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BYWATERS, Paul British social policy: the case of health policy Argumentum, vol. 3, núm. 2, julio-diciembre, 2011, pp. 190-210 Universidade Federal do Espírito Santo Vitória, Brasil
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ARTIGO
British social policy: the case of health policy1
A política social britânica: o caso da política de saúde
Paul BYWATERS2
Abstract: This paper is about the targeting of the UK health service by private international health care corporations who want to get their hands on the £200b annual budget and the collusion in that project by successive governments, including the present administration led by David Cameron which is the most ideologically driven government that we have had in the UK in my lifetime – more radical in their dismantling of our welfare state than Margaret Thatcher in the 1980s but building upon her legacy. It is a tale about neo-liberalism, about the power of global business interests, about privatisation, about reducing the role of the state, and about a weak democracy. And so it is a cautionary tale about progress – even when affordable universal health care has been secured, it is not immune from attack and from being reversed. Keywords: Health policy. UK. Social policy.
RESUMO: Este trabalho aborda as medidas direcionadas ao serviço de saúde do Reino Unido por empresas internacionais de saúde, que querem colocar as mãos no orçamento anual de £200 bilhões e na conspiração desse projeto que vem de sucessivos governos. Isso inclui a atual administração de David Cameron, que é o governo mais ideologicamente impulsionado que tivemos em toda minha vida — mais radical em desmantelar nosso estado de bem-estar social que Margaret Thatcher na década de 1980, mas que é baseado no legado desta última. Trata-se de um texto sobre o neoliberalismo; sobre o poder dos interesses empresariais globais; sobre a privatização; sobre a redução do papel do Estado e sobre uma democracia fraca. Trata-se também de uma advertência sobre o progresso — mesmo quando cuidados de saúde universais e acessíveis são garantidos, eles não são imunes à reversão.
Palavras-chave: Política de Saúde. Reino Unido. Política Social.
Submetido: 21/7/2011 Aceito: 2/9/2011
1 Partes dessas reflexões foram apresentadas no 6° Encontro Nacional de Política Social em Vitória (ES) entre os dias 28 e 30 de setembro de 2011. 2 Emeritus Professor of Social Work, Coventry University, and Honorary Professor, University of Warwick (UK) E-mail:
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Introduction the world is trying to move towards universal health coverage, in England our government is pushing through he WHO World Health Report policy changes which will end universal for 2010, published last equality of access, increase costs and December, was entitled ‘Health reduce the quality of our health care Systems Financing: The Path to system. How can this be? Universal Coverage’. T
So this paper is about the targeting of the It acknowledged what the Commission UK health service by private on the Social Determinants of Health international health care corporations had said in 2008, that the circumstances who want to get their hands on the in which people grow, live, work, and £200b annual budget and the collusion in age - education, housing, food and that project by successive governments, employment and the distribution of including the present administration led power in societies - are the most by David Cameron which is the most significant influences on how people live ideologically driven government that we and die. But timely access to health have had in the UK in my lifetime – services a mix of promotion, prevention, more radical in their dismantling of our treatment and rehabilitation – is also welfare state than Margaret Thatcher in critical. the 1980s but building upon her legacy.
‘Recognizing this, Member States of the It is a tale about neo-liberalism, about World Health Organization (WHO) the power of global business interests, committed in 2005 to develop their about privatisation, about reducing the health financing systems so that all role of the state, and about a weak people have access to services and do democracy. And so it is a cautionary tale not suffer financial hardship paying for about progress – even when affordable them.’ (Executive Summary 2010) universal health care has been secured, it
is not immune from attack and from But as I started to write this paper in late being reversed. July I received an email. It was a report of a newspaper article in the Daily How does the NHS Work? Telegraph, a leading serious, right wing national newspaper in the UK, under the Let me go back a step or two to explain headline. ‘The day they signed the death to you what has been happening in the warrant for the NHS’ - the English UK. In a sense the English National National Health Service. I suspect that Health Service is the story of my life. The you will have heard much more about birth of the NHS came in 1948, the year President Obama’s struggle to improve before I was born. And the NHS was health coverage in the USA, but there is founded on two key pillars. It gives also a profound fight in the UK to try to everyone access to comprehensive health save our national health service. While 191 Argumentum, Vitória (ES), v. 3, n.2,p. 190-210, jul./dez. 2011
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care that is ‘free at the point of delivery’ an expert in the aspect of medicine that – when you go to see a doctor or a nurse is relevant. or go to hospital you do not have to pay You cannot usually go directly to a anything. And the second pillar is that hospital to see a specialist doctor unless health care is paid for out of general you have an accident or are suddenly taxation. The UK does not have an taken seriously ill. In that case you can insurance based scheme, we pay our go directly to an Accident and national taxes, and some of the money is Emergency Department in a hospital and used to pay for the NHS. And with tiny get emergency treatment. exceptions, there are no co-payments. All of this is free – no money changes When a doctor recommends that you hands between you as a patient and any take medicine or drugs you have to pay of these services and effectively the a prescription charge but this is less than doctors prescribing treatment have no £10 per go and many groups – personal interest in the cost of the pensioners, the unemployed, pregnant treatments they prescribe – they cannot women – are exempt. make more money be prescribing one form of treatment, one drug rather than At the moment, the English health another, although there are some general service works like this from the patients’ controls on this to prevent waste. And so perspective. Virtually everyone is patients can trust their doctors not to be registered with a small group of primary acting out of personal gain. care doctors, what we call General Practitioners, GPs. If you are feeling ill, There is a relatively small market in or need a vaccination or other preventive private health insurance in the UK which treatment, you simply make an is complementary to the state provision, appointment with your GP and usually buying faster access to specialist care, or see them the same day. GPs are based choice of private care provider. locally – mine is about half a mile away from where I live – and grouped in However, by 2006 only 1% of total health surgeries or clinics, usually half a dozen expenditure went on private health or so doctors with some nurses and insurance with only 10% of the other health professionals and population having some complementary administrative staff. Numerically, the private health insurance (Thomson and vast majority of health concerns for Mossialos 2009). And a larger group of which the health service is consulted are people will sometimes use private health dealt with by GPs. Some investigations – care services, paying for the care blood tests, for example – will also be themselves without insurance. done through the GP. But if you need more specialist care the GP will refer you By contrast social care – care services for to an NHS hospital where you will see adults who are disabled or with learning disabilities, and care services for older
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British social policy: the case of health policy people who are no longer able to look developed countries. It was particularly after themselves without help because effective at making access to health care they are frail or suffering from dementia, independent of how wealthy you are for example – including services (Schoen et al 2010). As Table 1 shows, provided through social workers, are this is reflected in exceptionally high mostly not free in England and are run levels of adult confidence in the NHS. in through a completely different system The UK was the only country in which to the NHS. These services are heavily more than 90% of the adults surveyed rationed in two main ways: first you said that they were conifdent that if they have to be assessed as sufficiently in were seriously ill they would receive the need to be eligible for a service, and most effective health care including secondly, any services that are provided drugs and diagnostic tests and that they through the state are means tested. Your would be able to afford any care that income is assessed and the level of was needed. Most importantly, the UK payment you make is dependent on was the only country where access to your income level. In other words it is a good quality health care was not kind of co-payments system. The significantly correlated with people’s assessment of eligibility is made by a social class or income. worker employed by the locally elected council which holds the budget for However, despite this, over the past services. Increasingly that budget is then thirty years, especially since the rise of handed to the individual to spend in the the dominance of neo-liberal economic way they want to on care services. Care and political ideologies, right wing services are now mostly not provided by critics, in particular, have raised the state but by numerous private increasing concern about the costs of the companies and some voluntary sector English health service and its quality organisations, usually charities. But (Lees and Player 2011; Reynolds et al essentially you will only get state 2011). Throughout the Conservative support for these services if you have a governments of 1979 – 1997 the NHS low income and few savings, otherwise was consistently underfunded (growing you must just buy these services at 2% p.a. compared to an OECD yourself. average over forty years of 5.5%) so that, by the end of the period, expenditure on Health Care and Health Outcomes health in the UK as a percentage of gross domestic product (GDP) was amongst The NHS system is still seen as about the the lowest in the OECD countries at 6.9% best in the world in terms of quality of compared to an average of 8.2% care and value for money. The 2010 (Bywaters and McLeod 2001). The result Commonwealth Fund International was a health service in a poor state with Health Policy Survey showed that the long waiting lists for operations and UK health service was the most cost other medical procedures alongside big efficient and high quality service of 13 and growing health inequalities and
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increased social inequalities. The state of numbers of doctors and other health the health service was one of the big professionals in training increased political dividing lines between the right greatly and waiting lists fell to the point wing Conservative party of Margaret where no one was expected to wait more Thatcher and Tony Blair’s New Labour. than 18 weeks between a referral to In the 1997 election, after 18 years of hospital from their GP and their hospital Conservative party government, the appointment. However, alongside that Labour party manifesto warned that investment in public services, which the only the Labour party could ‘save the Thatcherite conservative governments NHS’ (Peedell, 2011). After the Labour would never have implemented - party won that election, expenditure on repeated attempts at reforming the the NHS massively increased during the structures of the NHS increasingly subsequent 13 years, particularly from moved it towards privatisation – of 2000 onwards. There was a huge which more later. programme to build new hospitals,
Table 1
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So when we look at health expenditures decade we see this picture. and outcomes at the end of the last
Table 2 Health Expenditure (2008) and Outcomes (2009) Country Per capita Total Government Private Life Under 5 total expenditure expenditure expenditure expectancy mortality expenditure on health as on health as % on health as % at birth rate (per on health % of GDP of total health of total health both sexes 1000 live ($US) expenditure expenditure births) Brazil 721 8.4 44 56 73 21 China 146 4.3 47.3 52.7 74 19 Cuba 672 12 95.5 4.5 78 6 India 45 4.2 32.4 67.6 65 66 Japan 3190 8.3 80.5 18 83 3 South 459 8.2 39.7 60.3 54 62 Africa UK 3771 8.7 82.6 17.4 80 5 USA 7164 15.2 47.8 52.2 79 8 WHO Human Development Report 2010 UNDP
What this table reveals is quite a health spend is a bit over 8% of complex picture. GDP. 2. The only other country in this 1. Two countries have average life table where expenditure per head expectancies of 80 years or over on health is more than $1000US (this is data for 2008): Japan and pa is the USA, which spends the UK. Both of these countries almost twice the proportion of also have the lowest under-five GDP on health care compared to mortality rates. In each country, Japan or the UK. But in the USA total per capita expenditure on the balance of private and public health is between $3000US and expenditure is completely $4000US per annum. In both different with more than half the countries the government’s spend being private expenditure. expenditure accounts for over And despite this immense drain 80% of total health expenditure, on household expenditure the with a small private sector. In the outcomes are worse: lower life UK the % of expenditure on expectancy and higher under-five private sector went down mortality. Something like one in between 2000 and 2008, as the three of all US health care dollars government increased the spend are spent on administration and on the NHS. In each country the management costs compared to
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one in 7 in the UK (Lees and care expenditure means that most Player, 2011). people cannot afford good health care. Inequality, measured by the 3. In fact, life expectancy in the USA gini coefficient, is much higher in is comparable to that of Cuba South Africa. while under-five mortality is higher. Cuba spends about one Of course, life expectancy and infant tenth as much per head of the mortality are not primarily or even population on health services as mainly a product of health care services. the USA but gets very similar They depend in the main on the social outcomes. One big difference, determinants of health I mentioned apart from the total expenditure, earlier. That is why some countries and is in how the money is spent. In regions within countries do relatively Cuba there is almost no private well considering their wealth overall and expenditure, the state provides. their expenditure on health services while others do poorly. Societies where 4. Brazil and China also have many there is less inequality and where similarities. The average life education is universal (particularly if expectancy in 2008 and the under- women are included in compulsory five mortality rates are similar as education) do much better. is the balance of public and private expenditure. The big Japan is more equal and cohesive a difference is in the total spend per society than the UK, where inequality head and the proportion of GDP has increased greatly over the last thirty spent on health. Both are much years and hence its health outcomes are less in China. better with similar levels of spend. The USA, for all its riches, bears a heavy 5. Finally, South Africa and India price for two factors, first the very high both have much higher under-five levels of inequality for a developed mortality rates and much lower country and limited state social life expectancy. India spends very protection, and secondly, its reliance on little on health care and only a private health care providers which small proportion of that is state despite the claims for the benefits of expenditure. South Africa spends competition push up the costs in a more but the outcomes are not variety of ways, including through over- good. In both countries the investigation, over- diagnosis and over- reliance on mainly private health intervention – the profit motive meaning
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British social policy: the case of health policy that it is in the interests of providers to In the UK, the government is formed by sell people more products rather than to whichever party has a majority of seats maximise their health and well being in the lower house of Parliament, the (Reynolds 2011). House of Commons, which has over 600 MPs each of which represents a The 2010 Election and the Dismantling geographical area of around 100,000 of the NHS. population. These seats are decided on a
first past the post system, so candidates In the election of 2010 David Cameron, with 40% of the votes, or even less, the leader of the Conservative party commonly win and governments are sought to neutralise the NHS as a usually elected with a minority of the political issue by promising to keep to total votes cast. Since 1945, the the Labour Party’s spending plans and government has always been either explicitly saying that he would not carry Labour or Conservative. The third out any major top down reform. His national party, the Liberal Democrats, slogan was that the NHS was safe in the usually gets between 10% and 20% of the Conservative’s hands. And for a variety votes but wins fewer than 50 seats. of reasons, particularly the economic crisis of 2007/8 and Labour government In 2010, despite Labour’s massive mistakes, including the Iraq and unpopularity, the Conservatives were Afghanistan wars, the electorate not entirely trusted and only beat accepted these promises and voted for Labour by a small number of seats. change after 13 years of Labour government.
Table 3 Party Number of seats Per cent of vote Conservative 307 36.1 Labour 258 29.0 Liberal democrat 57 23.0
This meant that they did not have an Britain and some people thought it overall majority in the House of would act as a break on the more radical Commons and had to make a coalition neo-liberal policies of the Conservatives. with the Liberal Democrats. This was However, that has not proved to be the completely new territory for post-war case.
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Using the poor state of the economy The politics of cutting the NHS following the global financial crisis of presented some difficulties because of 2007/8, the Conservatives are pushing the promise that Cameron had made in through a raft of neo-liberal social policy the election that he would match the changes, claiming that the budget deficit Labour party’s spending plans and not means that there is no alternative. Social inflict major reform. He has claimed that security payments are being cut or their NHS spending will not be reduced, eligibility restricted (child benefit, although at the same time £20b of so previously a universal benefit for all called efficiency savings are being children is to be restricted to those required over a four year period – a level earning under about $70,000 US; of savings which have never before been sickness benefits are being withdrawn achieved and the rate of inflation built from hundreds of thousands of people into the budget is below the level of by means of a very narrowly defined test health costs. of capacity to work; working family tax But Cameron did decide to support the credits payments are being reduced). health minister, Andrew Lansley’s, long Budgets for services provided by local planned desire to restructure the NHS. authorities are being cut by up to a Again Cameron and Lansley have used quarter. These cover such services as the deficit as cover to justify reforms. But schools, roads, rubbish collection and essentially they have simply ignored the social care. The state is withdrawing promise made during the election to support for university education for the bring in the most radical changes since whole area of the arts and humanities, the NHS was founded. However, as a with university fees set to increase 300% recent analysis by Lees and Player (2011) from around $5,000 US pa to $15,000 US has made clear the groundwork for the pa for most courses from 2012. But cuts privatisation had been carried out under cover almost every area of government the previous Labour government including defence. Many thousands of prompted by powerful lobbying from jobs are being lost or have been lost private sector corporations. Tony Blair, already and pensions for public sector with successive minsters of health, had workers are under major attack. The already made the changes to the NHS economy is stagnating with virtually no which made it ripe for fuller growth over the last nine months privatisation. (http://www.statistics.gov.uk/cci/nugget. asp?id=192). What is the plan? As Pollock and Pryce (2011, 800) describe it the plan is, ‘to replace the NHS system of public 198 Argumentum, Vitória (ES), v. 3, n.2,p. 190-210, jul./dez. 2011
British social policy: the case of health policy funding and mainly public provision Primary care trusts – and public administration with a geographically based competitive market of corporate organisations which have been providers in which government finances responsible for planning and but does not provide healthcare.’ purchasing health services – are to be abolished and The precise details are profoundly replaced by GP complex, and are still changing as I commissioning consortia, write, with political opposition being which all GP practices must mounted in Parliament and outside and join. GPs are, of course, not changes being made by government in trained in these roles: public response and as they realise that parts of health, management and the plans will not work. The key planning services. GP services elements are as follows. can be run by for-profit or not- 1. Responsibility for ensuring for-profit organisations not services are provided necessarily by the GPs Secretary of State for Health themselves whose main role is (the government Minister) will treating patients. 23 for profit no longer have a direct organisations already run 227 responsibility to provide GP practices in the UK Health Services but only to (Pollock and Pryce 2011). ‘act with a view to securing’ Consortia will purchase comprehensive health services services not for all people through the NHS management within a geographical area but board. only for those patients All Trusts providing services registered with the consortia. (hospitals or community GP boundaries will be services) will become abolished so that GP consortia independent foundation trusts can take on patients wherever – effectively operating as they live ‘effectively allowing separate businesses - and patients to choose their therefore will not be directly commissioner’. This means managed by the NHS that consortia will be able to management board. advertise for and compete for 2. Planning and purchasing of patients as private health care health services corporations and insurance companies do now.
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Commissioning consortia do (eliminating national pay not have a duty to provide a bargaining). There have comprehensive range of already been talks with services but only ‘such private companies including services of facilities as it the German company Helios considers appropriate’. (Ramesh 2011). They will have There is no duty to provide a formal obligation to work equality of access to health within their budget and so services. Annual responsibility for making commissioning plans only choices about cuts is removed require attention to financial from the government and viability and ‘continuous passed to commissioning improvement’. consortia, whose Boards will Commissioning consortia will include GPs and nurses. have the power to impose Patients will not know charges for services, a power whether the recommendations which previously rested with GPs make for their care is the Secretary of State (and was affected by how much the care only used in the case of will cost and this is thought prescription charges). likely to undermine trust There are parallel plans to between patients and their bring in personal health doctors. budgets – individual budgets The provider of last resort will which create the immediate be the local council if consortia likelihood that they will be decide that providing linked to top up charges comprehensive services will through out of pocket threaten their financial payments or insurance. viability. But local councils’ As private, independent income is determined by bodies, commissioning central government, they do consortia will not be directly not have the power to raise controlled by the government extra money to spend on minister for health but will be health care even if the able to enter into contracts councillors were with ‘any qualified provider’ democratically elected under and will set terms and that mandate and they have conditions for staff
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no experience of providing place. The necessity for public health services. regulation can be challenged in court by private health care 3. Quality Control and Management companies and this is already of the Provision of Health happening. Services The cap on service provider Provider regulation will be trusts’ ability to generate overseen by a market funds by selling services and regulator called Monitor resources to the private sector whose first duty is to promote is being abolished. A cash competition. ‘The strapped Foundation Trust government’s approach is that may restrict their own services where specific control and lease its assets to private mechanisms are needed for providers to make its accounts providers, these should in balance. They may increase general take effect through access to private patients and regulatory licensing and restrict access to NHS patients. clinically led contracting Health care provider Trusts rather than the hierarchical will be able to sell, or sell and management by regions of the lease back, or raise money centre.’ (Department of Health against assets they own (up to (DH) 2010) But markets are now what the public have widely thought by economists owned). This opens the way not to be efficient and effective for private equity companies mechanisms for controlling who may be contracted to run health care. ‘When market Trusts, to take over public contracts are used to regulate resources and asset strip. providers and commissioners, New competition duties will managers have an incentive to allow remaining public exploit the information deficit controls over health services to on the part of patients and be challenged by government by reducing multinational companies and service quality in order to investors anywhere in the maximise profits’ (Pollock and world. Pryce 2011, 800). Regulation will be limited by the duty of ‘maximising the autonomy of 4. Public Health individual commissioners and Public health responsibilities providers and minimising the are being removed from the obligations placed upon them NHS and passed to local (DH 2010)’. Regulation may be councils. dispensed with as more
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Essentially, then the government’s plan of Tony Blair pressed forward with is to demolish the NHS and replace it reforms opening up the NHS to with a market for health care which will privatisation despite a commitment to be increasingly fragmented and public services reflected in the level of privatised. The pace of change is the overall NHS budget (see the detailed extremely rapid and change is always analysis by Lees and Player, 2011). Tony easier when budgets are growing not Blair propounded the idea of a ‘third when £20b is being taken out of the way’ (Giddens 1998) in which while the budget. Many experienced managerial state would still be responsible for major staff have already left the NHS, many public services such as health and services have already been transferred to education, they should be opened up to private businesses, much of the process competition and the rigours of the of establishing the new consortia has market because it was believed – against been undertaken even before the all the evidence from the USA – that the legislation which is supposed to bring market could run such services more this into being has been passed by efficiently and effectively. Major Parliament. There is the likelihood that international private health care within a relatively short period, patients providers such as United Health, in some areas will be asked for co- particularly those based in the USA, payments or offered the choice of working hand in hand with leading topping up the quality of their care and consultancies such as McKinseys, private that will inevitably create an incentive equity companies such as Bridgepoint, for extending health insurance. Given and policy think tanks such as the Kings that the NHS is the favourite institution Fund and the Nuffield Trust, had of the UK and its political sensitivity, it developed an intricate, inter-twined is an enormous political gamble that the lobbying network which persuaded Conservative Party is taking. successive politicians that the NHS should be changed from a single public organisation to a market of private How was this possible? companies operating under the NHS as a brand name or kite mark. The policy conditions under which this raft of changes has been made possible The ways in which this was done are have been established by successive multiple and complex but they involved governments since the Thatcher broadly three stages of preparation (Lees governments of 1979 – 1997. and Player 2011): Paradoxically, the Labour Government
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Openings had to be created for providing added capacity for the NHS or private companies to provide negatively as necessary to make the NHS NHS services more efficient, to provide better value The NHS had to be split up for money. There was never an open into relatively small units declaration that a market was being operating as businesses introduced into the NHS and this has The clinical workforce had to allowed the Conservative government to be detached from the NHS say with much truth that their plans are and contracted to the only a development of what Labour had individual businesses. been doing.
During the period from the 1980s What about opposition to the plans? onwards, multiple opportunities were created for private companies to take Opposition to the plans have been over different aspects of NHS care. This widespread, creative but somewhat began with such tasks as hospital disparate. The plans have been sold as cleaning (with disastrous results in terms giving control over health care to GPs, of hospital infections), and developed who command considerable public into providing front line health care respect, but a large majority of both GPs services, IT and office functions, and the doctors’ union, the British management, commissioning and policy Medical Association have rejected the making tasks. Frequently the private reforms and called for them to be sector was utterly unable to compete withdrawn rather than amended. A with the NHS on quality or price and million people marched in a special conditions were set for them demonstration against cuts in general. which were both more costly to the NHS At least two thirds of the public indicate and carried no risk. For example, where their opposition to the changes. As I private companies carried out medical write today, 150 medical experts have and surgical treatments in a contract written again to Andrew Lansley, the with the NHS they were not liable to any Health Minister, calling for the Bill to negligence claims and patients whose scrapped and pointing out its lack of treatment went wrong were simply democratic legitimacy transferred back into the NHS. (http://www.guardian.co.uk/society/2011 /sep/11/doctors-letter-resists-nhs- None of these profound changes to the reform?CMP=twt_fd ). They also cite a NHS were ever presented honestly to recent British Medical Journal poll of the electorate. They were always 1000 doctors in which 93% called for the presented either positively as quickly 203 Argumentum, Vitória (ES), v. 3, n.2,p. 190-210, jul./dez. 2011
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bill to be withdrawn. The Wake Up Call Episode 1 - No Decision Commonwealth Fund survey mentioned About Me Without Me earlier (Schoen et al 2010) found that (http://www.vimeo.com/20667467) 62% of those lay people surveyed graphically demonstrate how the public thought that only minor changes were service NHS is being dismantled and needed to the NHS, a far higher replaced with private profit making. proportion than in any other of the 13 This opposition, including the countries. The Trades Union Congress – opposition of the Liberal Democrat the national body of UK Trades Unions – party, forced the government to has led a national campaign against the announce a period of listening in April changes as have several smaller lobbying and May of this year. But the groups. There has been the usual range government put in charge of the of lobbying activities, contacting MPs, listening process, the so-called Future signing petitions, holding public Forum meetings, letters to the press and so on. (http://healthandcare.dh.gov.uk/new- The Liberal Democrat party’s grassroots forum/), a GP who was known to voted for wholesale rejection of the Bill support the government’s general and this forced the leadership to take a approach. It was clearly rigged from the stronger hand within the coalition start but nevertheless came up with government in which they are the some possibly significant findings that minority player. But the Liberal the Bill as drafted was unworkable and Democrat leadership is economically could destabilise services. Some slowing liberally as well as socially liberal – in down of the changes might be detected other words it supports privatisation. and a number of amendments are being There have been some really creative made to the Bill. But none of them will forms of opposition in which modern significantly protect the NHS from social media and the internet. At one fragmentation and privatisation. point in the campaign against Opposition to the cuts was underlined privatisation a You Tube video ‘The by two major scandals in private health NHS is not for sale’ and social care which emerged in the UK (http://www.youtube.com/watch?v=Dl1j this year. The first was the recent PqqTdNo) went viral and made Andrew collapse of the largest private provider Lansley a laughing stock. Films made of residential social care in the UK – available on the internet, such as ‘In nursing homes and residential care Place of Fear’1 homes mainly for older people – (http://www.vimeo.com/26379391)and Southern Cross. Southern Cross was 204 Argumentum, Vitória (ES), v. 3, n.2,p. 190-210, jul./dez. 2011
British social policy: the case of health policy caring for 31,000 residents in around 750 of falling occupancy levels. By the homes across the UK when its business summer of 2011 they were unable to pay model collapsed their debts and the company is being (http://www.guardian.co.uk/business/20 wound down. Blackstone floated 11/jul/16/southern-cross-incurable-sick- Southern Cross on the stock market in business-model). Most of the income 2007 one year after taking over the group from those residents actually came from and secured a profit of £1.1 billion. For the state in the form of local councils the residents and their families this has who placed the older people in the care been a long summer of insecurity. The homes. These residents have little homes are being sold on to a variety of income and little or no savings of their other providers, because someone has to own and hence their care is the care for the residents, with more responsibility of the state. In 2004 the disruption and uncertainty for residents. then medium sized provider was taken The second major scandal in private over by a private equity firm, health care this year concerned the Blackstone. Blackstone applied a quality of care. Winterbourne View is a business model in which the homes privately owned and run hospital which owned by Southern Cross - the buildings caters mainly for people with learning – were sold and then leased back. In disabilities. A BBC reporter filmed a many of these deals, the new owners of series of serious assaults and other kinds the properties built in annual increases of abuse of resident and this has led to 6 in the rental payments which would members of staff being arrested and apply whatever the state of the care charged with offences. The owners, market. Particularly after the global Castlebeck, are a private investment financial crisis of 2007/8, three major fund based in Geneva constraints affected the residential care (http://www.guardian.co.uk/society/2011 market: the budgets of local authorities /aug/17/castlebeck-care-homes-close- in England were increasingly squeezed, unit?INTCMP=SRCH). Since the abuse the numbers of older people needing in Winterbourne View was screened on care continued to rise and the costs of television, the company has been forced providing care were increasing faster to close three homes after investigation than the general rate of inflation. These by the Care Quality Commission (CQC), three factors meant that local authorities the organisation which regulates the began to refuse to pay increased fees and quality of private care homes. However, so Southern Cross began to find itself the Care Quality Commission itself has with contractual increases in rental costs run into severe criticism for failing to but a relative decline in income because
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detect and prevent the abuses from fast food chains and drinks producers taking place. The CQC, now responsible like MacDonald’s and Pepsico at the for inspection of the NHS as well as heart of the bodies advising on obesity and alcoholism while negotiating residential and social care, has had its voluntary agreements rather than legally budget cut by a third since 2009, with the binding obligations against the evidence result that many inspections are now for likely effectiveness done on paper only (http://www.guardian.co.uk/politics/201 (http://www.guardian.co.uk/society/2011 0/nov/12/mcdonalds-pepsico-help- /jun/07/disability-abuse-winterbourne- health-policy). I see this as corruption view-care-regulator- on a large scale – another sign of the weakness of western democracies. review?INTCMP=SRCH).
However, the government has continued Why was this done? to press on with the reforms, determined to make them a fait accompli by The government’s public answer to this dismantling existing structures even question is that the NHS cannot continue before the Bill becomes law. One reason as it is, given the rise in demand for this is the power of the private health especially due to increased numbers of care lobby groups. As Figure 1 indicates, older people, and the need to increase the tentacles of the private health care efficiency. The values of individual sector reach right into government and choice and economic competition are have been cultivated for many years. As often presented as the rationale for the the Spinwatch video ‘The Health changes. The reforms are talked about as Industry Lobbying Tour’ putting the NHS in the hands of GPs (http://www.spinwatch.org.uk/blogs- rather than ‘bureaucrats’ (experienced mainmenu-29/tamasin-cave-mainmenu- and trained managers), but the reality is 107/5417-take-a-tour-of-lansleys-private- that a few GPs will sit on Boards while healthcare-supporters) illustrates, the real work of commissioning will still millions of pounds have been spent be done by managerial and securing the private health companies administrative staff. These tasks are extraordinary access to the UK’s top already being outsourced to private political leaders. In return many of those companies by many GPs. These public politicians and policy advisors have excuses are just a smokescreen for the been rewarded with highly paid roles in reality of wholesale privatisation, the private companies. I see this as creation of an insurance based health corruption on a large scale – another system. sign of the weakness of western Given the political risk, you might ask democracies. Similar pro-business why this has been done. In the face of policies are now dominating the the evidence about the poor quality, government’s approach to public health. increased costs and unethical and Andrew Lansley has put multinational fraudulent behaviour of private health 206 Argumentum, Vitória (ES), v. 3, n.2,p. 190-210, jul./dez. 2011
British social policy: the case of health policy care companies (Lees and Player 2011, To make a wider point, the demise of Lister 2011), I can only see four possible the NHS reflects a profound weakness in reasons: our democracy which can also be seen in the USA. The UK has had a major public An ideological belief in the scandals over MPs fraudulent claims for market as the best mechanism to expenses, but they are nothing to the deliver efficiency and benefits from directorships and other effectiveness. payments from private interests that our A desire to transfer costs and politicians have received while in office responsibility for health care from or shortly afterwards which have the state to individuals reducing received much less attention. We have the power of the NHS as an had the scandal of phone hacking, with electoral issue which benefits the Rupert Murdoch’s News International Labour Party. Corporation spying illegally on private The power and effectiveness of individuals and public figures while the lobby built by the nexus of exerting excessive power over both the health care, management and investigations of the police and the finance companies who saw their actions of politicians. The three key opportunity to get their hands on pillars of a democracy: the rule of law, the hundreds of billions of political integrity and a free press have pounds in the NHS budget. all been heavily undermined in the past Personal greed by politicians and thirty years, with the result that the senior policy makers. Tony Blair excesses of the rich have been and successive health ministers increasingly uncontrolled while the rest have made themselves of the population pays the price. profoundly rich through politics. Alan Milburn and Patricia Hewitt, Conclusion: does it have to be like this? for example, both took on a series There is clear evidence that there is no of directorships in health related need to take this direction. The changes national and international apply to the NHS in England but not to businesses within months of the NHS in the other countries in the leaving office. Many officials in UK, particularly Wales and Scotland, the Department of Health moved which have for years pursued separate between private companies and NHS policies completely at odds with public service with little or no the UK government plans for England restriction. (Lees and Player 2011) (Lees and Player 2011). In neither devolved administration is there any
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prospect of this wholesale privatisation Of course, there are other models than and in each country the Conservative these for running effective national party forms only a small minority in the health services, but right on the English national assembly. In Scotland, the split government’s doorstep here is evidence between purchasers and providers, a key that the claim that the NHS is failing and element in creating a market in health that marketisation is the only answer is care, was ended in the middle of the last patently false. decade. The health service in Scotland What has been largely lost from view remains directly managed through Area since the Conservative dominated Health Boards with plans having been coalition came to power is any focus on introduced for the majority of Board the social determinants of health (WHO members being democratically elected. 2008) or on the social causes of health Moreover, in Scotland, personal care for inequalities. Health care in England is older people living at home is free, being commodified and privatised. instead of means-tested as in England. Health is increasingly to be seen as a Hospital parking charges have been matter of individual responsibility in abolished, there are plans to abolish which the ability to pay for diagnosis, prescription charges and the one investigation, treatment and care will independent sector treatment centre has become more and more significant. In been taken into public ownership. These this climate, while low income families measures have been achieved with and individuals are suffering most from outcomes that are at least comparable the economic crisis, inequalities in health with those in England (Lees and Player and health care will continue to increase. 2011). By the next election, whatever Wales has followed a very similar path. conclusion the electorate then comes to Again the purchaser provider split has about these changes, the NHS in been abandoned in favour of a small England will have ceased to exist as a number of geographically based Local national, publicly owned institution. Health Boards which directly plan and Notes run health services in Wales with a 1. Aneurin Bevan was the strong emphasis on public health and government minister who links with social care. Wales led the way established the NHS in 1948. In in abolishing prescription charges and 1952 he published ‘In Place of hospital parking charges and in tackling Fear’ (Quartet Books 1978), means testing for social care (Lees and including a passionate defence of Player 2011). the NHS. Widely quoted from In 208 Argumentum, Vitória (ES), v. 3, n.2,p. 190-210, jul./dez. 2011
British social policy: the case of health policy
Place of Fear is the argument that abolish the NHS in England. BMJ, n.342, ‘The collective principle asserts p.800-806, 2011. that... no society can legitimately RAMESH, R. German company involved call itself civilized if a sick person in talks to take over NHS hospitals. The is denied medical aid because of Guardian, 4 sept. 2011. Available lack of means’. in:
GIDDENS, A. The Third Way: The SCHOEN, C.; OSBORN, R.; SQUIRES, Renewal of Social Democracy. D.; DOTY M. M. et al. How Health Cambridge: Polity Press, 1998. Insurance Design Affects Access To Care And Costs, By Income, In Eleven LEES, C.; PLAYER, S. The Plot Against Countries. Health Affairs, v.29, n.12, the NHS. Pontypool: Merlin Press, 2011. p.2323-2335, 2010. LISTER, J. (Ed.). Europe’s Health For THOMSON, S.; MOSSIALOS, E. Private Sale: The heavy cost of privatization. health insurance in the European Faringdon: Libri Publishing, 2011. Union: Final report prepared for the PEEDELL, C. Global Neoliberalism and European Commission, Directorate the consequences for health-care policy General for Employment, Social Affairs in the English NHS. In: LISTER, J. (Ed.). and Equal Opportunities. London: Europe’s Health For Sale: The heavy London School of Economics and cost of privatization. Faringdon: Libri Political Science, 2009. Publishing, 2011. WORLD HEALTH ORGANIZATION. POLLOCK, A.; PRYCE, D. How the Closing the Gap in a Generation. secretary of state for health proposes to Geneva: WHO, 2008. 209 Argumentum, Vitória (ES), v. 3, n.2,p. 190-210, jul./dez. 2011
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WORLD HEALTH ORGANIZATION. WHO, 2010. World Health Statistics 2011. Geneva:
Figure 1 The Political Private Health Care Nexus From Lees and Player 2011
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