28.03.2024
Thoughtful end rulers
As we head towards a general election, the Murdoch press is busy promoting big pharma’s ‘vision’ of future healthcare, writes Ian Spencer. But it is not ours
In February, The Times regaled us with its ‘Health Commission’ - a pseudo-objective investigation into what it would like to see in healthcare. Raconteur - a supplement distributed with the newspaper at the weekend to provide “stories that connect modern business” - last week focused on health.1
Raconteur is funded through advertising and sponsorship, including by drug companies, but maintains that it is editorially independent, and the articles’ sponsors are clearly stated. Raconteur is classed as a ‘B Corporation’ - the ‘B’ apparently stands for ‘beneficial’, although it does not specify to whom. The certification is provided by ‘B Lab’ - an international, ‘non-profit’ organisation, which awards ‘B Corporation certification’ to for-profit organisations that have ‘social impact’. In 2019, B Lab had an income of nearly $17.5 million and assets of over $9.5 million. Among its founders are Andrew Kassoy - a “champion of free-market capitalism”, who established B Lab to help capitalism “do social good”.
B Lab is funded by what are described as “left-of-centre” funders with a commitment to “embrace environmentalism, diversity, equity and inclusion”. They include e-bay founder Pierre Omidyar, Jeffrey Skoll, who financed Al Gore’s film, An inconvenient truth, and the Ford Foundation.2
What we seem to be dealing with is the more thoughtful end of the bourgeoisie, possibly not hell-bent on the destruction of the National Health Service, but, as we might expect, it is critical. Put differently, most of the articles contain familiar themes, such as the need to reduce obesity, prevent anti-microbial resistance to antibiotics, make better use of information technology to promote efficiency, and change the focus of healthcare towards community services. Let us take a closer look at some of these themes.
IT software
Those of us with experience of wading through volumes of medical notes, composed of indecipherable handwriting, will have a natural sympathy for being able to have ready access to the whole range of clinical data. Yet, each of the 229 NHS trusts and 1,250 primary care networks is responsible for its own software - not to mention the thousands of private care homes and private clinics.
The sharing of data frequently comes up against the problem of the compatibility of different programmes. Clinicians during a day may have to log into several different systems, which may or may not be able to link up to one another. A solution suggested by Charles Orton-Jones, a business journalist, is open-source software, making use of a single unique citizen signifier, as is employed in Estonia. Its use prevents ‘vendor lock-in’ and at £26 million annually, stands in favourable comparison with the NHS Connecting for Health programme, which costs an estimated £20 billion and was described in a public enquiry as one of the UK’s “worst and most expensive contracting fiascos”. But what the Raconteur article does not discuss are the reasons why the NHS system was such a failure - reasons which have some resonance with other IT disasters, such as the Horizon scandal at the Post Office. It was a ‘top-down’ system, hastily imposed with poor accountability and oversight.3
The NHS has a bureaucracy problem. Whether that is a feature of capitalism in decline is a moot point, but it certainly results from an attempt to force a pseudo-market onto a health system which had developed for 40 years outside of market forces. The hotchpotch of Poor Law, charity and county asylum provision that the NHS was based on was not exactly a ‘free market’ either. Bourgeois sociologist Max Weber wrote about bureaucracy in positive terms as a rational, goal-orientated alternative to feudal particularism. However, he understood that it was antagonistic to democracy and, of course, that is just the point.
When Marxists have written on bureaucracy, they have frequently focused on the USSR and its satellites. As we know, the Soviet product was almost universally defective, owing to the difficulty faced by the system of enforcing ‘planning’ and discipline on the workforce, without a market in which choice could exert its own influence on both discipline and quality. Although not some island of socialism, there was no sign of the NHS in the 1970s of being particularly defective for having been taken out of market relations, if judged against health outcomes of other societies of the time. It was, however, ‘efficient’ in the important sense of spending only a small amount of total expenditure on administration, especially when compared with US healthcare.
The justification for the abolition of area health authorities in 1982 was supposedly to remove an ‘unnecessary layer of bureaucracy’, as their responsibilities were taken over by smaller district health authorities - until they too were abolished in favour of single-tier health authorities in 1996 and then replaced by primary care trusts in 2002. However, some NHS trusts are now at least as large as the defunct area or district health authorities were. The bureaucracy, far from going away, has responded to the needs of the pseudo-market. The proportion of health expenditure that goes on administration has steadily grown, as an army of accountants manage the separation between providers and commissioners.
Perhaps more importantly, the dynamic behind the implementation of IT in the NHS is concerned only partly with making clinical records more efficient. In the 1960s, most nursing, for example, was undertaken by qualified nurses or trainees. Now an officer corps of registered nurses supervises an army of healthcare assistants with varying levels of training. The proportion of qualified staff is changing in other occupations too and is likely to undergo further changes in medicine, as physician associates take over from fully qualified doctors. The NHS is consistently failing to recruit as many qualified staff as it loses each year to the private sector or to overseas employment. Similarly, the NHS is wholly dependent on highly qualified nurses, doctors and many others from overseas to simply maintain current levels of staffing - the vacancy rate is currently about 9%.
One response is regulation. IT in the NHS is as much to do with replacing living labour as anything discussed by Marx in his famous chapter on machinery in volume one of Capital. If you have not recorded the patient’s blood pressure at the appointed time, your hand-held device will let you know. On the face of it, it is no bad thing “to make such machines of [wo]men as cannot err”. The fear is, though, that the algorithm will replace clinical judgement, as it certainly will not get as tired as a clinician towards the end of a 12-hour shift!
Technology in the health sector is as concerned with surveillance of staff as it is with replacing living labour with dead labour embodied in machines.
AMR danger
An article in Raconteur sponsored by the Japanese pharmaceutical company, Shionogi, leads the charge against the danger to antibiotics of antimicrobial resistance (AMR). It does so, supported by freelance journalist Heidi Vella, who quotes the World Health Organisation’s suggestion that AMR was responsible for 1.27 million global deaths in 2019. She goes on to point out the disparity between the £5.45 billion for oncology research and development, compared with £125 million for antibiotics.
Put simply, big pharmaceutical companies cannot make nearly enough profit from developing new antimicrobials. It is also difficult to make research into rare diseases profitable too. It is important to understand that pharmaceutical industries do indeed incur high costs in bringing new compounds to the market, especially since the catastrophe of thalidomide in the 1950s and early 1960s. The costs for research and development of a new antibiotic can be more than a $1 billion. Shionogi’s response to the awkward profit problem is to argue that “The market needs to incentivise that investment in research without companies needing to rely purely on large volumes of sales to recoup their outlay.”
However, the pharmaceutical industry makes super-profits from its guaranteed 20-year monopoly on the production of new medication. Ernest Mandel has argued that this constitutes a “technology rent”, rather than conforming to the normal actions of the law of value.4 The holy grail for pharmaceutical companies is something like therapy for cystic fibrosis, one of the most common life-threatening genetic disorders, whereby companies can charge high prices for medication, which the patient will have to rely on for life. In a system based on the meeting of human need, but without the abolition of commodity production, the NHS faces a potentially limitless demand for the products of human ingenuity. Again, the response is regulation.
It is also worth pointing out that the NHS constitutes a guaranteed market for the pharmaceutical industry - an industry which is not shy about being ‘tax-efficient’, when it comes to supporting the NHS that buys its overpriced wares. Alliance Boots, for example, has avoided over £1 billion in tax.5
We are invited to believe that AMR is the result of overzealous prescription to patients who expect antibiotics or do not take them properly - for example, by not finishing the course. While that may play a part, the fact is that AMR is evolution in action. As we saw with the Covid pandemic, microbes evolve quickly. What is a far bigger killer worldwide is the poverty in the provision of even basic requirements for a healthy population, such as clean water, good sanitation and adequate nutrition. One million children a year die from malaria, most of which could be prevented by the simplest of public health measures.
Even if we accept the industry’s argument about the cost of research and development, it is worth celebrating the power of human ingenuity. In 30 years, HIV/AIDS has gone from being almost invariably fatal to now having only a limited impact on life expectancy. Similarly, the development of the Covid vaccine would have been hampered without a large state input, both as a funder of research and guaranteed purchaser. Imagine what could be done if it was taken out of commodity production altogether. And how about nationalising some of those large pharmaceutical industries?
Obesity
The clichés about the ‘obesity epidemic’ are readily regurgitated in Raconteur, in an article sponsored by the pharmaceutical company, Lilly. It manufactures injectable medication for the treatment for type two diabetes, as an alternative to the oral medication, Metformin, which has been out of patent for a long time. However, the company has a point in observing that:
NHS data shows that 26% of adults are living with obesity across the country. However, this is not evenly spread across society - the least deprived areas have an obesity prevalence of 20%, whereas in the most deprived areas the rate is 34%.
Fat, and type two diabetes, are class issues - Raconteur is saying nothing new. Not only are poorer people fatter on average, but their obesity is more dangerous, with fat deposition around internal organs and inside arteries.
It is inherently stressful being poor. Stress hormones - particularly cortisol and the catecholamines, such as adrenaline - ensure the release of blood glucose and contribute to insulin resistance. This has been known for decades, as has the fact that type two diabetes is potentially reversible without pharmacological interventions.
What is really needed is a radical transformation of society at large. If you really want to bring down the blood sugar level of the nation, reduce the working week and give people democratic control over their workplaces. If you really want to ensure that big pharma concentrates research into AMR, rare diseases, and new antimicrobials, the solution is not to ensure that the poor guarantee the super-profits of Lilly, Shionogi and others, but to take them into planned public ownership.
Raconteur may represent part of the thinking bourgeoisie, but, despite any good intentions, the fundamental contradiction of capitalist society will never be addressed - or even properly understood - by the bourgeoisie itself.