtedly be a key issue in the coming general election. Ian Spencer analyses the recommendations of the Times Health Commission
Times Newspapers established the Times Health Commission in January 2023 to “learn the lessons from the best examples in this country and abroad in a dispassionate, clear-sighted, non-ideological fashion”.1
The commission was made up of the great and the good recruited by The Times from the worlds of “business, medicine, science, food, sport and policy”. Their mission is to “save the NHS” by putting forward a series of policy proposals that could be “taken up by any political party” - a phrase which probably says more about the state of current mainstream political parties than it does about the Times Health Commission.
Commissioners include, among others, a collection of retired presidents of assorted Royal Colleges (nursing, physicians, GPs and the Royal Society of Medicine), some of whom have been ennobled for their pains (considered by some to be the going-rate for leading a ‘Royal College of something-or-other’). The business contingent includes a former director of the Institute of Fiscal Studies, Paul Johnson, the chairman of Asda and “former M&S boss” Lord Rose of Monewden. Then there is paraolympian Baroness Grey-Thompson; Lord Darzi of Denham, “surgeon and former health minister” (under New Labour); and Waheed Arian, “Afghan refugee, doctor of the year and Times person of the year”. All of this is chaired by Rachel Sylvester, a “Times columnist”. You get the picture.
The commission’s report is 100 pages long - written in the style of a government white paper, but with more pictures and snazzy insets, illustrating what it is like ‘on the front line’. It includes interviews with paramedics, surgeons using laparoscopic (or as The Times prefers, “robotic”) surgical techniques and stories of Ukrainians having to return home (temporarily) to visit a dentist because of the non-availability of one on the NHS. This latter inset is a damning indictment of the steady destruction of NHS dentistry - without ever suggesting that has been a direct consequence of successive Tory and Labour policies, of course.2
The commission’s report has provided a rich source of self-referential copy for The Times for a while now, and is clearly timed to form a political intervention into the coming general election. For example, there is the headline, “Jeremy Hunt backs no-blame compensation scheme for medical errors”. This is a proposal which is “one of 10 key recommendations that will be made by the Times Health Commission, a year-long inquiry into the NHS and social care”.3 We are invited to believe that the government is considering introducing a no-fault system, in which compensation payments for those who have suffered harm because of mistakes in the NHS are “standardised and based on need”.4
The cost of litigation is acknowledged by the commission to be a major drain on NHS resources. For example, NHS financial liabilities, for obstetric litigation alone, has risen from £14.9 billion in 2016 to £41.5 billion in 2022. The human cost is also featured: “There are about 11,000 avoidable deaths every year in the NHS due to patient safety failings.”5
Anyone looking at the way the government has handled the compensation payments to those who have been harmed by the Post Office may be entitled to be a little sceptical. Is the aim to expedite claims made by people to meet needs or to protect the private sector from liability in an increasingly privatised system? In so doing, will it be, yet again, the privatisation of profits and the nationalisation of liabilities - namely, compensation for harm done by clinical services and a reduction of payments to those injured?
The proposal is typical of the other “key recommendations”, to do something, which sounds new and the consequence of the careful deliberation of the commission, but is, in fact, as old as the hills. For example, a no-fault compensation scheme was a recommendation of the Royal Commission on Civil Liability and Compensation for Personal Injury. This took into account a welfare state and the vast savings that could be made in lawyers’ fees, if claims for compensation were removed from an adversarial system.
The point about the welfare state is that, where needs are met from central funds - for example, for home modifications for someone left disabled by medical negligence - winning payments through litigation becomes unnecessary. The time-consuming, expensive and distressing process can be avoided, and the victim helped sooner. However, it reported in 1978, just as the post-war Keynesian consensus on the welfare state was being superseded by the current consensus for a dismantling of workers’ gains made since 1945.
Another example of the report’s recycled insights is the criticism of the NHS as being far too focused on secondary care in general and hospitals in particular. It asserts that the NHS is a “national illness service”. A superficial flick through the literature will see the same point made by jurist Ian Kennedy in his The unmasking of medicine.6 However, it would be churlish to argue that everything in the commission’s report is nonsense. It would clearly be a great benefit to have a system of no-fault compensation. The problem arises from the political-economic context of a declining capitalism.
Similarly, hospitals in their current form are as much an expression of social relations as a factory, church or school. The appalling idea that the elderly - particularly those with cognitive impairment - can simply be stored in institutions, as they were in the old asylums, was a feature of the development of the Poor Law. The commission acknowledges that the “state must underwrite the costs of social care, because the private sector will never take on such an unpredictable risk”.7
Yet, like the ruling class as a whole, it is wedded to the idea that the private sector has a role to play. After all, there are profits at stake. The heart of the contradiction is that, as human needs increase, a failing system is unable to meet them, without extracting a greater proportion of surplus from a working population - made more difficult by a tendency of the rate of profit to fall with the increasing use of technology.
At the heart of the commission’s proposals is a private system of excellent care for those that can afford it and a safety net for the rest. There is a world of difference between a privately owned care home and another that is effectively paid for by a mixture of local taxation and the partial expropriation of the dementia sufferers’ estate. No-one wants to go back to care in asylums, but in fact the asylum has merely changed its form!
The other “key recommendations” by the Times Health Commission include the advocacy of technological solutions (presumably forged in the ‘white heat of technological revolution’); tackling waiting lists; reforms to general practitioner contracts; the writing off of the student loans of some clinicians; a “National Care System” (a phrase that was a feature of the Corbyn manifestos); guarantees on the provision of mental health support; that old favourite, ‘tackling obesity’; incentivising NHS staff to take part in research; and establishing a “Healthy Lives Committee” to “empower by a legally binding commitment to increase healthy life expectancy by five years in a decade”. It is interesting that there is a need to have legal compulsion to increase life expectancy, but then Britain is unusual in starting to see a decline in life expectancy.8
And here is the rub: many of the recommendations are framed in such a way as to seem reasonable, fair and achievable - they even include the post-mortem endorsement of Aneurin Bevan on the back page. I can only imagine what the so-called ‘architect of the NHS’ would have made of a report which is written with the express purpose of showing how the NHS is failing, in desperate need of reform, and endorsing the need for a social care system “delivered by a mixture of public and private sectors”.9
The report is also interesting for what it does not say: that the problems faced by the NHS - the high turnover and loss of staff, worsening health outcomes and rising health inequalities - are direct consequences of successive Labour and Tory government policies. Waiting lists are partly attributed to clinicians’ strike action, without ever addressing the declining pay, which also does not feature in an explanation for the haemorrhaging of NHS staff. Instead, the problems of staffing are attributed to “cultural” issues, such as workplace bullying and high rates of sickness.
Then of course, there is what The Times could never say. The real costs of healthcare that is run on the basis of commodity production is measured in hundreds of thousands of excess deaths. For example, in England alone, “the many people who are currently dying prematurely each year because of health inequalities would otherwise have enjoyed, in total, between 1.3 and 2.5 million extra years of life”.10
It is not that the commission does not address the question of inequalities in health. After all, it is hard to avoid. Britain has a very long history of solid empirical evidence that class is the most important social determinant of health. The report devotes five pages to inequalities in health and makes the well-known point that “Men living in the poorest areas can expect to die 9.4 years sooner than those living in the richest areas and the difference for women is 7.7 years”. The focus on geography and the gap between poorest and richest effaces the importance of class and invites the suggestion that this is the consequence of local policy measures, which are amenable to reform, or lifestyle choices. It also leaves out the fact that there is a class gradient in almost every area of mortality and morbidity.
While a series of sweeping reforms aimed at reducing inequality would undoubtedly improve health overall, it informs no part of the commission’s perspective. Increasing inequality is made to appear as a natural feature or, at best, a regrettable failure of policy. Therefore, among the report’s recommendations are addressing the rates of obesity by means of “expanding the sugar tax, taxing salt and implementing a pre-watershed ban on junk food”.
In other words, the commission dishes up the usual mess of pottage. Personal responsibility, combined with innovative means of funding and technological innovation are the key to ‘saving the NHS’. This shows that health is something that is far too important to be left to bourgeois politicians or journalists. The solution to the question of health and social care is the radical transformation of society, where all production is to meet human need. Liberation from wage labour and the drastic shortening of the working week, will do more to improve health than any number of reforms to the NHS.
In the meantime, the vast amount of money that is currently being poured into the pockets of clinical negligence lawyers, owners of private healthcare facilities and shareholders of big pharmaceutical companies is a fruitful place to start, when looking for additional, creative forms of funding. That needs to start with paying all workers more.
We know that greater equality is good for health. We also know that the ruling class, which finds its interests expressed in the mainstream media, will never willingly concede it.
The Times February 4.↩︎
‘The Times Health Commission: a report into the state of health and social care in Britain today’, p36.↩︎
The Times February 2.↩︎
The Times Health Commission op cit p49.↩︎
I Kennedy The unmasking of medicine London 1980.↩︎
The Times Health Commission op cit pp65-66.↩︎