You are what you eat

Crude attempts to introduce ‘market incentives’ in the NHS have led to a massive increase in bureaucratic waste, writes Eddie Ford

A recent Bournemouth University study has damned the appalling decline in the quality and efficiency of NHS food provision - leading to The Sun rhetorically asking: “Guess who gets better fed - hospital patients or convicted criminals?” (September 2). A team of nutrition experts at Bournemouth, led by professor John Edwards, found that around 40% of patients are already malnourished by the time they arrive at hospital. But instead of their situation improving during their stay (as you would naturally expect) it actually tends to get worse - with many patients just not getting enough food, forcing concerned relatives and friends into the absurd position of having to smuggle in extra rations to make up for the deficiency.

The main reason for such a lamentable system, argues the study, is that NHS services have dramatically “fragmented” - so there is little follow-up by medical staff. Food trays are quickly whisked away by the cleaning staff, so doctors and nurses do not know how much food the patient consumed. Not to mention that, once the food is prepared and ready, it normally hangs around waiting for porters to then transport it to the wards - where it may be left for an extended period until it goes eventually goes cold.

Additionally, rigidly set meal times often mean that patients undergoing tests, or whatever, may well miss out altogether, and for those who need some degree of assistance when it comes to eating and drinking there is a chronic lack of support.

By vivid contrast, we discover, prison food was found to be much healthier and cheaper to produce - freshly cooked as it is on site, for the main. As professor Edwards explained, prison food nowadays is “actually better than most civilians have” - given that there is a “focus on carbohydrates”. And also the way prisons prepare the food is “very healthy”, as they “don’t add salt” and “there’s relatively little frying of food” - hence “if you have a burger then it goes in the oven”. Not the NHS. It fries and boils just about everything to near death, thus considerably decreasing nutritional value. Though, of course, unlike the prison service, the NHS does not have to worry about patients rioting in protest at the crap nature of the food - especially as going on the rampage is quite difficult if you are malnourished.

Of course, this study has been eagerly used as ammunition by Tory and far-right critics of socialised medicine. The NHS is painted as bureaucratic, inefficient and hugely expensive. Obviously there is more than a grain of truth in these charges. Only someone high on morphine could fail to see that the NHS is becoming increasingly bureaucratised - therefore more alienating as an institution for both patients and workers. Which in turn leads to a deterioration in the actual care provided, as poorly paid and poorly motivated NHS workers - like all workers, of course - find ever newer and inventive ways to cheat their bosses and just get through their often hellishly long day. Quite understandable, of course, for the individual worker concerned, but an unfortunate - and even grotesque - side-effect of such an invidious situation is that a vicious circle develops whereby demoralised staff begin (no doubt unintentionally) to treat their patients in a shoddy, sometimes even indifferent or cruel manner. Leading to what you could term the ‘culture of neglect’ that afflicts, and malforms, so many parts of the NHS.

Communists unconditionally defend the NHS from its various detractors on the right. But we do not do so blindly or out of a misplaced sense of patriotic duty. Rather our critical defence of the NHS is based upon a programmatic commitment to a fully socialised healthcare system, as opposed to a wholly or partly privatised one - which is the real aim in some shape or form of most, if not virtually all, of its most vocal reactionary opponents. So by defending the existing services provided by the NHS, and fighting to protect and improve working conditions, we are in effect defending and advancing the communist programme.

Therefore communists are not being in the slightest bit contradictory or hypocritical by freely recognising that the NHS is bureaucratic - and has been since day one. Control and management has always been strictly from above, whether in the guise of grim-faced state officials and their regulation clip-boards or primary care trust bosses with their infernal PowerPoint presentations. God forbid that those who work in or use the health service should be allowed to have a say in its day-to-day operations, let alone democratically run it from below.

So, yes, communists would effectively agree with critics who maintain that the NHS has become a “bureaucratic black hole” under Labour - to use the words of a recent Tory report/analysis which appeared in the Telegraph, a newspaper which it is safe to say has very little sympathy with the aims of communism (April 11).

We read that more and more cash is being siphoned away from the “front line” in order to pay for an increasing army of “administrators” - ie, bureaucrats to you and me. Spending on the numerous NHS quangos and committees, according to the Tory report, reached some £12.6 billion last year, representing a rise of 103% since 2003. Or, to put it another way, the ‘bureaucracy budget’ allocated above amounts to seven times the money spent on either maternity services or dentistry, each of which received a relatively paltry £1.8 billion by comparison - and the same goes for the accident and emergency departments, which received £1.7 billion. Furthermore, billions more were spent on administration at hospitals and primary care trusts (PCTs) across the country, for which specific administrative/financial statistics have not yet being compiled.

The Tory report also found the rise in the number of administrators outstripped the rise in the number of new doctors and nurses - there are twice as many bureaucrats as midwives, and 5,000 more managers than hospital consultants. Last year alone the number of managers rose by nine per cent, while nurse numbers increased by just two per cent and the average pay for a chief executive running a foundation hospital trust reached a princely £157,000. Indeed, one of the more lucrative NHS quangos was a body called NHS Professionals, set up in 2004 with a remit to reduce the amount spent - or wasted, some would argue - on agency nurses. Instead, it merrily spent more than £1 million employing two senior managers in just two years - with the lucky chief executive, John Faraguna, bagging himself £1,170 a day for his ‘expert’ services.

In fact, the roll call of so-called ‘arms-length’ NHS quangos, agencies, think-tanks, review bodies, committees, sub-committees and so on seems almost endless. So we have the Cosmetic Surgery Steering Group, Advisory Board on Registration of Homeopathic Medicines, Alcohol Education and Research Council, Herbal Medicines Advisory Committee, Independent Advisory Group on Sexual Health and HIV, the Leadership and Race Equality Action Plan Independent Panel, etc, etc. Jobs for the boys and girls, that is for sure. Overall, within the NHS there are 11 regional health authorities responsible for managing performance at 200 hospital trusts and 150 PCTs.

In other words, we have a situation roughly analogous to Stalin’s Soviet Union - where the ‘cure’ for bureaucracy is … more bureaucracy. Inevitably, this rapidly creates a self-perpetuating and self-expanding Leviathan, with bureaucrats chasing bureaucrats and watchers watching the watchers. Obviously, an ideal environment for any budding tyrants (including preening PCT bosses), but one which relentlessly eats away at all forms or notions of democratic accountability.

Of course, a defining characteristic of such bureaucratic structures is an obsession with quota-mongering and target-setting. With regards to the NHS, far from reducing bureaucracy, waste and inefficiency, the forced and crude attempts to introduce ‘market incentives’ (or the ‘internal market’) have only led to a massive - almost exponential - increase in bureaucratic waste. Which in turn generates huge levels of debt.

Clearly, the government’s beloved - and supposedly pioneering - private finance initiatives are a prime example of such waste, born out of an ideological infatuation with the so-called ‘modernisation’ that apparently only the market (or an imitation of it) can provide. Though the number of PFI schemes has declined somewhat over the last two years, the NHS will be paying out for this costly experiment for years and decades to come.

Thus, of the 133 new hospitals built since Labour won the 1997 general election, 101 of them were PFI-financed. To date, there are 149 PFI hospitals in Britain, the combined value coming to £12.27 billion. Yet, according to a recent report issued by Edinburgh University’s Centre for International Public Health Policy, the NHS will end up paying £70.5 billion for them - thanks, naturally, to the near commercial rates of interest charged by the banks on PFI schemes. Well, profits have to be made - don’t they? Accordingly, repaying the debt incurred through PFIs gobbles up well over 8% of the budget of London hospitals, as opposed to a 5.8% debt rate for non-PFI built hospitals. Half of the larger PFI hospitals are in “financial difficulties” compared with a quarter of non-PFI hospitals.

To further rub salt into the wound, Lloyds and the Royal Bank of Scotland - banks which dominate the market in lending tens of billions of pounds to hospitals built under the PFI scheme (and both of which, of course, recently received billions of pounds of state subsidies to stop them going under) - continue to “charge excessive risk premiums to the taxpayer”, as a Edinburgh University study notes. In summation, professor Allyson Pollock declared: “Instead of using the opportunity of the taxpayer bailout of Lloyds and RBS to re-open the contracts and negotiate better rates in favour of the public sector, the UK government is allowing the banks to restore their balance sheet by charging relatively high rates of interest for PFI schemes. The increased costs of servicing the debt are met from NHS annual budgets, and result in reductions in the money available for services” (The Guardian August 21).

Quite monstrously, the depressing fact is that a large percentage of these PFI-financed buildings and projects may not even be ‘fit for purpose’ in 30 or more years’ time - amounting to a criminal, and truly irrational, waste of resources.

Therefore, communists call for the immediate scrapping of the PFI scam - that would involve opening up the account books of those who have cocooned themselves within the NHS, exposing the multifarious shady business secrets hidden away behind the ‘commercial confidentiality’ clauses of the PFI contracts.

As a logical extension of this demand, we call for the nationalisation of the pharmaceutical and medical supplies industries - and for the removal of the PCTs, abolition of the ‘internal market’, and for the cancellation of all the debts racked up by the PFIs and other such endeavours. Similarly, cleaning, catering and other essential NHS services should not be run for profit, but for the public good.

Most vitally of all for communists, the NHS and its services should be democratically controlled from top to bottom - from the hospital ward and local health centre right up to a regional and national level. No more bureaucrats and petty dictators, no more arbitrary ‘target setting’ or chasing after phantom ‘savings’, but rather a rational plan that integrates the NHS into an overall plan for society as a whole.