The politics of health in England: "a National Health Service would be

a good idea"

Alex Scott-Samuel

Honorary Professor, School of Medicine,

Pharmacy and Health, Durham University

Acknowledgement

When asked what he thought of Western civilisation

Mahatma Gandhi is said to have said “I think it would be

a good idea”

Positionality 1

Positionality 2

The politics of health in England

A National Health Service would be a good idea

Towards a political science of health

A political science of health: initial areas for research

• political inequalities in health (care)

• health (care) and party politics

• health (care) and public policy

• health (care) and the (formal / informal) exercise of power

• political aspects of social epidemiology including political determinants of health

• policy based evidence making

Policy based evidence making

The commissioning, selection or invention of evidence to

support and justify a predefined policy position

Policy based evidence making - examples

• the Private Finance Initiative• the Choice = Equity ploy• the 2002 Treasury Cross Cutting

Spending Review on Health Inequalities (CCSR)

• the Health and Social Care Act 2012

CCSR - policy based evidence making 1

‘political and bureaucratic

considerations loomed larger than research

evidence’

CCSR - policy based evidence making 2

The CCSR failed to address:

• macroeconomic policy• globalisation and trade• arms dealing• patriarchy and gender inequity• defence policy and war• foreign policy• international development

Policy based evidence making 3

‘we are only looking for evidence among a prescribed list of diseases and target

groups. If it started with the question "where is health best improved and

what evidence for (any) action is available?" it would be recommending

quite different actions’

Policy level and PBEM / EBPM ratio

The H&SCA and policy based evidence making

Dr Jonathon TomlinsonHackney GP

abetternhs blog

tinyurl.com/n39mfss

‘Integrated care’

“I'm sitting in the diabetic clinic in the Royal after a conversation with my (private) insulin pump company Animas this morning in which

they refused to send me any kit for my pump (I did explain this is life or death) because they

hadn't received a piece of paper from the NHS. Seems I'm already living the

privatised/US style healthcare nightmare described by Allyson Pollock!”

The Health and Social Care Act is one of the biggest confidence tricks ever carried out by a government.

We've been defrauded of our beloved universal, comprehensive, integrated, equitable, public sector,

national health service.

The impacts of the Health & Social Care Act 2012

• loss of Secretary of State’s duty of provision• loss of universal service• loss of comprehensive service• loss of free service• loss of integrated service

NHS now just a logo for a privatised

healthcare contracting operation

Current NHS policy outcomes

Privatisation(Letwin / Lansley / Hunt)

+

Cuts(McKinsey / Osborne)

+

Rationing(postcode lottery)

Privatisation, cuts and rationing

•50% increase in A&E referrals since NHS Direct privatised – being blamed on GPs

•Harmoni responsible for baby’s death in Hackney – local GPs’ OOH bid rejected

•Nurses, not culture, blamed at Stafford

•Postcode lottery will increasingly cause people to go private – with increasing use of health insurance - and to have to pay top-up fees

Neoliberalism, insurance and trade

•Neoliberalism - Wendell Potter – Deadly Spin

• Insurance – Accountable Care Organisations

• Trade - Transatlantic Trade and Investment Partnership – TTIP

Origins of the Health & Social Care Act 2012

pcwww.liv.ac.uk/~alexss/toryattackonnhs.pdf

Informed neoliberal opinion

“In future, the NHS will be a state insurance provider not a state deliverer. In future ‘any willing provider’

from the private sector will be able to sell goods and services to the system. The NHS will be shown no mercy and the best time to take advantage of this

will be in the next couple of years. GPs will have to aggregate purchasing power and there will be a big opportunity for those companies that can facilitate

this process. The monolithic arm of state control will be relaxed which will provide a huge opportunity for

efficient private sector suppliers.”

Mark Britnell, Head of Health, KPMG; former NHS Director of Commissioning, 2010

What is to be done?

Suggested principlesfor a National Health Service

in England

Structural and functional integration 1

Physical and mental health and social care should be provided by

a single, public sector service. This should be managed and delivered locally, but funding and most policy should be determined centrally so

as to avoid inequalities and postcode lotteries.

 

Structural and functional integration 2

There should be coordination and rapid sharing of information

between all services in the demonstrable interest of

patient care.

Management and planning

There should be performance management of equity-, quality-,

integration- and user satisfaction-oriented objectives, indicators and targets.

Health and social care workers and users often know best how services need to

change: staff at all levels should be represented in management. Community health councils should be reintroduced

 

Funding 1

Health and social care should be entirely funded from the public

purse with no co-payments, user charges or insurance. Eliminating the transaction costs of the current

NHS market will make a major contribution – as would the abolition

of all six figure NHS salaries.

Funding 2

A substantial contribution could also come from the defence budget: citizens will hopefully prefer a strengthened welfare

state to an unnecessary armed forces budget. Once we stop

attacking other countries they will stop attacking us.

Prevention and intervention

Preventive services should always be prioritised.

Intervention will always receive adequate priority because of

clinical Individualism and because of the profit motive.

Health inequalities

Since capitalism cannot exist without inequality, acceptable inequalities should be debated and defined. To

reduce long term health inequalities it will be necessary to engage directly

with their root causes, such as inequalities in power, social status /

social connections, knowledge, income and wealth.

Repairing damageThe health service must return rapidly to the public sector. This will involve

terminating all external clinical contracts and bringing health related

professionals back into NHS employment under unified conditions of

service. The secretary of state will resume responsibility for the service.

Early announcement of these intentions will discourage private providers from

bidding for contracts.

Royal Commission

A participative Royal Commission on the NHS would help ensure the

service achieves everything the public wants in order to make it

once again a central element of a welfare society.

 

Chief Medical Officer’s Tips for Better Health (1999)

• Don’t smoke and don’t breathe others’ tobacco smoke

• Manage stress levels • Practise safer sex – use a condom • Eat at least 5 portions of fruit & veg

each day • Be physically active for at least 30

minutes, 5 days a week

Alex’s tips for the Government to promote our health

• No-one should profit from other people's ill health - resist the attractions of private finance and keep business away from the NHS

• In the context of health care, it is inaccurate to describe anyone as a consumer, and demeaning to describe them as a customer

Alex’s tips for the Government to promote our health

• Values matter - what counts is not 'what works' but 'what promotes and sustains our nationally agreed values of equity and mutual welfare'. Evaluate all policy against this criterion

• Practise safer macroeconomics - avoid free markets or fiscal policies that exploit poorer nations or disadvantaged groups

Alex’s tips for the Government to promote our health

•Excessive masculine gender roles damage both women and men. Make gender-equitable parenting and socialisation the top national political priority

•Practise safer politics - never appoint to Cabinet posts people of either sex who display excessive masculine gender roles

Alex’s tips for the Government to promote our health

• Violence is unhealthy and inequitable - don't permit arms dealing or engage in war

• Social (including health) and economic rights are as important as civil and political rights - steer clear of 'democracies' that deny social and economic rights to their citizens