The following article is the unedited version of a ‘rapid response’ that appeared in the British Medical Journal recently, in reply to an article rather provocatively entitled ‘Why shouldn't private companies run failing hospitals?’, by Nick Seddon - deputy director of the ‘independent’ think tank Reform.
Reply to ‘Why shouldn’t private companies run failing hospitals?’
In Politics and the English Language, Orwell wrote that the purpose of what he called “political prose” was “to make lies sound truthful and murder respectable, and to give an appearance of solidity to pure wind”, thereby allowing the writer to conceal his thoughts from himself and others. [2]
Though our bourgeois media invariably ascribe this tendency to ‘Stalinism’, it does not take a genius to identify that ‘political prose’ has in fact reached endemic proportions in the capitalist world, namely as what has come to be known – unofficially of course – as ‘management speak’.
Nick Seddon has given a fine example of the style with his November BMJ article ‘Why shouldn’t private companies run failing hospitals?’ Devoid of such trifling details as sources and context, Seddon cherry-picks facts and factoids alike apparently at random in support of his position, yet even then is clearly struggling to make the case.[ 1]
Perhaps, with his background in business management, he is unaccustomed to the standard requirement when writing in medical journals to tell the truth and to provide supporting evidence for your conclusions. I would be only too happy to enlighten him in these regards.
Seddon plucks a couple of examples that purportedly demonstrate the benefits of private-sector involvement in health care from Finland and Spain. This is disingenuous in the extreme, certainly in the case of Finland. To varying degrees, the continental western European economies have kept the social welfare provisions and business regulatory structures that have been decimated in the UK by three decades of Thatcherism.
When Seddon waxes lyrical about increasing private-sector involvement in the NHS, therefore, I very much doubt it is the strongly social-democratic Scandinavian model he has in mind. Rather, we catch a glimpse of his real vision of the future in the penultimate paragraph: “In the United States a range of organisations such as Kaiser Permanente, Intermountain, and Geisinger have long been leading the way,” he says, reassuringly ...
The United States has the most expensive and inefficient healthcare system in the developed world. Well over 40 million Americans therefore still have no health insurance coverage at all, and millions more remain significantly under-insured [ 3] – a situation which, by the way, promises to remain essentially unchanged even if President Obama’s much-hyped healthcare ‘reforms’ are ever enacted, which now looks increasingly unlikely anyway [4]
A child of 5 could understand why this is the case: self-evidently, the more you bring profiteers into the running of a service – any service – the more expensive it’s going to be for the people who need to use it. That’s why, outside of the business community and the hard-right fringe, the desire of the majority of the American people has long been for more public funding and more public provision of health care.[ 5]
As regards the so-called Health Maintenance Organisations (HMOs) – the likes of Kaiser Permanente – that Seddon apparently considers to be ‘leading the way’, the feeling of the majority of Americans towards these institutions is probably best encapsulated by a memorable anecdote from Professor Allyson Pollock’s seminal 2004 book NHS plc – The Privatisation of Our Health Care. In the 1997 film As Good as It Gets, the female lead played by Helen Hunt reacts with outrage to the revelation that her insurance policy will not provide her severely asthmatic son with the inhalers he needs, declaring frustratedly: “F*cking HMO b*stard pieces of sh*t!!!” By all accounts, cinema audiences across the US famously broke into spontaneous applause at this outburst.[6] Enough said.
At the opposite end of the political spectrum you have socialist Cuba, whose entirely publicly-owned healthcare system “represents an important alternative example where modest infrastructure investments combined with a well-developed public health strategy have generated health status measures comparable with those of industrialised countries”.[ 7] In other words, Cuba – a third-world country – has built a healthcare system at a fraction of the cost of those of developed countries, yet with broadly similar – and in some cases actually better – outcomes.
Moreover, it has managed to achieve this despite 50 years of unceasing economic warfare and sabotage waged against it by the United States, and despite the devastating effect of the collapse in 1991 of its Soviet ally.
It is not difficult to see how such efficiency has been possible. Firstly, at no point in the Cuban system is there anybody who is driving up costs by making a profit out of it; and secondly, the fact that the state is the sole provider of health care avoids the wasteful duplication, cherry-picking, and poor coordination of services that inevitably arise when multiple inter-competing providers are involved.
On reflection, this all makes Nick Seddon’s call “to make care more joined up” by privatising it look even more bizarre.
Of course, as anyone who does any real clinical work in the NHS knows, there are ultimately two very good and interrelated reasons why private companies shouldn’t be permitted to run any hospitals, failing or otherwise: 1) Because the whole story of the involvement of the private sector in the NHS over the past 30 plus years has been an unmitigated disaster from start to finish; and 2) Because it’s precisely as a result of this private-sector involvement that we have such things as ‘failing hospitals’ in the first place.
The story has been a tragedy in five acts. First, the Thatcher government’s implementation of the findings of the 1983 Griffiths Report (headed by Sir Roy Griffiths, a former director of Monsanto and Sainsbury’s) brought business managers in to run the NHS.
Second, the NHS and Community Care Act 1990 – inspired by Alain Enthoven, formerly of the US Department of Defence – set up the so-called ‘internal market’ in the NHS: the designation of NHS hospitals as individual business units (NHS ‘Trusts’) that henceforth had to compete against one another for funding from ‘purchasers’ or ‘commissioners’. Those that were less ‘competitive’ were by definition ‘failing hospitals’.
Third, the huge expansion of the Private Finance Initiative (PFI) by the Blair government from 1997 led many Trusts to run up significant long-term debts to private banks and construction companies in their efforts to out-compete one another. Ironically, Trusts that were subsequently unable to service these debts – principally through asset sales, ward closures, and job cuts – would again by definition be labelled as ‘failing’.
Fourth, the launch of ‘foundation hospitals’ after 2002 effectively provided a template for the transformation of NHS Trusts into embryonic private hospitals.
And finally, the Health and Social Care Bill 2011, if and when enacted, will administer the coup de grace to the NHS as we knew it, removing the historic legal obligation of the Secretary of State to provide a comprehensive health service, dissolving the Strategic Health Authorities, and compelling all remaining NHS Trusts to become – or be subsumed into – Foundation Trusts.[8]
What has happened, bit by bit, to the NHS over the past 30 years thus becomes blindingly obvious. When the Thatcher government wanted to privatise council housing, it was able to appeal to tenants’ aspirations to social mobility through home ownership. When it wanted to privatise gas, telecommunications, electricity, and water, it was able to spin illusions of a ‘shareholder democracy’ where the laws of the free market would operate to ensure cheaper bills (seriously).
Even when the Major government was itself running out of steam in the mid-90s it was just about able to use years of underperformance (actually a result of chronic underinvestment) as justification for rushing through the privatisation of British Rail.
But quick and out-in-the-open sell-offs such as these would never have been possible in the case of the NHS: it was depended upon and highly regarded as a publicly-owned institution by the overwhelming majority of the British public. Instead the government would need a slow, covert, and incremental privatisation process that could never be revealed as a privatisation process (instead cloaking itself in such anodyne terms as ‘reform’ and ‘modernisation’) until the final endgame, by which time, of course, it would be a fait accompli.
Only now that the end is almost upon us do the likes of Nick Seddon dare to show their true colours and argue publicly for out-and-out privatisation. “Look,” they say, “the NHS is just too expensive to run in the old way any more; we need to bring in the efficiencies of the market!” – deliberately obscuring the fact that it is precisely the semi-privatised world of multiplying managers, insane internal market-related administrative costs, and spiralling PFI debt that they have created that has made the NHS so unnecessarily expensive to run in the first place.
Anyone who can seriously, in 2011, continue to ignore the evidence of their senses and trot out the lazy right-wing dogma of ‘public sector inefficient; private sector efficient’ is, quite frankly, either lying or stupid. Has the selling off of council homes resulted in more affordable housing? Has the selling off of the electricity, gas, and water boards resulted in more affordable utility bills? Has the selling off of the railways resulted in more affordable rail travel?
Of course, what the likes of Nick Seddon really mean when they talk of ‘efficiency’ is profitability. And here we get to the crux of the matter: The privateers simply do not care that privatisation inevitably results in a shoddy, inefficient, disorganised, expensive – and not to mention downright dangerous – service, because the sole purpose of it is to pour money into their pockets.
These people do not get involved with the NHS because they really fancy the challenge of delivering better health care, no matter what their glossy press releases may say. What they are after is a captive market – a guaranteed pot of taxpayers’ money with which they are free, and indeed are legally obliged, to boost their own profits.[9]
And if the shareholders demand more profits, no problem! By Seddon’s own admission, they can ‘reform’ the workforce and ‘renegotiate’ staff pay and conditions. But won’t cutting staff numbers potentially undermine the entire service? No problem there either – the Health and Social Care Bill promises to remove the Secretary of State’s legal obligation to ensure a comprehensive health service.
No doubt, if this response to Seddon’s article is published, I can expect a very polite rejoinder to the effect that ‘polemics that polarise debate are unhelpful’. To the charge that my argument against the privateers is a left-wing polemic, I am happy to plead guilty. After all, right-wing polemics dressed up in the politically neutral ‘professional’ language of management speak are still right-wing polemics, and deserve a response that brings the real terms of the debate out in the open.
Nothing has been more depressing in the NHS in recent years than the experience of senior doctors expressing their dismay and unease at the often bizarre edicts of corporate managers in private, yet feeling hamstrung into grudging acceptance by management’s claims to ‘professional’ authority in public.
It is not difficult to see the sorts of things that are crying out to be done to make the NHS a genuinely better and more efficient service: things like slashing the number of managers and putting clinicians back in charge; kicking the internal market into touch; ending the ridiculous business management-inspired culture of audit-for-audit’s-sake; scrapping PFI and cancelling related debt; nationalising the pharmaceutical industry.
The fact that these may seem like implausible dreams in these politically bleak times does not make them impossible and certainly does not make them wrong. After all, at one time the idea of an NHS itself must have seemed like an implausible dream.
Many doctors, despairing of the power of the managers, imagine that the way to fight managerialism is to become managers themselves. This is quite wrong; you might as well argue that the way to fight crime is to become a criminal yourself. On the contrary, the only way to counter the politically regressive aspirations of the privateers is to expose and oppose them at every turn.
Doctors must act not as managers and businessmen, but as workers and as citizens. Indeed, they must act as doctors. The NHS depends on it.
NOTES
1. Why shouldnt private companies run failing hospitals?, 30 November 2010
2. G Orwell, Politics and the English Language, April1946
3. Health Insurance, US Census Bureau
4. ‘Obamas healthcare bill is enough to make you sick, by C Hedges, Truthdig, July 2010
5. Noam Chomsky interviewed by Amy Goodman , Democracy Now, April 2009
6. AM Pollock, NHS plc – The Privatisation of our Health Care, 2004
7. ‘Health in Cuba’ by RS Cooper, JF Kennelly and P Ordunez-Garcia, International Journal of Epidemiology, 2006; 35: 817-824
8. Health and Social Care Bill 2011
9. J Bakan, The Corporation: The Pathological Pursuit of Profit and Power, 2004
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