It's the 75th birthday of the NHS, so what better time for another rare intervention from Tony Blair. This morning his institute published a paper about the future of the NHS. In line with current Labour thinking that what public services need is reform, not funds (which, in turn, are informed by Tony Blair Thought of two decades ago), the report offers a number of technical and seemingly technical fixes to improve the health service. But the overall thrust is clear: bureaucratic centralisation is the chief opponent of efficient delivery, not lack of cash.
It shouldn't need saying that this corner of the internet rarely receives Blair's missives with open arms, but it would be churlish to file the report in the desktop recycling bin just because of its provenance. The report, authored by a health policy wonk and an academic, does make some good points. Yes, there does need to be an injection of capital so the NHS can fully utilise new technologies. Who would be against that? The report says this can be utilised to cut waste and introduce less labour intensive treatment. There should be local autonomy for what are termed 'integrated care systems' to treat and improve health outcomes in their areas, backed by the stability of multi-year budgets and incentives to innovate - which include keeping and reinvesting any savings made. A digitised 'Personal Health Account' - a souped-up NHS app enabling access to services and putting patients in charge of their own health data, which can be linked to secondary apps and wearable technology, would revolutionise and personalise our relationship to the NHS. Rolling health services out from GP surgeries and hospitals, which would reduce demand on those services through an expansion of provision is another floated suggestion. And making more use of personal-use genomic medicines, making sequencing available on a mass scale and integrating genetic susceptibilities it into one's personal data is another ambitious goal. If we absent social relationships for a moment, this is what a 21st century health service should look like.
But social relations aren't about to go away, and how the report frames this technologically enabled vision raises a lot of political questions. Firstly, the report says it wants to move the NHS away from a patch-them-up-and-let-them-go model of treatment to one more reflective of complex health needs. This is nothing new. In fact, the first NHS reorganisation in the mid-1970s was premised exactly on these terms. Of moving from treating disease to addressing the long-term health problems of a population that was living longer. Indeed, that is the main business of the NHS today. Therefore, the report's argument that we "must move from a health-care model set up to treat episodic sickness to one that prioritises continuously improving individual and population health" is an extension of what the NHS already does in part to the whole. A useful straw man if you want to exaggerate the case for reform though.
Then there are the rocket boosters these proposals have put under the so-called patient choice agenda. This is not an innocent idea of simply allowing patients more choice in their treatment, but was under Thatcher, Major, and Blair designed to introduce and bed down marketised relationships between different parts of the NHS. In the New Labour years, the idea was to allow patients complete choice of where they were treated. NHS organisations would compete with each other for patients, allegedly driving up standards and increasing efficiency. This was swept away by the Tories in 2012 for thoroughgoing marketisation, semi-privatisation, and outright scamming in which "any willing provider" was in with a shout of scooping up NHS money. What happened over Covid procurement and the missing billions was this writ large. The Blair Institute are proposing is something a bit more subtle. Through the use of personal health technologies, they want to bed down principles of individual responsibility for health - which can be monitored via the app. This builds on the individualist (and individuating) thrust of public health strategies in the Blair years, and one that attempts to evacuate politics from health altogether. I.e. You have the power to choose healthy outcomes informed by constantly updated metrics, and therefore what happens to you is (largely) in your hands. It's consistent with the modes of governance Blair enforced across the public sector, and one that proved (politically) effective quite recently. If you get ill, it's going to either be a case of 'pathogenic life factors' or bad luck. Never air quality, food quality, environmental despoliation, unhealthy work practices.
And then we have the private provider argument, because of course we do. There's the useless argument about "spare capacity" in private health that gets mentioned every five minutes by Wes Streeting. As an aside, Streeting often defends this saying he wants the NHS to get to the place where it can out-compete the private sector. Yeah, right. I'm sure the private health interests funding his operation do so because they want to be put out of business. The Blair Institute goes there, but they flag up more opportunities for private sector involvement. Remember the localised integrated care systems? "Freedom" of ICS chiefs would inevitably mean contracting in for-profit providers to meet targets, just as they did 20 years ago. Indeed, these organisations should "empower" patients to make "informed choices" about choosing between GPs and "secondary providers". On the dispersal of health services, the report is explicit that "high-volume, low complexity" services should routinely be hived off to "multiple providers". Again, it's all about patient choice. The patient data revolution the report envisages allows for more public private partnerships, and larger market for data add-ons to the key NHS app as well as "innovation". Undoubtedly encouraged by a generous system of state grants and inducements.
This, again, carries on where Blair left off in 2007. While there were plenty of New Labour true believers in marketised policies as drivers of best outcomes (the Tories, despite their well earned 'stupid party' monicker, are never daft enough to really believe this twaddle), the politics of this made sense because NHS outsourcing, PPPs, and Private Finance Initiatives tied - at least for a while - sections of British capital to what you might call the Blair Rich Project. By pouring state money into private pockets, this was one means by which New Labour was able to cultivate patronage and crony networks that helped ensure, for a brief window, that it was the favoured party of (most of) capital. It's entirely a matter of coincidence that ex-health ministers and certain MPs later enjoyed handsome consultancies and board positions advising private health and outsourcing giants. It didn't last, and when Labour was dumped out of office the Tories ramped up the openings through the total marketisation of the NHS. Here, the Blair Institute's programme for change is more than just about the future of the NHS. It is directly advising the incoming Labour government about how to use NHS reform to win over a section of British business, with the obvious consequence of diluting the popular pressures that will bear down on the party after such a long period of Tory rule.
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The Fifth of July ought to be the United Kingdom’s national day, celebrated as fulsomely in this country as the Fourth of July was celebrated across the Atlantic. But instead, with horrible predictability, Tony Blair has been wheeled out out from wherever it is that he is kept, to demand more of the privatisation that he, Alan Milburn and Paul Corrigan brought from the outer fringes of the thinktank circuit to the heart of government in 1997. For the third time, though, only in England.
ReplyDeleteKeir Starmer and Wes Streeting are funded by the American healthcare companies, and no one doubts that Blair has an interest in them, or he would have made no intervention today. So much for his retirement. We should be so lucky.
Yesterday, following the formal exposure of his daughter’s grift that had always been visible from outer space, no one mentioned that it should never have been Colonel Sir Tom Moore’s job to fund the NHS, that centenarians doing sponsored laps of their gardens was no way to do so, and that we were back to the Bullseye of my childhood, with people playing for the money to buy equipment for their local hospitals. All three parties have been in government, so they are all to blame.
That is why general media overage today has been of the question of “whether we can still afford” the NHS. There has been much use of the obligatory, bone idle line about “the national religion”, the purpose of which is to suggest that the people’s overwhelmingly strong support for the NHS could not have the rational and empirical basis that the media, like the political parties, would lazily regard as the opposite of religious belief. As is their wont, the cancelled have been everywhere, with the deplatformed taking their usual place on every platform to canter around it their hobbyhorse of “social insurance”. But that more bureaucratic version of National Insurance is not the insurance peddled by their paymasters. Do not believe a word of it.
And Streeting is their man. Backed to the hilt by Starmer, he is the greatest threat to the NHS since its foundation. Aneurin Bevan would have called them “lower than vermin”. Bevan would never have made it onto the longlist for a Labour parliamentary candidacy under Starmer. Anyone who now expressed his opposition to prescription charges would be expelled from the Labour Party. Yet the only part of the United Kingdom to have prescription charges is England, just as it is the only part to have privatised water, and the only part to be set to lose most of its railway ticket offices.
"A digitised 'Personal Health Account' - a souped-up NHS app enabling access to services and putting patients in charge of their own health data, which can be linked to secondary apps and wearable technology, would revolutionise and personalise our relationship to the NHS."
ReplyDelete"Through the use of personal health technologies, they want to bed down principles of individual responsibility for health - which can be monitored via the app. This builds on the individualist (and individuating) thrust of public health strategies in the Blair years, and one that attempts to evacuate politics from health altogether. I.e. You have the power to choose healthy outcomes informed by constantly updated metrics, and therefore what happens to you is (largely) in your hands."
If you can read those two paragraphs without your blood running cold, then you have very little real understanding of the modern world.
What it certainly is not is evacuating politics from health, just like that never happened across the Pond. Rather, it's a move towards pure abandonment of any idea that the state should do anything at all to help its hapless denizens in the arena of health, whilst retaining plenty of ability to harm them.
Behind the flimsy techno-utopian facade, this is inevitably headed to a banquet of excuses for US-style denial of healthcare, and that is presumably exactly why the vile old ghoul thinks that it has political legs. For "pre-existing condition" or "unemployed", instead read "failing to live the government-approved 'healthy lifestyle', as measured by your personal monitoring devices" (the latter of which will, conveniently, have no awareness whatsoever of how unhealthy a hole that society sees fit to provide for you to live in). So much more egalitarian, isn't it? I can almost taste the sunlit uplands of bedded-down "principles of individual responsibility". Surely that's what the NHS was always about; "principles of individual responsibility".
And, as a particularly enticing added bonus, all of your health biometrics are now available on the darknet in realtime, to anyone who can lob a fraction or two of a bitcoin to a hacker!
Truly, it's an appropriate birthday gift from Blair to the NHS - a rewriting of history which consigns "Road to Wigan Pier", and all of its lessons, to the Ministry of Truth shredder.
One of the most difficult areas I ever had to teach was how the NHS was run to students who were going to work in it. At the end one student summed it up, “so the Labour government actually runs it through “targets”(which we’d gone over throughout the course) and markets, which don’t exist, but pretend that they do?”
ReplyDeleteAnd as someone accurately pointed out, you might actually get the worst of both worlds, rather than the best.
I was reminded of this when I watched Sir Christopher Wormald, the health Permanent Secretary, giving evidence at the COVID Inquiry. The topic was the ability of the NHS to respond in a coordinated manner. His reply was to point out that the 2012 Act and the 2014 act dealing with social care, was intended to remove central control, a deliberate policy decision. After some dancing around from him, prompting this from the Inquiry QC “ I am sooo sorry to interrupt…”, and promoting from the judge, he agreed,
the system was too fragmented to respond in a timely manner.
BTW if you are ever in court, get Hugo Keith KC in your corner
Honestly, Britain (and more generally, the world) is circling the drain, and the Labour Party are saying: "maybe we'll tinker on the edges of the edges, if it's not too much trouble to the powers that be?"
ReplyDeleteMeanwhile, the Conservatives: "We have nothing, literally nothing, to offer except systemic sadism towards certain groups of people: immigrants, refugees, LGBT people, young (well, young to middle-aged) people, poor (well, poor, working-class, maybe lower middle-class... Fuck it, they'll all be poor by the time we're finished) people...."
Both parties (and, of course, the Lib Dems) are so totally fucking useless and fundamentally stupid. Their answer to the crises of neoliberalism range from "Uh... more neoliberalism?" to "more neoliberalism, yay!" (the only difference is the degree of genuine enthusiasm).
Neoliberalism, which is to say capitalism victorious and unrestrained by countervailing pressures, is very obviously unsustainable because the ruling class evidently lack the sense to restrain their immediate greed in favour of their, and their descendant's, own long-term interests. As if when the environment and society collapse, they'll somehow be fine, because the top of the economic pyramid doesn't depend for its existence on the rest of the pyramid below it! As if the rich don't need even such a basic necessity as breathable air (see Canada and the US right now) like the rest of us!
why do you care so much about the NHS? Why is the principle that the state must run it so sacrosanct?
ReplyDeleteMost European nations have free at the point of use systems that incorporate private provision. Having different private providers paid for by a national government funded health insurance scheme (ie free at the point of use) enables innovation, efficiency saving, and will allow health care professionals to get higher wages. What's not to like? Why is it blasphemy to look across the channel at how other European nations provided free at use healthcare, observe it is so much better, and then say 'let's do it like that?'
What a delightfully evidence free comment from the Dipper.
ReplyDeleteThe recent report from the Kings Fund found the NHS neither a leader or a laggard despite its below average spending, under investment in capital and low levels of clinical staff. And that there was little evidence that one country or model performed consistently better. Countries provided better health by reforming their existing system than adopting new models.
Imagine if we invested more and tackled the social and economic factors that add to ill health.
Ah, The Kings Fund. The only one that ever finds the NHS anything short of woeful.
ReplyDeleteBut lets go with it. Its an average mid-table performing system. So what are you moaning about?
If you want more money then where are you going to get that from? From higher taxes (and if so then who are you going to tax)? From more borrowing? (meaning a lower pound so higher prices of imported goods, higher mortgage rates)? From cuts elsewhere?
Or do you have some other sort of magic that is going to solve this?
«Honestly, Britain (and more generally, the world) is circling the drain [...] Both parties (and, of course, the Lib Dems) are so totally fucking useless and fundamentally stupid.»
ReplyDeleteThat for me is just an echo of the right-wing propaganda that "we are all in the same boat" (and "we are all middle class now", or the amazingly enduring hallucination that the right-wing politics is still about minimal state intervention in markets), that is the government of the past 40 years have impoverished everybody (except perhaps billionaires) with their gross incompetence. Which begs the question of how they get so many votes, if they are shafting everybody (except perhaps billionaires).
As I keep repeating, a left-wing analysis starts from the obvious point that upper-middle class and upper class Britain have been booming for decades, thanks to massive right-wing government intervention in markets to boost the finance and property sectors, and even the lower middle class has been doing fairly well; around 20-40% of voters have been smugly satisfied with big government
The lower classes have been "circling the drain" but that's not because right-wing governments have been “fucking useless and fundamentally stupid” but actually quite effective and cunning in using big government intervention in markets to redistribute large amounts of wealth and income upwards.
«Why is the principle that the state must run it so sacrosanct? Most European nations have free at the point of use systems that incorporate private provision.»
ReplyDeleteBecause in the UK the universal state health insurance principle and the NHS are pretty much linked. Indeed universal state health insurance principle *could* have been realized in a different way, and in theory the UK *might* switch to a different way to realize that principle.
But I think that it is at best dissembling to ignore that those who want to dismantle the NHS do so because they want by doing so to eliminate universal state health insurance, not because they want to keep it but realize it in a different form.
www.theguardian.com/politics/2014/jul/19/kenneth-clarke-views-no-10
«His first challenge at health was heading off Thatcher, who "wanted to go to the American system", he reveals. "I had ferocious rows with her about it. She wanted compulsory insurance, with the state paying the premiums for the less well-off. I thought that was a disaster. The American system is hopeless … dreadful." He prevailed on her to take a different route by introducing more competition into the NHS. It became known – in a phrase he didn't like – as "the internal market". Ever since then, successive governments have pushed in broadly the same direction.»
@McIntosh
ReplyDelete> And that there was little evidence that one country or model performed consistently better.
BUT there is a long, long trail of evidence that one particular country performs much worse than the rest of the developed world; many years of consistently topping the table for expenditure per year of life expectancy, whilst also having one of the lowest life expectancies.
That's the USA, of course.
And so, when the question of health provision comes up, even some of the most deranged right wingers can be found suddenly lauding our recently-spurned and denounced neighbours across the channel as a shining paragon of how things should be done. Whilst taking care not to mention the individualist Shangri-La across the Pond which they are more often seen fawning upon.
Dipper wrote
ReplyDelete"private providers ... enables innovation, efficiency saving, and will allow health care professionals to get higher wages. What's not to like?"
The fact that it's a non-sequitur. That's what's not to like. Thames Water, anybody...?
The fact that some people still find a way, even now, to believe that "innovation", "efficiency", and "higher wages" - or even any functioning service at all - necessarily result from privatisation according to some iron law of the universe, would really beggar belief... if I wasn't well aware of some of the unfortunate evolutionary neurobiology that has bequeathed us this sad state of affairs.
One wonders if Dipper also still believes in trickle-down economics.
But there's always a shrill cry of "you'll run out of other people's money!" to fall back upon, eh?
Is there no health provision on the European continent? Does everyone who gets ill die?
ReplyDeletePractically nobody who is arguing for reform of the NHS is arguing for the US version. Everyone is arguing for a continental version. So why do you lot keep going on about US healthcare as if there is no provision on the continent?
Blissex,
ReplyDeleteYeah, I'm aware of all that, but my point is this: IT ISN@T FUCKING SUSTAINABLE. The ruling class isn't merely selfish, but also incredibly stupid, to the degree that they will end up killing not only the rest of us, but ultimately themselves.
Blissex,
ReplyDeleteI think there is a very clear difference between rational self-interest and mindless greed. Bear in mind, I'm saying this as an addict: I know very well that what you want and what is good for you aren't necessarily the same thing.
For the ruling class, what would be in their rational and long-term interest is very different from what would maximise their short-term profits; it's the difference between some kind of social democratic and environmentally sustainable capitalism (if such a thing is even possible!) and the reality we're living in.