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Our NHS: efficient and free- a heresy which the market fundamentalists must destroy
The official ministerial briefing for the Health and Social Care Bill, as published on the website of the Liberal Party, justifies the changes as follows:
Myth: The NHS doesn’t need any change.
Fact: Someone in this country is twice as likely to die from a heart attack as someone in France. Survival rates for some cancers are amongst the worst in the OECD. Premature mortality rates from respiratory disease are worse than the European average. The number of managers in the NHS doubled under Labour, and productivity went down year-on-year.
After quoting from that document, Prime Minister Cameron asserted:
In addition, the NHS faces enormous financial pressures in the years ahead – driven by factors ranging from ageing and obesity, through to the cost of new drugs and technologies.
So, apparently, something drastic must be done. Cameron continued:
Sticking with the status quo and hoping extra money will meet the challenges is not an option. If we want to deliver better results for patients, we need modernisation.
'Modernisation', like 'reform', is merely a code word for privatisation and the increased role of market forces. Remarkably, neither the ministerial briefing nor Cameron's statement conceded that 'extra money'- or, conversely, the lack of it- is one of the key differences between healthcare arrangements in the UK and those of the other main West European countries. French spending on healthcare, per person, is over one quarter higher than it is in Britain. Except in a system as dysfunctional as that in the United States, one would expect that much higher expenditure to produce significantly better outcomes for patients.
Appleby's intervention
In an article in the British Medical Journal (BMJ) on 27th January, Professor John Appleby, who is chief economist at the King's Fund think tank, de-bunked two aspects of the government's use of mortality figures to support their NHS changes. He pointed to the gap in healthcare spending between France and Britain, and also to the matter of the long term trends in mortality:
On the basis that if it ain’t broke don’t fix it, England’s health secretary, Andrew Lansley, has said that his reforms for the NHS are needed because the country’s health outcomes are among the poorest in Europe. But are they?
...Although statistics from the Organisation for Economic Cooperation and Development (OECD) confirm that in 2006 the age standardised death rate for acute myocardial infarction was around 19/100 000 in France and 41/100 000 in the United Kingdom, comparing just one year—and with a country with the lowest death rate for myocardial infarction in Europe—reveals only part of the story. Not only has the UK had the largest fall in death rates from myocardial infarction between 1980 and 2006 of any European country, if trends over the past 30 years continue, it will have a lower death rate than France as soon as 2012.
These trends have been achieved with a slower rate of growth in healthcare spending in the UK compared with France and at lower levels of spending every year for the past half century. The most recent OECD spending comparisons show that in 2008, the UK spent 8.7% of its gross domestic product on health compared with 11.2% for France—28% more.
On the issue of cancer mortality figures, Professor Applebly added:
Our apparently poor comparison with other countries on cancer deaths has also been a key argument for reforming the NHS. However, comparisons are not straightforward and depend where you look. Death rates for lung cancer in men, for instance, rose steadily to a peak in the UK in 1979. But since then they have steadily fallen, mirroring long term changes in smoking patterns, and are now lower than for French men, where the peak death rate occurred over a decade later in the 1990s. Similar long term trends are evident for breast cancer mortality. Since 1989, age standardised death rates per 100 000 in the UK have fallen by 40% (from 37.8 to 24.4) to virtually close the gap with France, where they have fallen by just 10% (from 25.5 to 22.0). Again, if trends continue, it is likely that the UK will have lower death rates than France in just a few years.
Appleby's intervention received wide media attention, and has helped to highlight the real, ideological purpose of the government's programme. But there is a third aspect of the Conservative-Liberal manipulation of health statistics which also needs to be exposed.
Inequality, obesity and bingeing
In his article, John Applebly remarked on the pitfalls of making direct comparisons between the effectiveness of health systems in different countries. Among the complexities is that the level of funding and the nature of the organisation of those systems are far from being the only main factors in healthcare outcomes. Merely presenting mortality statistics can be highly misleading, unless the underlying rates of ill-health among different populations is considered. If, for whatever reasons, country A has a higher prevalence of health problems among its population than country B, then even if both countries have health services with similar levels of funding and efficiency, country A will have worse mortality statistics than country B.
Thus to be fair, it must be conceded that relatively very poor public health outcomes in the USA, despite the appallingly high costs of the US health system, are not merely the result of the dismal failures of the privately owned and market-driven healthcare industry in the USA. They also reflect the impact of the wider circumstances within the United States, its very high levels of inequality, insecurity and relative extreme poverty, its individualistic, competitive and commercialised culture, the associated social breakdown and its effects on individual behaviour.
Among the effects of this, which cannot be specifically laid at the door of the American health insurance and medical corporations, is the rate of obesity in the USA: 34% of all adults are clinically obese, with a resultant annual cost of 147 billion dollars in 'weight-related medical bills'.
When assessing the comparative outcomes of the UK's health system, an allowance must be made for the higher level of inequality in Britain as compared to the other large west European countries, along with lifestyle factors including dietary and alcohol consumption habits.
Within Britain- as in other countries- economic inequality is the main factor in the health gaps between different areas, as shown in the wide geographical variations in life expectancy. For example, in Blackpool in the North West of England, average male life expectancy is 73.2 years, 10.5 years lower than in the affluent London Borough of Kensington and Chelsea.
By the way, this class-related gap in life expectancy, though for sure not a deliberate result of capitalist policies, can be considered to have an impact on electoral outcomes. An average working class person, having a lifespan ten years lower than an upper middle-class person, gets to vote, during his or her lifetime, in two general elections less than an elector from the upper middle-class.
As shown by the authors of The Spirit Level, among the developed countries, higher inequality within a country is associated with worse general health and greater social problems among the population.
Britain has the most extreme income inequality of all the rich European countries (the UK's Gini index, a measure of the unequal distribution of income, is 0.33 as compared with 0.26 in France). The UK also has the highest prevalence of obesity in Europe- approximately double the rate of obesity in France.
On the specific issue of mortality from heart attacks, even putting aside John Appleby's point that Britain's death rate for myocardial infarction is improving relative to that in France, it has to be noted that the incidence of heart disease varies very widely between different countries. Unfortunately there is no systematic research on the overall rate of cardiovascular disease in the UK in comparison with that of the rest of Europe; however the surveys which have been carried out indicate that there is a north-south and east-west gradient, with people in the eastern and northern parts of Europe tending to suffer much more frequently from heart problems.
In a study by the MONICA Project, looking at the incidence of heart attacks in various areas in Europe, the two UK cities that were included in the survey, Glasgow and Belfast, had the among the highest rates of acute heart disease- respectively 777 and 695 'cardiac events' per 100,000 people. By comparison, in the French cities of Strasbourg and Tolouse there were only 292 and 233 'cardiac events' per 100,000 people. More recent research has suggested that 'binge drinking', as practiced by many people in the in the UK- as distinct from the southern European habit of consuming alcohol more frequently but moderately- may be an important factor in differences in rates of heart disease.
Of course, Belfast and Glasgow are particularly unhealthy places and do not represent the UK average. Nevertheless, the striking contrast in their prevalence of heart disease when compared to cities in continental western Europe shows that Britain's Tory-Liberal government- in using heart attack mortality figures to attack the efficacy of the NHS, as if the underlying rate of cardiac illness was identical among Europeam nations- is conducting an excercise in deception.
Health and efficiency
Though he has emerged as a scourge of the current government's assault on the NHS, it must be pointed out that John Appleby is not an opponent on principle of policies which increase the role of the market within the health service. Far from it- until quite recently, he has been a key academic activist in bolstering the support of the medical hierarchy for pro-market reforms, and has weighed in against critics who opposed the changes in the NHS carried out under Margaret Thatcher and Tony Blair.
What is different about the changes that will be enforced in the present government's Health and Social Care Bill? It is not only that the new round of 'reforms' goes much further in unleashing commercial forces to demolish the National Health Service; it is also that, unlike previous moves to fragment and marketise our health system, the changes will not be accompanied by extra money for the health sector. As Appleby showed in a December 2010 blog post on the King's Fund website, the current government's ever-repeated promises to increase NHS expenditure are false. In fact, when current and projected inflation rates are taken into account, state health spending is already slightly falling and will continue to fall during the term of the present government.
As can be gleaned from an earlier article by Professor Appleby, published in 2008 on the occasion of the sixtieth anniversary of the founding of Britain's socialised health service, this is in marked contrast to previous periods when internal markets were imposed on the NHS.
Before commenting on the changes conducted under Margaret Thatcher and Tony Blair, Appleby observed that Sir Keith Joseph, a radical right-winger who was minister for social services in the Conservative govenment of Edward Heath in the early 1970s, sought to move the UK's national health system away from its fully tax-funded model, replacing it with a partly insurance-based system. This would have brought the British health system more into line with those of most of the continental West European countries. Joseph's move was defeated, and among the reasons for this was the recognition that such a move would not only be less equitable, it would also have been more expensive than the existing NHS system:
...with the Conservative government of 1970, Sir Keith Joseph [attempted] to switch the funding base of the NHS away from general taxation and towards a social insurance model. This last idea was resisted by the Treasury and many health officials, who saw it as a more costly and potentially inequitable way of raising finance for the NHS.
As can be seen from the costs and outcomes of the National Health Service in its classical period, the forces within the UK establishment of that time which opposed the abandonment of the British publicly-owned, tax-funded and state-controlled health system had good reasons for their intransigence. The following figures on health spending per capita and the results, in terms of infant mortality and life expectancy, of the UK, compared to the global OECD group of rich nations, the 15 countries of the European Union at that time, and the United States, are for the year 1980; the relative costs and outcomes are similar also for other years between 1960 and 1990.
Health spending per capita (% of GDP)
OECD average 7.3%
EU 15 7.3%
USA 8.7%
UK 5.6%
Infant mortality per 1000
OECD average 17.5
EU 15 19.4
USA 12.6
UK 12.1
Life expectancy
OECD average 70.0
EU 15 70.8
USA 70.9
UK 71.0
Source: Prof. Allyson Pollock, from the OHE Compendium of Health Statistics (NHS Plc, 2004)
So, until Britain's National Health Service began to be subverted by the introduction of market forces, the UK's health system was not only very much cheaper than the health systems of the other rich developed countries, but was also accompanied by better outcomes, on average, on two key measures of public health.
Extra money made the wheels- of marketisation- go round
But under the Conservative government of Mrs Thatcher, the issues of public health results and the costs of the system were eventually trumped by pro-market ideology. In his 2008 article, Applebly remarks:
NHS funding jumped in the first full year of Margaret Thatcher's new 1979 government, as with many previous administrations' first years in power. But as often in the past, a combination of Treasury parsimony and, as Harold Macmillan noted, 'events, dear boy, events', soon diminished government generosity and funding levels fell back once again. Pressures to cut costs were unabated. Cleaning and domestic services were to be tendered competitively, 'cost improvement programme' targets had to be met.
Noting that government healthcare spending was 4.4% of Britain's GDP at the end of the 1980s, Prof. Appleby continued:
The Conservatives' introduction of an internal market in the NHS, following the 1989 Working for Patients white paper, was destined not to be another historical footnote. Increased funding oiled the wheels during the 'slow take-off' of the market, reaching a new high of 5.7% of GDP in the early 1990s.
So while the first main commercial reforms of the service were implemented under Margaret Thatcher, the government threw large amounts of extra money at the NHS.
During the first two years following the 1997 electoral victory of New Labour, the Conservatives' changes in the health service were partially rolled back under the brief reign as health minister of Frank Dobson, and the NHS reverted somewhat towards its original non-market model; but during that time, the Labour government barely increased health spending. Then in 1999, Tony Blair replaced Dobson with Alan Milburn, a minister who endorsed a return to marketisation. Appleby remarks:
Although the government was officially committed to abolishing the internal market and sweeping away GP fundholding, policy changed when Alan Milburn took over from Frank Dobson as health secretary. Milburn appropriated three central ideas of Thatcher's reforms: the 'internal market', GP fundholding and self-governing hospitals.
And at the same moment, the New Labour government began its large increase in funding for the NHS, a growth which was to rise by an average of more than 6% annually until 2009. Thus again, as the role of market forces was increased in the health service, the 'reforms' were accompanied by very significant rises in expenditure.
From the New Labour point of view, this was a wise move. Contrary to the constant assertions of pro-capitalist ideologists, commercialised and fragmented systems incur costs which are not faced by state-planned and integrated systems. As the think tank Civitas concluded in a February 2010 paper on the effects, so far, of NHS marketisation:
"...the available research indicates that the NHS may have found itself in a lose-lose situation—taking on the extra costs of competition without yet experiencing the benefits."
The word 'yet' reveals only the bias of the authors, who are forced to invoke an imaginary future where the theoretical prescriptions of free-market economists- contrary to experience- actually work in practice. Civitas is a right wing, pro-market organisation.
Of course, there are examples of commercial companies which have reduced costs consequent on privatisation. But, as the contacting-out of hospital cleaning and domestic services has shown, this has largely been achieved through a combination of worsening the pay and conditions of the workforce and providing a worse service. Overall, competitive markets require armies of staff to conduct and manage all the buying, selling, accounting and promotion; smaller units lose economies of scale and involve duplication of management and technical functions; a state monopoly has much greater bargaining power when negotiating prices with suppliers than does a multiplicity of small sections, each having to operate as competing businesses.
Love, fear and struggle
Thus we enter a new phase in the healthcare system in England, in which funding will go down while the extra costs of competition will go up; the regional and local planning functions abolished and replaced by GPs having either to spend their time being market traders or hiring firms of traders to carry out the purchasing and contracting; the ethic of patient care overwhelmed by the tempting reward of city-banker style bonuses; publicly-owned hospitals not only competing with each other as hostile entities, seeking to maintain their market share by selling the cheapest operations, but increasingly driven out of 'business' by the profit-hungry private firms, including those based the United States of America.
The prime morality of these companies is the duty to raise the wealth of the chief executive, the board members and the shareholders, and, like vultures in the desert, they are eagerly circling the imminent corpse of the NHS.
But that will not be the end of it. The more they get, the more they want.
For the duration of this term of power for David Cameron and his faithful deputy Nicholas Clegg, a key aspect of our socialised health service will remain. Access to healthcare- however badly affected by, and infected with, the capitalist marketplace- will still be the right of every citizen, and (with some exceptions) free of charge at the point at which it is needed.
That vestige of the upsurge of working class power and socialist influence in the wake of World War Two, fought in alliance with the Soviet Union, is an existential insult to the high priests of capitalism, a practical heresy which, when the time is right, must be burnt away at the stake of the 'free market'.
The abolition of free healthcare will not be in the joint Liberal-Conservative manifesto for the general election of 2014 or 2015, just as neither of the 'coalition' parties included the current demolition of the NHS in their 2010 manifestos. And nor did they run for election last year on the promise that they would end the Education Maintenance Allowance for working class children, close the public libraries, privatise the forests, and terminate rural bus services.
Well in advance of the 2010 general election, the highly radical anti-public service and ultra-capitalist agenda of David Cameron's coming government was foreseen and forewarned by some. The writing was on the wall- though many, quite understandably, did not wish to see it, and dismissed those who pointed to that worrying and uncomfortable prospect as scaremongers.
If challenged on their intention to end free provision of health services after the next election, the Tories and Liberals will deny it again, again and again, until and unless they are re-elected to govenment. And after that, they will pronounce that a careful re-reading of their manifesto proves that they were re-elected on the pledge to introduce charges for healthcare- just as, as they now declare, "no top-down reorganisation of the NHS" was actually a promise that they would abolish the structures of the National Health Service.
Unless and until... and so much depends both on the extent to which the rising understanding of the current health service 'reforms' can be translated into practical resistance by health sector workers and the wider population, and also on the extent of 'scaremongering'- ie, telling the truth about the Conservative-Liberal aim of the complete abolition of our public health service. But we not only have fear as a motivator, we also have pride and love, based on experience: our National, nationalised Health Service- as yet remarkably efficient and effective despite the 'reforms' so far and its comparative underfunding- and still available free, as of right, irrespective of ones financial means, to every one of us.
No wonder that the 'free marketeers' despise the NHS. If we can mobilise our love for it to a fraction of the extent of their hate of it, we might yet succeed in protecting what is left of it, and even- under a different government- reverse the commercialisation and privatisation, and raise its funding to the level which the French system receives. Then again, as was the case from 1948 until the onset of Thatcherism, our National Health Service would be the envy of the world.