Monkey and organ grinder

One of David Cameron’s favourite sayings is apparently, “It’s not where you’ve come from, it’s where you going to.” That’s right, the same David Cameron who went to Eton and Brasenose College, Oxford, and who is now leading a Cabinet full of millionaires. The grain of truth in the NHS being a ‘national religion’ might be that the polls consistently return the verdict that the public generally like the idea of a national well-run state NHS. They likewise oppose the notion of its privatisation.

A state-run NHS, funded out of general taxation, free-at-the-point of use is of course critical to the NHS, as is the fundamental duty of the Secretary of State having a duty for the provision of universal healthcare. Conversely, Ed Miliband is terrified of the voters rejecting him. That was of course Tony Blair’s fear too (and his second fear, for the record, was a failure to get re-elected). The purpose of a ‘loyal opposition’ is to provide sharp, constructive criticism of HM Government’s policies, but it seems perhaps at present that the Government is going overboard on the ‘loyal’ bit with not with much opposition. Tony Blair’s vision of the National Health Service can perhaps be for autonomous units in the National Health Service have clinical and financial independence, with more ‘accountability’. PFI was hailed as giving an infrastructure boost to the NHS, but was a natural progression of Conservative policies under John Major.

Because of the bungling nature of the Labour opposition, we can see an ‘extension’ of this “motherhood and apple pie”. Nobody can inherently object to the NHS being run ‘efficiently’, in that nobody aspires the NHS to be run ‘inefficiently’. However, the view of the NHS as a conglomerate of failing businesses is an inaccurate one, and lends itself to a malignant caricature of the uncritical media. There is not so much evidence that introducing a market into the National Health Service improves ‘efficiency’, and yet conversely there are bucketloads of evidence that implementing a market into healthcare reduplicates transactions unnecessarily, introduces various sources of waste and efficiency, and generally can increase the wastage of the order of fifteen fold.

Ed Miliband is a card-carrying social democrat. Whether he is simultaneously a socialist is a matter for his conscience, and to some extent to his own ballot box in Dartmouth Park. Recent mutterings from Ed Miliband have suggested that he, and his partner in crime Lord Stewart Wood, are reluctant to touch taxation with a bargepole, as Miliband is petrified of Labour being tarred with the taxation brush. Of course, apparently Blair is the ‘most successful election winning machine’ Labour ever had, but he was also a man who lacked any socialist principles. As a card-carrying social democrat, however, Ed Miliband can purport to have more than a trivial interest in solidarity. He can also have an interest in social justice, despite the fact that his opposition has presided over one of the most clinical murders of English legal aid in recent times.

The concern is how far Ed Miliband wishes to pursue ‘equality of opportunity’. The Conservatives and Liberal Democrats have prioritised liberalising the market for competing private providers to have a slice of the action. ‘Equality of opportunity’ may have a rather mamby-pamby meaning of Prof Michael Sandel when it comes to social mobility or other society-based issues, but for free market fanatics it literally means a ‘free-for-all’ where you pursue the reduction of barriers-to-entry. The present Coalition have successfully implemented the outsourcing part of the privatised market, but the lack of proven effective regulation could yet prove to be its comeuppance.

The failure of regulation of the new NHS is already being seen on a number of different fronts. The corporate acquisition of Plasma Resources UK raises patient safety implications for blood products being produced as an output of  a business model seeking a quick return on investment. Secondly, a lack of a safe staffing level of nursing staff, coupled with PFI NHS Foundation Trusts hiding from data disclosure requirements under the Freedom of Information Act, is a recipe for disaster while NHS FTs try to implement the “McKinsey efficiency savings”. Thirdly, despite all the tack of ‘greater accountabiltiy’ in the ‘prime contractor’ model of private providers providing “integrated care” (however defined), contractors and subcontractors are subject to the legal doctrine of “privity of contract”, meaning that anybody who is not party to a contract cannot enforce any rights within it.

Being a social democrat, Ed Miliband might also have a fundamentally different definition of ‘redistribution’ to socialists, again reverting to the issue of avoidance of taxation (not “tax avoidance”) to fund the fabric of society. This is illustrated in Ed Miliband’s flagship policy of ‘predistribution’, originally introduced by Professor Jacob Hacker. However, under a liberal market, redistribution could mean instead easily transfer of funds between CCGs, as is already happening. In this neoliberal market, seen already through sporadic national closures of A&E departments not directly protected by PFI funding, this can mean some CCGs will literally wither, and ultimately could leave themselves open to acquisition themselves from the private sector. This is literally an elaboration of the “money following the patient” policy which has been bobbing on the surface for a few years now, with money literally following the money out of the public sector into the private sector.

The effect of this neoliberal ‘survival of the fittest’ CCG architecture, seen by some as providing the infrastructure for full integration with the private insurance industry, will mean that there are some losers and winners. If one wished to ensure an excellent NHS throughout, you would pump money into underperforming Trusts to bring them up to a level of safety and throughput acceptable to the general public. The consequence of members of the public not going to Trusts with longer than average waiting lists could mean that those Trusts get starved of the money they need to function well, and so their performance further deteriorates. And yet nobody wishes openly to have a NHS where, if you can pay, you get special treatment, but surely there are less guards against this type of behaviour in a social democratic NHS.

The opposition led by Ed Miliband is currently full of inherent paradoxes. It sets to repeal the Health and Social Care Act (2012), without a coherent explanation of what it wishes to do about PFI-funded trusts or the McKinsey Efficiency Savings. On the latter two points, it appears it even agrees with the Conservatives (and the Liberal Democrats). It says it wants to reverse competition, but a significant part of introducing the competitive market was achieved in the dying days of the Blair/Brown government. Ed Miliband has promised to restore ‘the duty of the Secretary of State to provide a universal National Health Service’, and yet some members of the Labour health front bench seem more quiet on this issue. One prominent Labour member is reputed to have said recently that he or she would not like to talk about re-nationalising the NHS as this would be ‘political suicide’ for his or her career. There is clearly a lack of political philosophy ability amongst some current influential members of Labour: is it beyond the wit of man to wonder why ‘efficiency savings’ have not been adjusted to take account of the dire performance of the economy, as measured in the last three years?

With monkeys such as this alleged one, one can only look to the organ grinder for clues about where the NHS is heading to. To that extent, where it has come from may in fact be quite irrelevant.