Sunday, 16 October 2011

You are the NHS

Some aspects of Wednesday's post about the NHS have surprised me by the reaction they have generated amongst readers. Some were sceptical that the NHS bill is actually going to make much difference from the patient perspective. After all, care is care, right? And anyway, others said, news stories like the recent one about the CQC inspection of hospitals show us that maybe the NHS could do with some assistance from the private sector to help raise standards.

I have a lot of friends who work directly and indirectly for the NHS. They include nurses, commissioners, analysts, care staff and more. On the basis that these people from their various disciplines will have a greater understanding of the trials and challenges facing the service than I do, I have decided to thoughtfully reflect on some of the comments they have made to me since my previous entry. I will also try to look at a few of the central tenets of the pro-bill argument, and do my best to analyse them in greater detail.

The NHS is already costing the UK more, year-on-year, as the general population increases and the baby-boomer generation approaches retirement.

Put simply, it will cost more to provide healthcare to a bigger population with a high elderly contingent. As the population grows, greater taxation will offset the effect somewhat, provided there are jobs available for the population to do. This process will self-regulate to some degree in a well-managed economy, as businesses are more likely to hire staff when labour costs are low, and pressure of increasing unemployment lowers labour costs for unskilled workers.

General government expenditure on the NHS as a % of Gross Domestic Product (GDP) has risen year-on-year from 3% to nearly 9% since the early eighties. However, the figures shown here suggest that the bulk of that increase has ocurred since 2000 and thus part of the increase shown could be a reflection of the recent economic crisis on the UK's GDP.

The graphs also show that real-term % increases on NHS spending vary wildly and tend to be lower in years when growth is stagnant in the economy. This suggests that previous governments have reflected economic pressures in their spending decisions on healthcare.

Also, there are figures available that suggest that the US healthcare system we seem eager to emulate spends more per person on healthcare than practically anywhere else in the world, but continually ranks among the lowest in terms of quality care. The conclusion we can take from this is that how money is spent is as important as how much.

If a private provider can carry out NHS work for a lower price, doesn't it make sense to let them do so?

The question to ask is WHY a private provider can do this. If the reason is a genuine one - economies of scale, access to skills or equipment that the NHS does not have as standard, then all very well and I agree that this makes sense.

However, let us not forget that private companies also have to factor in profit margins, and therefore this is not a zero-sum equation. Private sector workers work longer hours for lower rewards, have worse working conditions, reduced access to pensions, collective bargaining and so on.

These conditions create low-skilled, low-motivation workforces where mistakes are commonplace, and we should not compromise on quality of service or workers' rights to deliver lower-cost procedures.

The choice agenda means that if people prefer to use in-house NHS services, they can stil do so.

I have to confess that I've never quite understood the choice agenda. In theory, care is free to all at the point of delivery, and assuming that every area shuld have equal access to the same healthcare, why would you even need a choice? We would all simply go to our nearest health centre and get treatment later the same day.

In practise, of course I realise that things are not this simple. If you needed heart surgery and had a choice of two hospitals, one of which had a 90% survival rate and one of which had a 10% survival rate, you wouldn't need to be Einstein to make the choice between the two.

The problem I have with this is that this decision requires us to apply rationalisations without ever exploring the underlying causes for the figures. To use the above (rather fatuous) example, rather than spending money on putting an infrastructure in place to allow me to make a decision informed by nothing more than a malleable statistic, why is the money not spent making the necessary improvements to the hospital with the 10% survival rate to increase it?

To sum up - I think it's a safe assumption that people will opt for quality of care as being more important than distance to travel and that while the patient isn't paying the cost, cost will therefore be an irrelevant factor. As long as the necessary standard of care can be provided, people will not care whether their provider is a private or a public sector organisation.

The NHS shouldn't be seen as sacred - it is a means by which the government dispenses healthcare responsibilities to UK residents, and nothing more.

Oh, danger. The NHS is a national institution and internationally renowned. There are some who see it as part of a greater national identity and that is why politicians talk of it as special.

There are an awful lot of people whose limited understanding of the proposals means that they will see any suggestion of changes to the NHS as a bad thing regardless of the rationale for doing so. Additionally, people will have seen on the television and in the media that the British Medical Association (BMA) is concerned about aspects of the changes. They will see stories about practises asking for money for procedures and start to fear that they will be asked to pay to see a doctor. They will worry, justifiably, about the over-reaching powers of the competition regulator, Monitor, and the unclarified role of the Secretary of State.

As a socialist, I am concerned by this government's frantic desire to push through NHS reform without clarifying or consulting with the electorate about what they want. They use terms like 'choice' and 'consultation' wihout giving anyone a choice about what happens or paying heed to consultation outcomes.

If there is scope for improving the NHS, this is something that can be debated on a national level and agreed changes can be phased in as appropriate. We are all aware of the supposed need for austerity. This could be used as a means to make people think about the economic realities of our situation and engage them in ways to make improvements. 'So Mrs Smith, do you want us to build more hospitals or to spend billions of pounds of public funds to bail out failing private banks?'

Finally, we are quick to criticise our healthcare staff but the thankless job they do in difficult circumstances is generally an excellent one. Politicians claim the headlines and put forward consultations, initiatives and more but it is dedicated NHS workers who make sense of the chaos imposed upon them on a daily basis. We should all be thankful that they do.

Wednesday, 12 October 2011

A Bad Day In Britain

It's a bad day to be living in modern Britain. As the unemployment figures reach their highest level for seventeen years, the House of Lords has rubber-stamped the Government's plan to tender the NHS to any willing provider. Let's hope you weren't planning to get ill any time soon, because frankly, none of us can afford it.

I'm not going to go into a right wing vs. left wing debate about the merits of publicly vs. privately provided services, especially when there is plenty of scope to do that underneath the comments on the Guardian website. I especially love the trolls who comment that anyone with a public-sector ethos doesn't live in the real world and thinks that money grows on trees. All I can say by way of slightly smug response is that you can get a lot of money in the short-term by selling a goose that lays golden eggs, but that doesn't necessarily make it a good idea.

For the benefit of the lobotomised, here's a quick summary. All else being equal, if a private sector company can deliver the services that the public sector would deliver to the same standard while funding the profit margin that the shareholders demand at the same or lower cost, then you should use the private company. Otherwise, public will out.

Simple, right? A calculation that any of us could do, surely. I have spent my career watching the private sector cherry pick public services and I know that as with most things, sometimes the private sector contracts work well and sometimes they fail. I also know that the failures tend to be expensive and spectacular, and for your convenience, I have enclosed links to news items on the Connaught and Southern Cross debacles which have both directly impacted on people living in Norwich.

What is often forgotten or ignored in the midst of howling rhetoric and hysterical political point-scoring is that the true cost of such failures goes well beyond the balance sheet. How can any accountant, however skilled, put a price on the anxiety of a private sector worker with no employment protection, or an elderly person who fears they may lose their home?

As George Osborne presides over a second risky round of quantitative easing in a desperate and forlorn attempt to kick-start the economy and inflation begins to spiral upwards, the ministers in charge of the government of these isles are spending their days debating cats rather than putting their noses to the grindstone and coming up with some new ideas for creating growth and social prospects.

At the head of the table, David Cameron dons his top hat, pours tea and spouts nonsense as his unelected minions ride roughshod over public opinion with all the social grace of Panzers in wartime Europe.

An amusing image it may be, but it could soon spell the end for a free health service envied worldwide but nonetheless soon to be sold off for private profit.

Saturday, 1 October 2011

Protests in the US: Occupy Wall Street

America! Greatest of nations, shining democratic example, policeman to the world's oppressed.

What is not to love about the other green and pleasant land? Bono once said that America is more than just a country, it is a idea, and a contagious one. They are a nation that has freed slaves and torn down barbaric regimes. They gave us Hollywood, rock and roll and the great road stories of Jack Kerouac. You can have just about every kind of experience you could imagine somewhere across 50 huge states, most of which are bigger than the entire whole of the UK. It is famously described as a land of opportunity where anybody can grow up to be President, and the calm, collected black boy from Hawaii proved it to be so.

Perhaps most of all, I like Herbert Hoover's description of America as a "great social and economic experiment, noble in motive and far-reaching in purpose." It is easy as a non-American to deride the country for the things that it does badly, such as assisting the low-paid with welfare and protecting their interests politically. However, it is also easy to forget that the American principle of self-reliance makes for a resourceful and resilient people, and they are fiercely proud of their country. There is much to admire about America.

While British politics has come to be dominated by a narrow band of socialite nitwits with silly hair and no idea about the real world, American politics is about polished media excess, and despite the supposed opportunities, political office is generally reserved for those with big money, or those who can influence the same. The self-assurance of those who have influence in the world's most capitalist country is buoyed by the knowledge that there is little chance of social unrest among the populace.

However, signs are that this may not be the case for much longer. After proposed legislation in Wisconsin that would have limited collective bargaining rights, 100,000 people came out in support of state workers and the the Wisconsin Capitol building was temporarily occupied. Supportive actions were seen in every other state.

Erosion of incomes and living standards for the majority need not be a cause of great social unrest if the austerity measures employed by governments are perceived to have a fair impact upon all members of a society. But while media moguls continue to twist the truth in a harmful fashion and CEOs and top-level bankers continue to make millions, normal working people will show their anger and discontent at the skewed excesses. Is there a danger that sustained protests could strike the US this Autumn?

New York City Mayor Michael Bloomberg certainly thinks so. He suggested recently on a local radio show that students graduating college could not find jobs and that protests of the type seen earlier this year at Tahrir Square in Cairo could be replicated in American cities. There are certainly others too that believe that youth disenfranchisement could lead to despair and unrest. But at the moment, there is still a lack of will and organisation by those who are suffering and who might wish to take collective action.

That could be about to change. A trending Twitter update - #occupywallstreet - called for people to occupy Zuccotti Park in Lower Manhatten in an effort to raise the profile of the group's aims, which it claims are to defend the rights of 99% of Americans against the greed of the other 1%. Initial gatherings were broken up by police and there were arrests, but subsequent gatherings are now taking place and at least some of the protesters are there in response to the arrests made earlier. There are currently an estimated 2000 protesters in the area, with numbers reported to be rising.

If you support the goals of the Zucotti Park protesters, you can log onto Twitter, send them your support using the hashtag #occupywallstreet and spread the word about their actions. As in our own country, there are many people in the US who could benefit from hearing their voices heard, and well-supported peaceful protests to achieve specific goals for the disadvantaged majority may just inspire the noble, far-reaching outcomes that Hoover once described.