The DeAbolition of the National Health Service
The NHSBill is now irrevocably destined for enactment. Now, the only hope is repeal. #StopTheBill becomes #repealHASCA.
This process has been a shocking display of how not to run government. Coalition was supposed to bring us consensus; instead it has brought us a foul fudge. There are lessons to be drawn about democracy.
Our much-lamented health service certainly needed reform. On that, almost everyone agreed. The impending demographic shifts in the population mean it had to change. But HASCA12 is the wrong change, mostly because of the way it came around. It is driven by the ideological obsessions of Andrew Lansley himself. He believes that there should be a market in the provision of health services, and that competition will drive down the price while driving up the quality. Whatever the merits of the case, in a democracy, you shouldn’t just impose your ideology. Even if you are elected, it is tyrannical to do so, and it is a weakness of our Parliamentary democracy that there are few controls against this tyranny, within the lifetime of a Parliament. Actually, we hoped that coalition might act as some form of control, and the fact that it didn’t suggests that British politics is more rotten than we thought.
If you plan major reform of any part of the public realm, you should make your case before an election, so that you have a mandate. The shape of the reform should be in your manifesto. Then, you could realistically say that you have democratic legitimacy. On the other hand, if your campaigning should suggest, for example, that you do not intend any major top-down reforms, and then – contrary to your campaign statements – you impose reforms against the will of the majority affected, it is acting tyrannically.
That this Bill was first approved by Cabinet, without vociferous LibDem complaints, was a bad sign. The LibDems in Cabinet only started to get concerned when the public started to complain. Their first, and only, success, was to win last year’s pause.
No doubt Andrew Lansley is so convinced of the rightness of his position, that he believes that it would be wrong to consider the views of practitioners whose vested interests would inevitably set them against reform. He would, of course, be the first to point out that many practitioners, including the BMA, were indisposed to the creation of the NHS in 1948. But revolutionary thought it was, the NHS was a continuation of a much older tradition of medical treatment driven by motives other than money. Barts, for example, had provided treatment free at the point of use since its foundation in 1123. The quality of its care advanced dramatically between 1123 and 1948, driven by the tradition of charity and the competition of scholarship . Its ethos, with that of many other constituents, became part of the wider principles of the NHS to serve the nation as a whole. It is one that the nation’s GPs now adopt wholeheartedly, despite the reservations that their forbears had in 1948.
These latest marketisation reforms, which are much more radical than the “internal market” imposed under the Tories’ previous regime, infer an equally old ethos – that of commerce. Medicine will become a trade, as it is in the United States, and being traded, we are asked to believe that the forces of the market will bring down the price and improve the quality – despite the impressive history of advance from competitive scholarship.
Yet I do not think that the problem is medicine, and its non-commercial exceptionalism. Rather, it is public procurement. It is very unlikely that your GP, under the new system, l – when you need a hip replacing or a course of chemotherapy – will lookout for the best provider on that day. Rather, he will send you to the wholesale provider of orthopaedic surgery or oncology that his Clinical Commissioning Group selected at the last round of contracts. Now that wholesale provider – say, Virgin Orthopaedics, or Serco Cancer Care, will have bid low to get the contract. To make its margins, it will cut out the fripperies and will try to charge you for as much extra as it lawfully can, and if not you, the commissioning group. Pay extra for the latest chemo? Grieving relatives are always good for a whip-round. Watch out for claims that the orthopaedics contract only included one session of post-op physio per patient – and upselling to Virgin Active.
It’s these contracts that are the problem. Negotiating, drafting, enforcing and mediating them is fertile ground for parasitic professionals who will command high fees and suck money away from frontline care. These professionals, and the institutions who employ them, are largely responsible for the additional costs of the US healthcare system. They are different in every sector, and jurisdiction, and they are a significant part of the economy. In this country, mostly they are Tory. They are part of the web of corruption in which Lansley and over 100 Tory peers who supported the Bill are implicated.
So how should the Secretary of State for Health have set about addressing the reform that the NHS needed?
Government in a democracy is essentially about consensus, but consensus-building is an art to which today’s partisan politics does not lend itself. It needs active, multilateral engagement; it did not just need a “pause”. It means approaching the problem with strongly-engaged opinions and yet being ready to change them. To build consensus in the face of the health sector’s myriad slightly differing vested interests – from patients’ groups to Royal Colleges, not to mention the hospital trusts and the pharmaceutical industry – is a job that could have taken a political genius the lifetime of a parliament. Every vocal representative would use every opportunity to grandstand at meetings and in phoneins and talkshows: tyranny must seem a much simpler option. Yet there are many strategies that can be adopted to build consensus: for example, conducting meetings under the Chatham House Rule helps to temper grandstanding.
There is, fundamentally, a difference between tyranny and leadership. What Andrew Lansley has shown has been tyranny; because had he shown leadership, the troops would be following.
Instead, they are mutinying, and mutiny is the only sane response to tyranny.