Dr Bob Gill (@DrBobGill) explains the unreported and sinister drive behind the push for changing junior doctors’ contracts. Reposted with the author’s permission from the Keep Our St Helier Hospital website.
The latest assault on the NHS involves the imposition of a new contract for junior doctors that will see their salaries slashed by 30%, with a requirement for evening and Saturday work.
The excuse used to justify this change is to provide a seven-day service and improve patient outcomes on weekends.
The reality is that more qualified staff are being driven out in preparation for the de-skilling that is always part of healthcare privatisation and corporate takeover. For the UK, this is mapped out in the Five Year Forward View by Simon Stevens, the head of NHS England. Stevens used to be an executive of the US based private health care company, UnitedHealth.
What all junior doctors – and the rest of us – need to know
Many junior medics – which means all doctors not yet senior enough to work in consultant positions – have been stirred into action, but it is crucial for them to understand the context of their current predicament to mount an effective campaign to protect patients, restore decent treatment of staff and block the completion of the privatisation of the NHS.
But first, a little history lesson…
Conversion from the NHS model, a publicly funded, provided and universal system, to a private insurance model has been proposed for decades.
In 1968 Arthur Seldon, later Margaret Thatcher’s privatisation policy adviser, produced a pamphlet for the Institute of Economic Affairs called After the NHS, explaining the aspiration to “improve the NHS” by abolishing it, so as to build profit opportunities for the insurance industry.
Further incarnations of this plan to enable the insurance industry to increase its profits in the UK by destroying the NHS surfaced in the 1980s. These included Health of Nations by the Adam Smith Institute and, in 1988, Britain’s Biggest Enterprise: Ideas for Radical Reform of the NHS. The latter was the vision of current Conservative Minister of State for Government Policy, Oliver Letwin MP, in the NHS privatisation manifesto he authored with John Redwood MP, published by the Centre for Policy Studies, a Thatcherite think-tank.
The stealth privatisation of the NHS had quietly begun under the Thatcher administration and has continued unabated ever since. The sole attempt to bring the plan out of the shadows, its presentation to a Conservative cabinet in 1983, was so roundly rejected that the decision was taken to complete the privatisation by covert means, under a series of false narratives to distract the public from what was really going on.
This has involved a number of seemingly disparate measures, from the outsourcing of non-clinical services, to the introduction of market bureaucracy, splitting up of the hospital network into independent Trusts and the usurious Private Finance Initiative (PFI) scheme, designed to create an opportunity to gouge the public purse through inflating the costs of funding new hospital building. Started on John Major’s watch, PFI continued under Tony Blair and Gordon Brown.
Indeed, Blair’s New Labour government enthusiastically continued with the privatisation project, while maintaining the deceptions contained within successive pointless top-down reorganisations. hese actually took the NHS further down the privatisation road, precisely following the steps laid out in the Health of Nations NHS privatisation plan.
Why the hell didn’t we know about this?
Consecutive governments have diligently obscured the intent of health reforms with spin and misdirection, while senior NHS positions have often been filled by those who would not be likely to point out these lies to their medical colleagues and the public. The success of the project depended on public ignorance and distracting attention with myth creation. The propaganda agents include large sections of the media, in particular the BBC. Our public service broadcaster has avoided scrutinising health reforms and instead simply regurgitates government spin, peddles myths and presents pro-privatisation think tanks as if they were independent.
In contrast, growing public and professional protest has been conveniently ignored. It is censorship by omission.
The British Medical Association (BMA) has spent the last two decades gently nodding through marketisation and privatisation under the guise of ‘critical engagement’. They have provided no effective challenge to government policy, and kept members in the dark to a degree that could suggest complicity at leadership level. Genuine opposition by BMA leaders to the Health and Social Care Act 2012 could have prevented the NHS being carved up for profiteers for example.
What state is the NHS in now?
The NHS has been fundamentally transformed in the last 20 years. Our nationally integrated hospital network has been split up into distinct business units (“foundation trusts”), which were deliberately burdened with PFI millstones which would throw them into insolvency as soon as a funding squeeze was applied to trigger this at the right time for privatisation.
Since 2013, health services have been funded through clinical commissioning groups (CCGs). These were designed by John Redwood MP to be self-collapsing, state-funded insurance pools. Though many CCG boards are fronted by GPs, the commissioning decisions they take are ultimately shaped by a set of rules which incentivise outsourcing to private healthcare companies with administrative support provided by yet more private companies.
CCG boards have great discretion over which services they will pay for. NHS-funded care will be increasingly restricted, damaging universal and comprehensive care. This will inevitably lead to patients paying charges for care, out of pocket, or through private top-up health insurance. Or, to quote Letwin and Redwood on page 16 of Britain’s Biggest Enterprise: Ideas for Radical Reform of the NHS:
“Another avenue which has been tentatively explored by the Government is charging. In principle, this could be extended to the point of universality – a charge for every service.”
CCGs were designed as transitional bodies to be taken over by private insurers, accountancy firms and management consultants, an army of unnecessary intermediaries siphoning away taxpayers’ money from delivery of healthcare. GPs have been set up to be the scapegoats for the demise of the NHS.
Disempowerment, corruption and the scapegoating of health professionals
To change the NHS from a health service to a business, the traditional medical leadership had to be replaced with a general management structure. Hospitals and health boards across the country had their small, clinically dominated, patient-focused members replaced by a leadership that is less inclined and equipped to protest about damaging patient services and quality of care.
Introduction of the internal market in which NHS services can be farmed out to the private sector, the setting of targets, and forcing performance management standards that are inflexible or unsuitable for hospitals has led to an explosion in the number of administrators and managers required to implement these reforms.
Despite the public being sold a narrative about saving money, the changes have made the NHS more bureaucratic and expensive than ever, and none of this funding is being spent on patient care.
The purchaser-provider divide-and-rule manoeuvre pits GPs against hospital doctors, handing GPs the axe to take to hospital services, contrary to the interests of patients – and in the face of opposition from hospital colleagues.
As a result, the line between the public and private sector in the NHS is blurred. The changes to the NHS provided the infrastructure for siphoning money away from the delivery of care to patients.
This bloated administrative structure has for some time imposed government policy irrespective of outcome for patients. The most infamous example of this was at Mid Staffordshire NHS Trust. Priority was given to meeting financial performance targets to qualify for Foundation Trust status instead of ensuring adequate staff levels to run the hospital safely. Spin-meisters have carefully crafted messages for officials and politicians to redirect responsibility away from management and government policy failings. Instead, hospital staff are blamed for lacking compassion or commitment.
A culture of fear and intimidation for those who dare speak out about preventable patient harm has been exposed repeatedly over recent years. The perpetrators escape sanction and many are promoted, in contrast to career destruction and psychological torment for whistleblowers.
Public money is also wasted on cover-ups of malpractice linked to the privatising leadership clique in hospitals. Some whistle-blowers are banned from coming into work, and this costs money. Dr Kim Holt told her superiors of the risks that later led to the death of Baby P, and their reaction was to send her home from work and hire locums to do her job, at a cost to the public purse of around £1 million.
The incredible, shrinking NHS
Clinical autonomy is severely restricted due to lack of resources, so doctors may no longer be allowed to do what is right for patients because of bureaucratic restrictions introduced as part of the reshaping for privatisation.
The NHS has lost more than 50% of acute beds since 1979, leaving us with some of the most meagre hospital provision in Europe. The UK has just 2.8 beds per 1000 population compared to 6.3 and 8.3 for France and Germany respectively.
It is all a big false economy.
Doctors have to discharge patients prematurely to make space for sicker patients, but that can hamper recovery, or worse. Outpatient clinic appointments are also being cut, and the marketised system prevents patients being referred directly between specialists without first being sent back to their GPs.
These frustrating and inefficient additional bureaucratic hurdles have been created to suit neither patient nor doctor, but the marketised NHS. The costs of NHS administration increased from 5% of the total budget before the privatisation process started in the 1970s to 14% by 2005, amounting to more than £10 billion per year additional cost without patient benefit. And the American system to which the government aspires was spending 31% on administration by 2003.
The cost of repayment of £11 billion in PFI loans will exceed £80 billion. Doctors agonise over patients being denied a bed or other essential care, whilst extortionate sums of money are squandered on market administration, outsourcing and PFI payments.
Betrayal of doctors and patients – by doctors
A significant minority of doctors have assisted in betraying the public and their colleagues. They are motivated by self-interest, realised through promotion, performance-related pay and bonuses. They have been busy downplaying and distracting from others’ concerns over privatisation; and this in turn is an attempt to make the BMA less effective at representing doctors.
When the complicit doctors collude with management and politicians in promoting hospital cuts and closures, patients’ lives are endangered.
We have doctors who are now paid advocates for reconfigurations of NHS services expensively concocted by management consultants and accountancy firms whose glaring conflicts of interest largely go unmentioned.
In this environment of constant flux, confusion and stress, most NHS workers rarely delve into the detail of what is going on around them but remain preoccupied with dealing with the consequences. Apathy, ignorance, fear, disempowerment and sense of futility combine to make a powerful disincentive to push back. Instead NHS staff just keep their heads down and get on with the day (and night) job.
This is so far from the idealised vision most would have had of being a doctor in a civilised, open, accountable democracy. Working in the NHS has been transformed from feeling like part of a large family working for the common good to resembling a totalitarian state where survival is dependent on wilful blindness to all that fails our patients and colleagues. No wonder more than two-thirds of NHS employees are seriously considering leaving.
Part 2 of this article, in which the implications of privatisation for the future of healthcare and the important of the Junior Doctors Strike are analysed in more detail, will be published tomorrow.