Thursday 7 April 2011
When I hear slogans such as ‘Save Our National Health Service’ or ‘Keep It Public’, I think it is worth asking what it is about the NHS that is worth defending.
I recall being involved in a campaign against the closure of a local hospital – St Leonards in Shoreditch – under the Labour government of the late 1970s. When I approached a young man in the local street market on a Saturday morning asking him to support the campaign, in a dramatic gesture he pulled up his shirt to reveal a spectacular midline scar up his abdomen. ‘That’s what they did to me in that hospital, just to get my appendix out.’ As far as he was concerned, the sooner it was closed down the better. He refused to sign our petition. (Though the hospital was closed, St Leonards, the site of a nineteenth-century workhouse, remains the base of local community-health services.)
This encounter reminded me that while, as both professionals and as patients, the middle classes have generally benefited from the NHS, the less prosperous have often experienced poor-quality care and inferior standards of service. In more recent years, as the focus on health has widened to the concept of wellbeing and the concerns of doctors have expanded to cover wide areas of personal lifestyle and behaviour, a substantial section of the population (amounting to at least a quarter) has become the particular object of medical condescension and authoritarian public-health intervention. It is not surprising to find a marked lack of enthusiasm for campaigns to ‘save the NHS’ among a public that is regarded – and treated – with such contempt by the modern NHS.
Alan Milburn, New Labour health minister from 1999 to 2003, has emerged as a leading critic of the Liberal-Conservative coalition government’s proposed reforms to the NHS (1). A prominent Blairite moderniser who pioneered the extension of the private sector into elective care, intermediate care and critical care through the NHS Plan of 2000, Milburn now opposes further privatisation. However, he emphasises the common ground that critics of the reforms generally share with their promoters: the conviction that the NHS faces a major challenge ‘from an explosion in chronic diseases like diabetes and obesity’.
Though there is an increased prevalence of diabetes, partly resulting from more enthusiastic case-finding and a lowered threshold of diagnosis, the notion of ‘explosion’ suggests terror and danger, blame and shame. Obesity, of course, is not a disease, but a pathologised and stigmatised condition supposedly affecting around 25 per cent of the adult population, and particularly justifying coercive interventions among children. The casual deployment of these disease labels and the associated metaphors of catastrophe is such a familiar feature of health policy discussions that it generally passes without comment.
Having discovered the breadth of opposition to the Health and Social Care Bill currently before parliament, the coalition government is apparently having second thoughts about some aspects of its plans to hand over financial control of the system to general-practitioner consortia. Given the dubious records and political commitments of some of the individuals and organisations now opposing the government’s plans, I find myself – as someone who regarded the reforms as irrational, ill-considered and illegitimate from the outset – obliged to reconsider my own position.
I have generally found it a useful rule of thumb in medical politics to assume that if the British Medical Association (BMA) opposes something (like the NHS in its first decade), then there must be something good about it. If, on the other hand, the BMA has decided to campaign for something (like coercive measures against smokers and drinkers), then it is unlikely to be worth supporting. Now that the BMA has come out against the Lib-Con reforms, I have to look again to see if I have overlooked some progressive content.
Furthermore, another former health minister, the loyal Thatcherite Stephen Dorrell, who presided over the mad-cow crisis of the 1990s and is now chairman of the cross-party Commons Health Committee, has put forward a set of alternative proposals to the coalition reforms. The cowed Liberal Democrat party conference and even Labour’s ineffectual leader Ed Miliband have finally raised a feeble protest. Such a powerful consensus among such an unprincipled bunch of politicians raises even stronger suspicions that the coalition health minister Andrew Lansley and his team must be doing something right.
Indeed, there are some positive features to be found in the coalition White Paper. The trouble is that for every tentative step these reformers take forwards, they can be relied upon to take two backwards. There is much to be said for abolishing the Primary Care Trusts (PCTs): when central government officials asked these servile local bodies to jump – whether to put out local surgeries to private tender or to implement ludicrous pandemic flu contingency plans – they simply asked ‘how high?’ But replacing PCTs with GP consortia or local commissioning boards incorporating wider professional and public representation (as favoured by Dorrell and other influential critics) amounts merely to a disruptive and expensive bureaucratic reshuffle.
Removing public health from the prominent and intrusive role it has played in primary health care under the PCTs would be beneficial to doctors and, even more, to patients. But simply moving the crusaders against obesity, smoking, drinking, sex and any other enjoyable activities to new ‘Health and Wellbeing Boards’ in association with local councils ensures the continuation of these moralistic campaigns and their pernicious role in the NHS.
Another welcome initiative taken by the coalition in the sphere of health policy was its announcement of a bonfire of the quangos. Yet scarcely had the celebrations begun before the government reprieved organisations, such as NHS Direct, which continue to promote health-related anxieties, and social engineering projects such as the Teenage Pregnancy Unit.
Too much discussion of the NHS reforms has focused on the structure and organisation of health services rather than questioning the quality of healthcare that doctors and others working in the NHS are appealing to the public to defend.
reprinted from: http://www.spiked-online.com/site/article/10374/