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Saturday, 19th April 2014

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Totem of the people

We in Britain live in a right wing country. The UK led the world in privatisation; we have a growing gap between rich and poor; the Labour Government boasts of our de-regulated labour market; and now it appears likely that the Conservative Party will win the next general election. Yet our nation's most popular institution, the 60th anniversary of which we are currently celebrating, is based on principles which are intolerable to capitalist ideology.

Adverse 'reforms' imposed on the National Health Service since the early 1980s under four pro-market prime ministers- Thatcher, Major, Blair and Brown- have included the creation of an internal market, the contracting out of many services (from cleaning to some routine surgical operations) to the private sector, the abolition of national planning and its replacement by competition between hospitals, and the diversion of billions of pounds of NHS money to private companies through the notorious Private Finance Initiative (PFI) scheme.

Nevertheless, the basic principles of socialised healthcare remain- Britain's National Health Service is still funded almost completely via the state through general taxation, its staff are still mainly public sector employees, it is is still free, or almost free, to use- and it is used by almost everybody.

The patriots' game

Britain's pro-Conservative Party newspaper, the Daily Telegraph, in an editorial composed by the paper's 'team of leader writers and commentators', noted bitterly on 5th July:

Apart from the Monarchy, few institutions define this nation more. And therein lies the problem. The NHS has become almost untouchable.

To propose radical reform, as opposed to the obsessive and morale-sapping fiddling of the past few decades, is to invite opprobrium. To question the validity of the oft-made claim that the NHS is "the envy of the world" - no longer true, if it ever was - is to risk a mighty wrath.

This inviolability has been a characteristic of the NHS almost from the start. In 1959, an American observer suggested the health service was "accepted as an altogether natural feature of the British landscape, almost a part of the constitution".

It is a talismanic quality that has made successive governments terrified of reform. As a consequence, the infant has grown into a voracious 60-year-old with an insatiable appetite for taxpayers' money.

[...] while the NHS has evolved over the years, its structure and the way it is financed still owe more to a 1940s belief in the efficacy of state monopoly than to the realities of the modern world.

The Daily Telegraph team, comprising David Hughes, Philip Johnston, Simon Heffer, Janet Daley, Con Coughlin, Robert Colvile, Iain Martin and Alex Singleton, espouse an interesting version of patriotism. While denigrating and seeking to abolish the institution which their country holds most dear in its home, they reserve the right to demand that Britain should use economic sanctions and even military force to impose their version of 'British values' abroad.

Most of the content of their editorial was oddly at variance with its title. In the body of the article, the leader writers and commentators remarked: 

Politicians must prepare the country for the realities that need to be faced; yet the totemic power of the NHS to stifle debate seems undiminished.

But the headline of the editorial was optimistic:  "Happy birthday, NHS: retirement beckons".

In the previous Daily Telegraph editorial on the NHS, published in the June 30th issue, the paper's leader writing team gave two reasons for this optimism.   One is an opinion poll conducted for the Telegraph by YouGov, from the results of which they drew selectively in order to suggest that there is a possibility that the British people can be brought to accept the 'retirement' of the NHS.

Another is the likely agreement by the Department of Health to allow those patients who can afford to do so to make co-payments in order to receive drugs which are deemed too expensive to be provided by the NHS; this, they hope, will deal a fatal blow to the concept of  free and equal hospital treatment, and will "open the floodgates" for the revival of private insurance schemes, thus breaking the state monopoly in mainstream health provision.

There is also a third reason, unmentioned and unmentionable- the likely success of the Conservative Party at the next general election.

At least for the present, the terrifying power of public support for the NHS is such that, in order to become electable, the Conservative Party under its leader David Cameron has re-branded itself as 'the party of the NHS'; the party even created a giant birthday card for the 60th anniversary of the system. Should any possible doubt be left, Mr Cameron declared on the eve of the birthday:

"At the heart of the NHS is a really special idea: if you are sick and if you need help, it doesn't matter who you are or where you're from or how much money you have or what your credit card looks like, you get the best care there is."

So, although it is a pro-Conservative and anti-NHS paper, the pages of the Daily Telegraph must contain not the merest hint that the election of a Conservative government could present the slightest threat to the future of the National Health Service.

Nevertheless, as was clarified by last month's High Court ruling against Stuart Wheeler's attempt to force the UK government to hold a referendum on the Lisbon Treaty, there is no legal duty on politicians to make good on commitments which they have made, in the utmost sincerity, in order to get elected.

Rational health

Janet Daley and her colleagues at the Daily Telegraph use the words 'talisman' and 'totem', to imply that the British majority, the supporters of the NHS, are followers of a primitive belief system which lies beyond rational understanding. They are not the first to make such an analogy. Nigel Lawson, who was Chancellor of the Exchequer under Margaret Thatcher, famously remarked in his memoirs:

"The National Health Service is the closest thing the English have to a religion, with those who practise in it regarding themselves as a priesthood."

The victories of 'free-market' capitalism over socialism and social democracy during the last three decades have been intellectual victories as well as practical victories. Seizing the ground of rationality, modernity and efficiency, the promoters of liberalisation and privatisation have been able to present their opponents as outmoded die-hards, holding to principles of equality and collectivism due to a combination of mental rigidity and misty sentimentality.

But through its survival to the age of sixty, Britain's National Health Service has earned the right to be considered on its merits; and this week has seen the publication, even in mainsteam media outlets, of some articles which show the efficacy of the NHS model in delivering healthcare. Nick Louth of MSN Money remarks on the superiority and cheapness of the UK's system in comparison to that of the USA:

The US spends more than twice as much per head on healthcare as Britain does, yet 41 million Americans, 13.5% of the population, are not covered by insurance and more people die of preventable causes than anywhere else in the developed world. American medical insurance fees have risen 91% since 2000.

In Britain, with the notable exception of dentistry, no-one goes without healthcare because they have no money. That was the simple promise that Aneurin Bevan made when he launched the NHS in 1948, and so long as you don't mind waiting, it still holds good.

It is perhaps worth recalling what had gone before. In the 1930s, you had to pay to see a doctor. Hospitals were sometimes grim and squalid places. There were some charitable hospitals, in which some doctors worked for free, taking private patients later in the day. But the postcode lottery then makes today's NHS seem like universal service.

Other rich European countries, which have mixed state and insurance-based systems, do produce better results than those of Britain's NHS. There are two main reasons for this- the most obvious being that these other countries spend far more on health than the UK does. As a BBC report by Stephanie McGovern observes: 

Valerie Paris, a health economist at the OECD, says: "In France the access to physicians and hospitals is easier than in the UK. We don't have waiting lists."

There is a catch. In France you have to pay upfront for some appointments with doctors and then claim back the money from a compulsory social insurance scheme.

Experts admit that this could be a problem for some patients.

But why do people in the French health care system get more? The answer is they spend more.

If you remove the exchange rate factor, the UK health spending is £1,799 per person per year. That is for both the NHS and private health care.

But in France the figure is £2,250 per person.

There is another key reason for the generally better performance of the health systems of comparable EU countries when compared to Britain. Overall, and beyond the control of the NHS, people in the UK suffer on average from a lower quality of life, and enjoy on average a more unhealthy lifestyle, than do people in the other wealthy European countries. Britain has one of the highest rates of income inequality in Western Europe. The British working week is one of the longest in the EU. Britain's problem of binge-drinking is one of the worst in the EU. And by far, the British are the most obese people in Europe. The UK's National Health Service has to stretch the lowest allocation of resources of any major EU country over the highest rate of health-impacting problems of any major EU country.

And yet, 82% of users of the British NHS, in the poll comissioned by the Daily Telegraph, say that they are satisfied with the service that they receive.

Were it not for the adverse reforms of the last 25 years, the NHS would be performing much better, even on its current low budget. Dr Kailash Chand, a member of the Council of the British Medical Association, stated in the Guardian on 30th June:

To many people, it is clear that the NHS is being taken over by big business and private healthcare teams, so money that could go towards clinical care is diverted to corporations and their shareholders.

As Allyson Pollock has pointed out in her book, NHS plc, huge amounts are paid to large private firms for advice about PFI and independent sector treatment centres (ISTCs). Profits made by consortia involved in PFI are swollen by the scandalous practice of refinancing buildings, while cash-strapped hospitals must pay the mortgage for 30 years.

The NHS's founding principles and values have stood the test of time. We must continue to fight for those ideals - for comprehensiveness, universality, access based on need not on ability to pay, for a service that is free at the point of use, for mutuality in which the public accepts that priority should be given to those in most need.

What is required, even at this late stage, is to abolish the purchase-provider split and reintegrate health services. This will save on transaction costs, marketing, billing and invoicing but it will also ensure patients are not treated as commodities, forced to shop around for care.

Dr Chand observes that the ideals of the NHS have stood the test of time. Yet, snorting with derision at the nostalgic airs of their fellow citizens, the patriots of the Daily Telegraph dismiss:

...the oft-made claim that the NHS is "the envy of the world" - no longer true, if it ever was...

But before the market reforms of the NHS began, our system was indeed the the envy of the world, and rightly so. Prof. Allyson Pollock, on page 35 of NHS plc, produces the statistics on health spending per capita, both in monetary terms and in GDP pecentage, and the results, in terms of infant mortality and life expectancy, of the UK, compared to the global OECD group of rich countries, the European Union, and the United States. The figures she cites are from 1960 to 2000; the following figures, sourced from the  OHE Compendium of Health Statistics, are representative:

Health spending per capita (% of GDP) in year 1980:

OECD average     7.3%
EU 15                   7.3%
USA                      8.7%
UK                        5.6%

Infant mortality per 1000, in year 1980:

OECD average     17.5
EU 15                   19.4
USA                      12.6
UK                        12.1

Poll of honour

The survey on the NHS which was conducted by the YouGov polling organisation on behalf of the Daily Telegraph contained a question which was heavily weighted with right wing discourse. The participants were told:

Some NHS services are now provided by private companies - for example, 'walk-in' surgeries at railway stations, and hospitals where routine operations are performed. These services are free to patients, and paid for out of the Government's NHS budget.

They were then asked to choose from two options:

Do you think…

More private involvement in the NHS is a good thing – it improves efficiency and helps the NHS provide a better service


More private involvement is a bad thing – the profit motive undermines the principle of public service and weakens the NHS

Notably, the preamble to the question associated private sector involvement with convenience- the 'walk-in' surgeries- it made no mention that hospital cleaning (or rather, in general experience, lack of cleaning, contributing to the spread of infections) is carried out by private companies. It also stressed that these services are free to use; no mention of the hopes of Janet Daley and her colleagues that a more privatised health system will result in a future in which which the most advanced treatments are available only to those who can afford them.

More subtly, of the two options available, the pro-private answer involves efficiency and better service; while the anti-private answer rests only on adherence to principles, those of public service and defending the NHS. The view that privatisation results in a loss of efficiency and a worse service was not on offer. Of the 2,163 participants in the poll, a total of 70% chose an option, the remaining 30% not knowing or not minding.

It is quite remarkable, after a quarter century of pro-market reforms, and in the face of the biased preamble and the loaded question, that a big majority, 56% of those who made a decision, chose the anti-private answer, with 44% choosing the pro-private answer. Even among the participants whose declared intention is to vote Conservative in the next election, 34% gave the anti-private response, with 41% pro-private and 26% of don't knows and don't minds.

The Daily Telegraph editorials of 30th June and 5th July, the first of which was headlined "Politicians must heed the voters over NHS reform", selectively cited the YouGov poll in support of its dissent from what the paper described as the "rather cosy cross-party consensus [which] has developed over the NHS". The articles implied that the poll indicates that the voters reject the idea that "the NHS should remain a taxpayer-funded, free-at-the-point-of-use system of universal healthcare on which more money should be spent".

But, as can be seen from the full results on the YouGov website, the participants in the poll were never asked their opinions on whether the NHS should continue to be taxpayer-funded, universal and free-at-the-point-of-use. The poll results quoted accurately by the Daily Telegraph, allegedly in support of its position, were these- most people think that the NHS has more managers than it needs and wastes a lot of its money; and most people think that it is more important to reorganise the NHS than to provide it with more cash.

The first of these are what can be politely described as 'no-brainers', which offer no validity to the Telegraph's anti-NHS position. The public can be relied on to surmise that almost any large organisation is wasteful and employs too many managers, and in this case they are right. The proportion of managers to front-line staff in the NHS, and the amount of cash diverted away from clinical services, have risen with the imposition, since the early 1980s, of the internal market, competition, and part-privatisation. Markets cost money.

In contradiction to the main thrust of the article, the 30th June editorial in the Telegraph noted ruefully:

...the poll also shows just how hard it will be for policy-makers to reshape the NHS, so deep-seated is the resistance to radical change. Three quarters of voters want the health service to be uniform across the country, rather than having priorities decided locally.

Despite the concerns about the way money is spent and services managed, there remains an extraordinarily high level of satisfaction with the NHS, with 81 per cent professing themselves happy with the treatment they receive, though that is down 10 points on a decade ago. Such stratospheric ratings owe much to the perception that the NHS is a "free" service (though of course we pay for it through our taxes).  

Neither of the two editorials in the Daily Telegraph, nor any other article in that newspaper, has made any reference whatsoever to the question in the poll about private involvement in the NHS, to which the participants clearly gave the 'wrong' response. Of course, this is fine under capitalism. Having paid YouGov to ask the questions, it is quite up to the Daily Telegraph to decide what do do with the answers.

But the Telegraph is wrong about the British people and their love of the NHS.  The system is free to use- that is, we share the costs of it; it brings health and saves lives; and it belongs to us. Of course we love it. Why should there be anything extraordinary about that?