There is a coalition lovefest going on over the new reformed NHS reforms, which have suddenly gone from being the worst think since the plague to the greatest thing since sliced bread, all with a few tweaks.
The problem is, it is the entire principle on which the reforms are based, not the mechanisms operating on that principle, which is fundamentally wrong. The underlying principle is that the NHS will work better if it operates on competition between healthcare providers, both existing NHS hospitals and clinics, and private and charitable hospitals and clinics which will have new access to NHS patients and cash.
Both Sky and the BBC have been telling us all day that competition drives up efficiency and quality.
But this is not true. If financial profit is the motive, then competition does indeed increase efficiency, in terms of maximising profit by minimising costs. But the natural tendency is for this to be at the expense of quality, except in certain specific areas of luxury good provision. Competition and profit drives the producer to give just as much quality as required to provide something the consumer will still take, while undercutting rival sellers. Where there are a limited number of providers, (and in most parts of the country there are obvious limits to the number of possible clinics and hospitals), this increasingly becomes a race to the bottom in quality, with the added temptaitons of cartelisation on price.
For a brilliant demonstration of the effect competition between providers has in real life, read “Cheap Clothes and Nasty” by Charles Kingsley.
It is hard to believe that anybody could for one moment accept the premiss that something done for love and care, will always be of less quality than something done for private profit. Yet that is precisely the hogwash promoted by Thatcherism and which New Labour under Blair signed up to completely.
Not only will a large percentage of the NHS budget now go as profit into the pockets of large business (as though Southern Cross were not sufficient warning), but there will be a whole new and still bigger infrastructure of accountants and paper shufflers regulating and processing the entirely artifical NHS “Market mechanism”.
It also worries me that so much attention is paid to the desires of the medical profession. I don’t much care what doctors think. Remember, doctors were strongly against the creation of the NHS in the first place. Remember, the medical students you knew at university are doctors now. Remember the guy at your local surgery who pulls in over £100,000 and won’t see you out of hours or at weekends, and normally has a Polish locum see you while he’s off in Corfu? Why do you care what he thinks about it? If you wanted to find a wealthy right wing nutter, you would have an easier chance in a group of doctors than among the general population.
Wow a bunch of pro-reformers say reforms are good.
What next, wheeling out Condems mums to say they really
deserve re-election?
One massive subsidy which never gets discussed is training. The private sector does not train doctors, the public sector does. Damn expensive it is too. Doctors are then free to bugger off into the private sector. Let the private sector build its own teaching hospitals, train it’s own doctors, and then see how competitive it is.
Even by their own crazy logic, competition in healthcare providers does not drive down total costs. In order for their to be anything approaching meaningful competition, there has to be an overcapacity i.e. too much infrastructure than is really necessary. While a single provider may be able to drive down their own costs and grab a bigger slice of the cake, the total cost to society is higher. Who pays for the overcapacity which is not fully utilised? Mmmm, now let me think…
Dear Craig, You put it extremely well in a post a few weeks ago when you said that quality, efficiency and low cost are best achieved by the simplest possible structures. I can confirm this from my own experience. I used to be an adviser at the Royal Courts of Justice. Over the twelve years I worked there structures became steadily more complex in the quest for greater efficiency. What this meant in practice was the same number of front line workers (basically me and one or two others)and an ever increasing number of people we reported to. The result was that where at the beginning I was reporting and being managed by one person by the end I was reporting to and being managed by about forty people. In the end it all became a nightmare with endless internecine conflicts and an explosion of paperwork that I could only keep up with by constantly extending my working day so that I would often have to leave after midnight.
“…something done for love and care…”
Oh come on now, Craig! Forensic exaggeration is one thing, but that is way, way, way over the top. Have you been in an NHS hospital lately? How much love and care did you experience?
I’m not suggesting that one should expect love and care, either, in a population of hundreds of thousands of workers – many of whom are fairly low-paid and perhaps not over-enthusiastic about their work.
Least of all would I look for love and care among the suits who run the NHS today. Whether it is technically privatised or not, any large organisation these days is run by managers who are in it almost exclusively for their own financial gain (plus a variable amount of power lust, I guess).
Dear Tom Welsh, The cynicism you are describing is a direct consequence of the process Craig is discussing. When I started working as an adviser at the Royal Courts of Justice I gladly worked for a far smaller salary than I could have obtained in the private sector precisely because I believed in what I was doing. This was not true of many (not all) of the managers who proliferated as a result of the “reforms” made in the quest for “efficiency”. Ultimately it was the attitude of these managers that won out especially as we front line workers began to feel increasingly resentful and exploited.
Bit of a broad brush there Craig! When you were treated after your illness did you refuse to be treated by a rich rightwing nutter?
Working at a University I have to say I’d rather talk to a Medical Student than someone studying Law. General concensus is they are the worse. The doctors I have had (all non-private) have been thoughtful and considerate. Yes you can make a lot as a doctor but a bloody lot more as a lawyer/banker.
Spot on once again Craig.
The fact is that there is the potential for healthcare companies to make a vast amount of money. The ‘efficiency of the market’ is just a line spun by those keen to get their hands on the money.
Perhaps Craig is being a little arbitrary in his last paragraph concerning doctors. The BMA agreed in principle with the establishment of the NHS although the BMA objected to the administration methods and the lack of consultation and negotiation with doctors regarding the scheme. They proposed and gained a number of concessions before the bill passed into law.
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Over the years I have have admired the tenacity of Dr David Halpin an orthopedic and trauma surgeon and his work in Gaza.
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At the BMA conference last week doctors voted by loud applause when the chairman Dr Buckman said, “The BMA does not support the unfettered extention of private involvement into the NHS” – I suspect the strong undercurrent of ConLib fundamental changes to the NHS. He went on to say, “”We do not need competition to run the NHS. We need collaboration and cooperation,”
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Dr Buckman on Care Quality Commission registration said, “The whole thing is too complex for its own good. it is a creative writing exercise that will cost money and take GPs from patient care.”
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Dr Iona Heath warned that the reforms could reduce health to a commodity and patients may become consumers out for ‘the best bargain’.
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Despite this Coalition’s proposed ‘rationing’ of the Health Service we can be confident doctors by oath *will always put the patient first* and the best doctors *will* always show altruism to any problem that degrades or harms your existence.
Personally, the idea implicit in the last paragraph is pretty repugnant; it’s a pretty serious statement of the idea that Practitioners in a given field will ultimately allow their personal circumstances to take priority and not the wider needs of their profession. But as cynical as this is, I don’t believe you can realistically extrapolate out from that that ALL doctors were against the formation of the NHS, which is the other suggestion implied. Does that mean that all Practitioners would be against it now? and by your logic, why should any other field be any different?
With regards to Medical students though, that my be more of a question of the company an individual keeps – none of the ones I knew fit your slap-dash characterisation, quite the opposite in fact (though I’m sure we can all give anecdotal evidence for whichever position we want to take).
I’d prefer to the target the blame for the current impasse of the NHS on the ‘wealthy right wing nutters’ who started the current ball rolling (one of several successions in government I hassen to add) – Oh, and we all should reserve a special place in our hearts for the professional enablers (and their supporters) that got us there.
Craig makes important, intelligent, fearless and engaging points, as always.
One thing I would say is that I was at a faculty conference recently where I heard a keynote speech by the President of the BMA, Sir Michael Marmot – he’s a wonderful orator and a passionate supporter of the NHS. In fact, if I’d closed my eyes, I might’ve mistaken Michael Marmot for Craig Murray! Will the Govt listen to The Marmot Report? Unlikely. The Thatcher/Major Govts ignored The Black Report of the 1980s. This Govt pays lip-service to Marmot, but that’s all it is. We’ve had all this crap about competition before, during the 1980s/90s. We’ve also had the utter rip-off of PFI under New Labour.
In essence, Marmot presented the well-known and long-accepted and proven truth that economics determines health and that since, and directly because of, the onset of Thatcherism, health inequalities in our society have grown – and that there was no difference in this aspect under New Labour cf the Tories. He made the well-accepted, proven truth that unemployment is the single greatest evil wrt health and that shite, low-paying jobs aren’t much better. He presneted both a national and a global picture and he made the point that none of this is inevitable, that nationally and globally we have the means and the knowledge but that we lack the will.
I came up against those viscerally right-wing medical students at University (of which Liam Fox is an extreme example). I sometimes wonder where they’ve gone. Perhaps they’re all high-flying consultants, working for big bucks in the private sector; perhaps they’re in the USA, who knows? Nowadays, most docs I meet seem quite different from those awful medical students (though even then, in the bad of 1980s not all were awful, I hasten to add, the awful ones just had the loudest voices!) with whom I spent 5 years. There are greedy doctors, just as there are greedy plumbers. Most GPs in Glasgow also do out-of-hours and indeed run the out-of-hours system; I accept though that this may not be the system everywhere. GPs’ pay certainly went up with the New Contract around 2002-ish; prior to that, pay was relatively modest, when one takes into account overheads, payments for practice premises, etc. and in fact I took pay cuts during the 1990s. I’m not a full-time GP now (I happened to leave in 2001, just before the pay rise; typical of my crap decisions!), but I still do GP out-of-hours. The chestnut about 1948 gets rolled-out, every time there’s a discussion on health; well, I know many people in the West and the East and the South who back then supported ‘Uncle Joe’ Stalin, but I don’t hold it against them! None of that generation now works; in fact, most are in their 90s or else are dead.
The answer – there is no perfect answer, that must be understood – lies in a public health nexus, in economics and in the economic system, the distribution of wealth and jobs. That is the modern-day polluted sewer-system. If you want to change health inequality, you must first blow-up the sewer-system (courtesy of ‘The Citadel’, by A. J. Cronin).
Here’s a good article by Johann Hari: http://www.independent.co.uk/opinion/commentators/johann-hari/johann-hari-its-not-just-dominique-strausskahn-the-imf-itself-should-be-on-trial-2292270.html
The pay increases and hours reductions for doctors made by previous governments were a bribe to stop resistance to the the master plan to privatise the NHS from the doctors themselves . Now that under another government the ransacking process is to be put into action, cautious doctors are worried that they are going to get the blame for the chaos that will follow. But green scuffs will appear on cricketers’ whites and criticism of the medical profession will accompany the reforms. The British regard this as a price worth paying. After all we participated in the bloodbath of Iraq, and a couple of elections later we are restored to completely squeaky clean.
There is truth in some of that, Anno, re. bribery, etc., though as usual, the New Labour Govt were duplicitous in much of their dealing. There is also so much essentialising and, I think, class resentment (a peculiarly British phenomenon responsible for many of our society’s problems) in your sweeping statement, it’s difficult to know where to begin. I think you’ll find that many doctors actually are – and always have been – extremely angry at PFI (and New Labour managerialism) and the proposed crap from this govt. But of course, it doesn’t matter what I say, ‘doctors’ (as though they represented a single, monolithic group; but then you would wish to assign similar monolithism to ‘Muslims’ wouldn’t you?) are a facile target always for the Left (or whatever the oppositional forces might be nowadays), aren’t they? Have you forgotten that Che Guevara was a doctor and that what he experienced as a doctor turned him into a revolutionary? David Widgery? A. J. Cronin? There are many more. When I tell you that the President of the BMA gave what was a revolutionary speech calling for the dismantling of the current global and national economic system and openly and with evidence slamming both Labour and Con-Dem economic and health policies at an official faculty conference in London, you infer that he is simply “a cautious doctor”, ‘afraid he’ll get the blame’, and not someone who has dedicated his life to the ideal of egalitarianism and who has produced a report antithetical to the very privatisations to which you refer. But now, no doubt we will get twenty anecdotes of how rude someone’s doctor was, how incompetant, how he (it’s always a ‘he’, isn’t it, even though most GPs now are women; it’s not trendy to knock women as authority figures, you see), etc. etc. There is no point in me making the points I have made, I realise that. Many people clearly prefer a dualistic world, where certain groups are demonised, others, beatified. Meanwhile, amidst our disarray, the oligarchs who sit in power over us dismantle all that was good in favour of ever-greater concentrations of resources in fewer and fewer hands.
Yes, I agree, the intention of government to soften up doctors for privatisation will have been seen through by most doctors. But they lapped up the poison, and are nicely bought up anyway. So Cameron can tell them that they condoned the increase in their salaries and they have to condone the extra burden of management of privatising the system. You see Suhayl I am sure that the doctors have the best of intentions as you say. Life’s complicated, but you don’t always seem to ‘get’ irony.
If a religion is becomes different shades of grey instead of black and white, it becomes not just futile but malicious. If salt loses its flavour, with what will you salt it? If you go to the doctor and get referred to a consultant whose heart is in his private practise and personal profit for his company, will not 99% of the British people agree with him that a company’s first responsibility is to make profit?
Cameron’s privatisation programme is totally against the principles of the majority of doctors, but he’s got them by the private parts anyway. Most doctors will be forced to allocate funds to service providers who are profit-first companies. I can’t see why consulting with nurses etc makes any difference to that reality. The money class want privatisation and they know how to get their own way.
Further down the line, when it’s clear that the old in-house concept of employment is more cost effective than than the outsourcing capitalist model, as was recently discussed on Radio 4’s File on 4 about pfi’s, there will be an unsolvable crisis of funding, because the privatised medical services will have stitched up the resources for many future decades.
If people don’t protest, and vote with their feet, and refuse to be bribed by vast salaries when it’s clear where those bribes are leading to one and all, then they will end up getting the blame for the changes and people will accuse them of serving their own pockets instead of using their authority to resist change.
Not ALL doctors Anno. I know several members of this organisation who have fought the ConDem proposals long and hard. My brother is one and is fiercely opposed to this latest ‘reform’. He worked through seven such reorganisations in his time but thinks that this latest is the most damaging to the whole of the health service as we know it.
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http://www.nhsca.org.uk/pages/alliedOrganisations/keepOurNHSPublic/KONP.html
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One of the members wrote today – Please see the following statement in the Government’s response to the Future Forum:
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“We will outlaw any policy to increase the market share of any particular sector of provider. This will prevent current or future Ministers, the NHS Commissioning Board or Monitor from having a deliberate policy of encouraging the growth of the private sector over existing state providers – or vice versa. What matters is the quality of care, not the ownership model.”
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This statement is disguised as a control on privatisation, but note “or vice versa”. This means the revised bill will outlaw the Government now, or in the future, from naming the NHS as preferred provider.
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The terminology of the NHS as preferred provider implies a deliberate attempt to encourage NHS public provision, so this policy will be outlawed (by legislation if the bill passes). However, the key point is that the policy of “Any qualified/willing provider” does not explicitly encourage private sector provision per se (although it is obvious that this is what it is designed to do.)
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As long as Government policy is not seen to deliberately and directly encourage private sector provision, the market share will be allowed to change. In fact, the decisions to involve private companies will actually be made locally by the clinical commissioning groups. This is therefore local decision making and not Government policy itself. So increasing NHS privatisation is still clearly on the agenda and the idea of the NHS being the preferred provider with be confined to the dustbin of history.
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You really have to hand it to them. They have managed to produce of paragraph that looks as though they are ruling out privatisation, but it actually means that they are legislating against the NHS being the preferred provider! They are very clever and devious buggers who find all sorts of loopholes and phraseology to push forward their agendas.
So more of our taxes, direct and indirect, are to be funnelled to big pharma and the moneylenders? I have a better idea: abolish income tax and ‘donate’ a percentage of our earnings into the accounts of GSK etc to save on red tape and make it more efficient and ‘fair’. Afterall it wil be our lives in their accountants hands. RIP NHS
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Yes, anno, thanks, I agree with much of what you say in your latest post. Indeed. Thanks. Sorry if I was a bit OTT earlier – was rushing, etc. Good on you.
Well said, except for the last paragraph. It is somewhat unfair of you to stereotype all doctors in Britain based on a few unrepresentative examples. People become doctors for all sorts of reasons, not just self-interest. A bit like ambassadors, really.
Discount Ugg Boots a bunch of pro-reformers say reforms are good.
What next, wheeling out Condems mums to say they really
deserve re-election?
Mary, thanks, that’s a fascinating link/quote. Yes, the “vice-versa” is the key. Talk about doublespeak!