Life & Times

Debrief

The Adam Smith Institute, a powerful think The bleeding edge of tank that refuses to reveal its funders, is neoliberalism openly neoliberal. It was a significant player in the establishment of GP fundholding and Excluding vulnerable patients from the the opening of an internal market in the NHS. In June 2019, the candidates in NHS. It supports the abolition of national pay the Tory party leadership were quick to bargaining that will pit trust against trust as distance themselves from innuendo that they compete for staff. Across the board it the NHS market could be opened up advocates increased competition and private as part of future trade negotiations with provision in the NHS. the US. Yet, that hasn’t stopped us from quietly experimenting on the vulnerable Commissioning is a neoliberal beachhead. and disenfranchised. Substance misuse Substance misuse services bear the scars services were, in effect, privatised over a of long years of privatisation and we would decade ago. There is nobody to shout and do well to regard them as the canary in the scream for them. No newspaper headlines coal mine. “Yet, what’s often on excoriating the architects. Clare Gerada is a The Health and Social Care Act 2012 offer is the freedom to notable exception. In 2011, as Chair of the extended market-based approaches and College, she highlighted how users are: there is evidence that this resulted in be refused health care if ‘Rejected by the health service. They are the more contracts being awarded to private 1 the market decrees you unworthy ill.’ providers,3 although the King’s Fund has The Advisory Council on the Misuse of pointed out that overall NHS spend on private unprofitable, the freedom Drugs published a report in September contractors seems to be static at around 2017 on the commissioning of substance 10.9%.4 I remain wary of commissioning. It to be made homeless, or 2 misuse services. The findings were is an essential requirement of high-quality the freedom to be denied damning: re-procurement is damaging care primary care that we have some measure a life-saving medicine …” before, during, and after commissioning of control over the services we provide to for prolonged periods. It’s been a race to communities, yet often commissioning the bottom and short contracts perpetuate looks like a fortified neoliberal beachhead the dismal cycle. Valued staff leave the on the NHS coastline. system and barriers are created between REFERENCES We have to build the case for evidence- core NHS services for ageing users who 1. Gerada C. Making patient centered care the based policies that achieve more than desperately need high-quality primary care. imperative. Keynote speech. 16th National enriching the rich; the most vulnerable Conference: Working with Drug and Alcohol The churn has devastated continuity of care should never be allowed to be the subject of Users in Primary Care. The Public Health and, although it scarcely seems possible, Agenda: Making Patient Centred Care creeping privatisation. The UN report from marginalised this group further. the Imperative. Royal College of General the Special Rapporteur, Philip Alston, on Practitioners Sex, Drugs and HIV Group, extreme poverty and human rights found Harrogate, May 2011. The freedom to be denied life-saving that 1.5 million in the UK experienced 2. Advisory Council on the Misuse of Drugs. medicine. Neoliberalism is an all-pervasive destitution in 2017.5 He suggested the social Commissioning impact on drug treatment. creed, an ideology, and it has become so The extent to which commissioning structures, glue has been replaced by a ‘harsh and successfully ingrained into our thinking the financial environment and wider changes uncaring ethos’. It’s the inexorable logic of that we barely even acknowledge it. Since to health and social welfare impact on drug the market. We are all consumers now: misuse treatment and recovery. 2017. https:// Thatcher’s era it has become normalised. consuming goods, consuming the planet, assets.publishing.service.gov.uk/government/ Chant robotically after me: the markets know uploads/system/uploads/attachment_data/ consuming the most vulnerable. best. The central fallacy of neoliberalism is file/642811/Final_Commissioning_ This is the bleeding edge of neoliberalism that economic freedom and political freedom report_5.15_6th_Sept.pdf (accessed 9 Jul 2019). at its most pernicious. 3. A third of NHS contracts awarded since are bound together. It is a powerful message health act have gone to private sector,BMJ that resonates with many people. Euan Lawson, investigation shows. BMJ 2014; 349: g7606. Yet, what’s often on offer is the freedom to Deputy Editor, BJGP. 4. Is the NHS being privatised? King’s Fund, 2018. be refused health care if the market decrees https://www.kingsfund.org.uk/publications/ Email: [email protected] articles/big-election-questions-nhs-privatised? you unprofitable, the freedom to be made (accessed 9 Jul 2019). homeless, or the freedom to be denied a 5. Human Rights Council. Visit to the United life-saving medicine such as methadone DOI: https://doi.org/10.3399/bjgp19X704777 Kingdom of Great Britain and Northern Ireland. and die of an overdose. Report of the Special Rapporteur on extreme Powerful forces are lined up in support poverty and human rights. 2019. https://undocs. of neoliberal policies and they pose an org/A/HRC/41/39/Add.1 (accessed 9 Jul 2019). existential threat to the NHS.

390 British Journal of General Practice, August 2019