Shadow politics: The NHS is more than a logo

Perhaps the most blatant example of the shadow politics is what the political class has doing to the NHS over the past 30 years. To most people, the NHS is more than a logo - but for how much longer?

Just over a year ago, the world was wowed by the Olympics opening ceremony - famously dismissed as “leftie multicultural crap” by Tory MP Aidan Burley (previously sacked as a ministerial aide for attending Nazi-themed stag party). Centre stage in the ceremony was the NHS logo, with children saved from a marauding child catcher (Andrew Lansley?) by multiple Mary Poppins. If only we could be so confident that the NHS will be rescued in real life.

As Jacky Davis and Raymond Tallis recount in their new book NHS SOS, doctors, unions, the media, and politicians who have claimed to be the NHS’ most stalwart defenders have failed to protect it, most recently with regard to the Health and Social Care Act. (Call it Cameron’s Law: The more a politician claims that they will ‘back the NHS’, the more they are likely to set out to wreck it). It’s an excellent - if depressing - story, and one you should read for yourself (profits from the book go to the campaign group Keep Our NHS Public).

Beneath all of the detail that necessarily accompanies such a large and complex organisation like the NHS, the story is pretty simple: since the 1980s the political class has been successively rewiring the NHS away from a needs-based, publicly-provided health service, and towards a market-based, privately-provided health sector. Such is the public’s attachment to the NHS that these changes have necessarily been concocted in the shadow politics, and presented for the public as being motivated by ’efficiency’, ‘productivity’, ‘patient choice’ - anything but what they really are: a sustained programme of ‘reform’ to dismantle what has made the NHS so distinctive, and turn it into a money-making scheme for private interests.

A good summary of the steps taken can be found in a Keep our NHS Public briefing. In short, the story is:

• 1980s - Increasing outsourcing of support services, starting with tasks such as cleaning and portering, and moving onto more advanced activities such as diagnostic testing, logistics and supplies, and administration and financial management.
• 1990 - The introduction of the ‘purchaser/provider split’, between providers (for example an NHS Hospital Trust or increasingly, a private company, charity or social enterprise, and purchasers (formerly Primary Care Trusts, now Clinical Commissioning Groups).
• 2000 - Outsourcing clinical services, for example, via the NHS paying for treatment in private hospitals, the introduction of ‘independent treatment centres’, and the takeover of some GP surgeries and out of hours services.

What has been the result? A health service that is:

• More complex and fragmented - the recent and on-going A&E crisis being one example, with people becoming so confused about services they don’t know where else to go;
• Less efficient and more expensive - the NHS’ record as one of the most efficient healthcare systems in the world is being undermined as a result of complexity and fragmentation, and the costs of commissioning, contracting, managing, monitoring and auditing an increasingly market-based system. Administrative and management costs have tripled since the end of the 1970s, according to the Department of Health’s own research. Add to this the devastating impact of PFI schemes, and the massive cost of successive reorganisations (the most recent having cost more than £1 billion already, according to the National Audit Office, including £435 million in redundancy payments);
• Less transparent and accountable - with private providers not subject to the Freedom of Information Act, contracts developed in secret, and often it not even being clear to the public who is actually providing services under the NHS ‘brand’;
• Less responsive to what people want - reforms have often been presented as ensuring greater ‘choice’ for patients, but with whole services being outsourced they are actually being offered less of what they really want: a say in how they are treated, rather than who they are treated by, in a properly joined-up public service. As a result of the latest reforms, CCGs are forced to put services out to tender, and the NHS Support Federation claims that of more than 100 contracts have been put up for contracting, only two have been won by the local NHS. What is far more likely than ‘patient choice’ - and what is actually happening - is that a few large private healthcare interests are increasingly taking over. Nearly £9 billion of services have now been outsourced, and contracts are getting ever larger (witness the latest outsourcing of services in Cambridgeshire and Peterborough, worth between £700 million and £1.1 billion);
• More vulnerable - with providers failing or pulling out of services, the latest example being the 111 helpline service, alongside cuts to frontline staff and services (including nearly 5,000 fewer nurses).

But perhaps most fundamentally, these reforms are created a service that is less ‘ours’. At what point, if delivered by private companies, does a public institution cease to be one? This is the threat now posed to the NHS, and it is exactly what the political class has intended through its thirty years of shadow politics with the health service. (Consider the attempt in the Health and Social Care Bill to abolish the Secretary of State’s responsibility to ensure a ‘comprehensive health service’).

The next step is to introduce charging - witness the latest intervention by Shirley Williams (to her shame), floating the idea of charging for GP visits, on the basis that it “might get people to value the service.” The political class are desperate to introduce so-called ‘co-payments’, since they represent a way of edging into an insurance-based system, with ‘top-up’ payments paid for by insurance (the former Department of Health director of strategy Chris Ham, now at the Kings Fund, has suggested this is the direction of travel of recent reforms, with the NHS becoming an insurer rather than a provider).

At the same time, the political class is trying to pose as the champion of patients (for example, using ‘death rate’ data), by criticising the instances of poor care that are often due in large part to the ‘reforms’ that they have pushed through over the past 30 years. While the funding demands and pressures faced by the NHS are real, there is a danger of falling for scare stories that suggest that the NHS is ‘fundamentally unaffordable’, thus justifying steps such as charging (no doubt these too will be presented as being necessary to ‘save the NHS’).

There was much criticism when the NHS advertised last year for a ‘head of brand’. Ironically of course, many of those who complained have also consistently advocated the advance of private businesses into the health service, necessitating the need for a brand manager in the first place. More seriously, the use of the NHS logo serves to cover up just how much of the NHS has been privatised already.

The NHS celebrated its 65th birthday at the start of last month. It was established at a time of huge public debt following the Second World War, food shortages, a chronic lack of housing, and widespread poverty. What’s our excuse for not striving to save it?

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