NHS SOS: How the NHS Was Betrayed - and How We Can Save It

This book is a collective project drawing on the work of numerous individuals and organisations who have been campaigning to ensure that the National Health Service envisioned by Aneurin Bevan remains a reality. The contributors to this volume are:

Jacky Davis

Oliver Huitson

John Lister

Stewart Player

Allyson M. Pollock

David Price

Raymond Tallis

Charles West

David Wrigley

Keep Our NHS Public

London Health Emergency

NHS Consultants’ Association

openDemocracy

A Oneworld Book

First published by Oneworld Publications 2013

Foreword copyright © 2013 Ken Loach

Introduction copyright © 2013 Raymond Tallis

‘Breaking the Public Trust’ copyright © 2013 John Lister

‘Ready for Market’ copyright © 2013 Stewart Player

‘Parliamentary Bombshell’ copyright © 2013 David Wrigley

‘The Silence of the Lambs’ copyright © 2013 Jacky Davis and David Wrigley

‘The Failure of Politics’ copyright © 2013 Charles West

‘Hidden in Plain Sight’ copyright © 2013 Oliver Huitson

‘From Cradle to Grave’ copyright © 2013 Allyson Pollock and David Price

‘Stop Press: The Final Betrayal’ copyright © 2013 David Wrigley and Jacky Davis

Afterword copyright © 2013 Jacky Davis and Raymond Tallis

All rights reserved

The moral rights of the contributors to be identified as the Authors of this book has been asserted by them in accordance with the Copyright, Designs and Patent Act 1988

Copyright under Berne Convention

A CIP record for this title is available from the British Library

ISBN: 978-1-78074-328-8

Ebook ISBN: 978-1-78074-329-5

Cover design by www.rooted-design.co.uk

Typeset by Tetragon, London

Printed and bound by CPI Mackays, Croydon, UK

Oneworld Publications

10 Bloomsbury Street, London WC1B 3SR

Contents

Foreword by Ken Loach

List of Abbreviations and Acronyms

Introduction by Raymond Tallis

1 Breaking the Public Trust by John Lister.

2 Ready for Market by Stewart Player.

3. Parliamentary Bombshell by David Wrigley

4. The Silence of the Lambs by Jacky Davis & David Wrigley

5. A Failure of Politics by Charles West

6. Hidden in Plain Sight by Oliver Huitson

7. From Cradle to Grave by Allyson M. Pollock & David Price

8. Stop Press: The Final Betrayal by David Wrigley & Jacky Davis

Afterword: What You Can Do to Save the NHS by Jacky Davis & Raymond Tallis

Further Resources

Appendix 1

Appendix 2

Notes

About the Contributors

For Aneurin Bevan and all those who continue the fight for the NHS

Danger of abuse in the health service is not in the way that ordinary people use the service. Abuse is always at the point where private commercialism impinges on the service – where an attempt is made to marry the incompatible principles of private profit with public service.

The solution is to decrease the dependence on private enterprise.

A free health service is a triumphant example of the superiority of the principles of collective action and public initiative against the commercial principle of profit and greed.

Aneurin Bevan, In Place of Fear

The first guiding principle is this: maximise competition ... which is the primary objective.

Andrew Lansley

‌Foreword

Ken Loach

The reform of the National Health Service is, of course, to bring it back into the marketplace and degrade it back into making health care a commodity – so it’s not reform at all.

If we don’t understand that we’ve got to do everything, up to and including breaking the law, to defend the National Health Service, then we’re finished.

First the words of a distinguished GP, then those of a former Liverpool dock worker. Across society, there is a realisation that the National Health Service is one of our greatest social achievements and that to keep it is an enormous political challenge.

This book is a weapon in that struggle. It shows how politicians of all parties, to a greater or lesser extent, have prepared the way for privatisation. It is a familiar pattern. The process in the health service began in the early 1980s, with the subcontracting of cleaning services. Why have we taken so long to respond? Are we so gullible that we believe politicians who say that the National Health Service is ‘safe in their hands’ when all the evidence is to the contrary?

In order to fight back, we need to understand the reasons for the attack on the NHS. This is an ideological issue. If it were simply a matter of finance, there are solutions to hand. There are billions of pounds in unpaid and uncollected taxes. Trillions, we are told, are kept off shore, beyond the reach of national governments. The wealth that is created by the work of ordinary people is siphoned off so that it cannot be used for the common good. If the political will to sustain a publicly funded health service existed, a way would be found.

It is a battle for ideas. To some, the drive for profit is a necessary discipline. Private business will see a need, provide the service in the most cost-effective way and make money in the process. Greed is good. When everyone pursues their own self-interest, so the theory goes, we all benefit.

Except that we don’t. When the need can’t yield a profit, the need goes unanswered. The health service and care services are full of examples of where people’s requirements are not met. All who work there could fill many pages with stories. Further privatisation will widen the care gap and the so-called austerity programme diminishes every aspect of our life.

The resistance to this has been very weak. Those organisations that should be our first line of defence have let us down. The trades unions, crippled by Thatcher’s government and abandoned by the Labour Party, have barely made an intervention. The Labour Party itself has followed the same path as its Tory predecessor in government. While trying to present a more humane face, it has continued the policies of privatisation and deregulation. When Labour adopted the slogan ‘Labour Means Business’ it was not immediately apparent that it was meant literally.

This has left a political vacuum. Who puts forward the idea of working together for the common good? That we should be our brother’s and sister’s keeper? That we have the technology and the knowledge to provide a decent life for all but we are in the grip of an economic ideology that makes that impossible?

There is a fight-back taking place across Europe. Strikes and direct actions are seen in the countries hit hardest by mass unemployment and other consequences of economic failure. In Greece, France and Germany there are new political movements on the Left, putting forward alternatives. It has not happened yet in Britain. When people ask who they can vote for to defend the NHS, what do we tell them?

This book explains how current politicians have betrayed the principles of the NHS. In my view they are not worthy of our vote. If ever there was a time for there to be a broadly based movement, democratic and principled, which stood for the interests of the people against the demands of business and the politicians who speak for them, that moment is now.

‌List of Abbreviations and Acronyms

ACEVO Association of Chief Executives of Voluntary Organisations

APMS Alternative Provider Medical Services

ARM Annual Representative Meeting

BMA British Medical Association

BMJ British Medical Journal

CQC Care Quality Commission

CCG Clinical Commissioning Group

CCP Co-operation and Competition Panel

DoH Department of Health

EGM Extraordinary General Meeting

FESC Framework for Procuring External Support for Commissioners

FT Foundation Trust

GPC General Practitioners Committee (of the BMA)

GPCos GP Provider Companies

HMO Health Maintenance Organisation

ICO Integrated Care Organisation

IPA Independent Practitioner Association

ISTC Independent Sector Treatment Centre

KONP Keep Our NHS Public

LHE London Health Emergency

LIFT Local Improvement Finance Trust

MCO Managed Care Organisation

NAPC National Association of Primary Care

NHSCB NHS Commissioning Board

NLN National Leadership Network

OFT Office of Fair Trading

PCT Primary Care Trust

PFI Private Finance Initiative

PHO Physician Hospital Organisation

PPG Patient Participation Group

QIPP Quality, Innovation, Productivity and Prevention

RGCP Royal College of Psychiatrists

RCGP Royal College of General Practitioners

RCM Royal College of Midwives

RCN Royal College of Nursing

RCP Royal College of Physicians

RCOG Royal College of Obstetricians and Gynaecologists

RCS Royal College of Surgeons

SHA Strategic Health Authority

‌Introduction

Raymond Tallis

The only thing necessary for the triumph of evil is that good men do nothing.

Edmund Burke

This book was conceived in desperate circumstances. In the summer of 2012 I attended the British Medical Association (BMA) Annual Representative Meeting (ARM) for the first time, in order to put forward a motion related to legislation of assisted dying. Three months earlier, Andrew Lansley’s Health and Social Care Act had been passed in the House of Commons after a very protracted and bumpy ride (as Dr David Wrigley will describe). In the packed hall there was an attempt by one or two brave souls, including my co-editor, Dr Jacky Davis, to hold the BMA to account for its ‘too little, too late’ gestures towards opposing Lansley’s bill. The debate was largely procedural, intended to make sure that no one was held responsible, and to deflect attention from the main issues. It was worse than uninspiring. Is this the best that the profession could do, I thought, when required to respond to the greatest threat to the health and well-being of the patients they are supposed to serve since the birth of the NHS?

On the second evening of the ARM, in deep despair, I decided to follow Jacky’s advice to attend a fringe meeting at a pub near the conference centre. The contrast with the main event could not have been greater. There were about twenty people (half a dozen of them speakers) in a little back room, as opposed to the many hundreds in a beautifully appointed hall. The atmosphere was informal as opposed to the highly choreographed, closely scripted and minutely regulated show I had been sitting through earlier in the day. However, there was a more profound contrast. First, it was obvious that those who were present cared for the NHS and were enraged at what was going to happen to it. Second, the speeches, often given with the minimum of notes, were searching, well informed and impassioned. I had moved into another world, a world of which the medical profession was once a part.

The two hours I spent listening to the speakers was a crash course in what remained of principled medical politics. For the first time, I was able to see clearly how a toxic bill that few had foreseen and no one other than its proponents saw as desirable, even less necessary, had got on to the statute book. I felt that what I had learned in that small room should be more widely publicised. It seemed as if there were the makings of a book. I arranged for a few people to meet together for an early breakfast a couple of days later. And so began the process that led to NHS SOS.

This book is about the betrayal of the NHS – and of the people who depend on it for health and health care – by politicians, journalists, the unions and, perhaps most culpably, the leaders of the medical profession. Without the active collusion, passive acquiescence or incompetence of all of these players it would hardly have been possible for the Tories – who did not command a majority in Parliament – to have succeeded in getting Andrew Lansley’s nightmare vision for the NHS enshrined in law. After all, prior to the 2010 election, the Tories had promised to defend the NHS not only from cuts to its budget but from the continuous redisorganisation that successive governments had inflicted on it over the preceding decades. This had been reaffirmed in the Coalition agreement: ‘we will stop the top-down reorganisations of the NHS that have got in the way of patient care’.‌¹

Within a few months, the Coalition was boasting of the most radical shake-up of the service since 1948, the mother of all top-down reorganisations. This would be hugely destabilising and expensive,‌²

at a time when, according to Sir David Nicholson, the NHS chief executive, the service would have to make £20 billion of efficiency savings in four years. Nor had any of the political parties given a hint in their manifestos that they would open up the NHS to wholesale privatisation. The impression from the Tory manifesto had been that the NHS would be financially protected – with increased spending year on year (a promise broken) – and otherwise left well alone. It was evident, however, that the plans had been in preparation a long time, though, as Nicholas Timmins has discovered, Lansley was banned from talking about them ahead of the election.‌³

Such blatant deception, such chutzpah, such contempt for the electorate, should have meant that the bill was doomed. While its passage to the statute book required (as Edmund Burke might have said) that good men should do nothing (or, with a few exceptions, very little), many other conditions were required, as described in the pages of this book. While each of these conditions was individually outrageous, the fact that they were able to come together to deliver the planned destruction of the NHS says something shocking – about the condition of the nation, the pervasiveness of corruption, the debased state of the national conversation about matters of supreme importance, and the marginalisation of professionals who, when faced with the greatest threat for generations to the institution and the values for which they claimed to stand, in most cases preferred appeasement to confrontation, insisting that the latter would be pointless.

While much of NHS SOS is about the failure of those who should have sunk the bill – their failure to oppose it effectively, or even with conviction – it is important not to forget that Andrew Lansley’s vision had its advocates. There have always been those to whom the very idea of universal health care publicly funded, publicly delivered and publicly accountable is repugnant, and would remain so, even if it were shown that such services were the most effective, cost-effective and popular mode of delivery. While attachment to the NHS has often been described as ‘religious’, hatred of state-provided and state-funded services qualifies more fully for the status of an article of passionate faith. The recent release of the 1982 Cabinet papers shows how the ‘mild-mannered, courteous’ Geoffrey Howe and his leader Margaret Thatcher dreamed of ‘dismantling the welfare state’, accepting that this would be ‘the end of the NHS’.‌⁴

This caused a near riot in the Cabinet, not because it was a wicked plan – which it was – but because it was deemed ‘politically toxic’. It took another thirty years of neoliberal consensus thinking, as described by Stewart Player, for this to become thinkable. As Ken Clarke said in 2008:

Labour secretaries of state have got away with introducing private sector providers into the NHS on a scale which would have led the Labour Party onto the streets in demonstration if a Conservative government had ever tried it. In the later 1980s I would have said it is politically impossible to do what we are now doing. I strongly approve.‌⁵

It was still unacceptable to the vast majority of those who provided and used public services. Moreover, in 2009 Andy Burnham, Secretary of State for Health before the Coalition, made up for some of the sins of his predecessors in the Labour administration by making the NHS the service’s ‘preferred provider’. Consequently, deceit was still necessary and, when the Lansley plan was eventually brought into the open, it had to be spun. Doctors and patients were to be reassured by politicians presenting the key aim of the bill as putting the clinicians, notably GPs, in charge of health service budgets and what they were to be spent on, and, naturally, to ‘increase patient choice’. Just how far this is from the truth is set out in terrifying detail in chapter 1 (Breaking the Public Trust) by John Lister, and in chapter 7 (From Cradle to Grave) by Allyson M. Pollock and David Price. That this spin was not adequately challenged, or even critically examined, in the mass media is an outrage, as discussed by Oliver Huitson in chapter 6 (Hidden in Plain Sight).

There were several potential sources of opposition to Lansley’s bill which, if fully mobilised, would have prevented its passage. These were the medical profession, non-Tory politicians and the media.

The health care professions were best placed not only to understand the true implications of Lansley’s Health and Social Care Bill but to influence public and parliamentary opinion against it. The Royal College of Nursing made its hostility very clear but it was the doctors whose views would carry most authority in the public mind. After all, Lansley’s assertion that his bill would put clinicians in the driving seat would look rather strange if the majority of doctors said either that they didn’t believe him, or that they didn’t want to be running NHS budgets and were unqualified to commission services for populations. Unfortunately they, or at least their leaders, failed abjectly to oppose the bill effectively until it was too late, as Jacky Davis and David Wrigley reveal in chapter 4 (The Silence of the Lambs).

As Davis and Wrigley discuss, of the doctors who very much liked the idea of a service where they had control of the budget, some were motivated by altruism and others by self-interest. For some, to be blunt, the blatant systemic conflict of interest in providing services that they would themselves commission was embraced as an opportunity for personal enrichment. Greed was the spur. They were in a minority but they had disproportionate influence because they were pro-market and pro-GP commissioning and so had the government’s ear. It would be interesting to know how much gold had been promised to stuff in the insatiable mouths of certain doctors. The rewards would come quickly. A survey in Pulse – the GPs’ magazine – reported that by December 2012 over one-fifth of board members on clinical commissioning groups had financial interests in private health care providers; the BMJ put the number at more than one-third in March 2013.‌⁶

Things are looking good for Dr Fat Cat.

Greed was not the main reason for the failure of many to question Lansley’s bill before it was too late. After all, as I shall discuss, the most powerful, articulate and sustained opposition came from the Royal College of General Practitioners (RCGP), who looked at first as having the most to gain. No, there was a deeper malaise in the medical profession.

The political class has, over the last few decades, regarded doctors with increasingly open contempt. Instead of being respected as patients’ advocates, and as having unique expertise in the best ways to care for patients and the best context in which that care might be delivered, they are portrayed as instinctively conservative, irrationally opposed to change, unable to see the need for it and obsessed by their own perceived self-interest. This has resulted in a progressive marginalisation of the role of doctors in the process of reshaping the services within which they work. Of course, each administration has found a sufficiency of useful idiots within the profession to act as cheerleaders for whatever idea crosses the mind of an ambitious Secretary of State. They are rewarded by flattery, first-class fares, gongs,‌⁷

elevated office and financial opportunities. But the majority of doctors have gradually drifted to the margins of decision making, doing their best to work with whatever ill-thought-out ideas are foisted upon them by Whitehall.

I discussed the first twenty years of the marginalisation of the medical profession in Hippocratic Oaths: Medicine and Its Discontents, published just under a decade ago. Successive redisorganisations have further reduced the influence of the medical profession. In the late 1990s and early 2000s the opportunistic exploitation by politicians, most notably Alan Milburn, of medical scandals such as the problems with heart surgery in Bristol, the retention of organs at Alder Hey hospital and the mass murders by Harold Shipman, placed the profession on the back foot. Treating these episodes as symptomatic of a profession that was arrogant, dangerous and unaccountable was very damaging to its reputation.

Not everyone bought that image of the profession carefully fostered by politicians. As shown in poll after poll, doctors remain highly trusted – in contrast to politicians. Even so, the ‘managerialism’ in the NHS, which has progressed remorselessly since the first steps were taken in 1983 with the recommendations made by Roy Griffiths, has reduced many doctors to mere sessional functionaries. They are concerned to deliver on contracts narrowly defined, and less exercised by larger issues such as the context in which care is delivered and the health of the nation. Brian Jarman, in a recent article,‌⁸

which should be required reading for anyone concerned about the health of the NHS, has examined the long-term effects of ‘managerialism’, most notably an imbalance of power between doctors and managers. Managers have considerable influence on the funding of hospital and other units, appointments to posts within hospitals and pay rises through the clinical excellence awards. They can refer doctors to the General Medical Council and there is no redress for groundless referral. Whistle-blowing doctors may be dismissed and, with their cards marked as troublemakers, they may find it difficult to obtain further employment in the NHS. (The Francis Report identified this as an important factor in the silence of doctors in the face of the wholesale abuse of patients in the Mid Staffordshire NHS Foundation Trust.) The Department of Health has spent very large sums of money on ‘gagging agreements’ for individuals dismissed from the service. A ‘culture more of fear and of compliance, than of learning, innovation and enthusiastic participation in improvement’ was identified in a report commissioned from Joint Commission International (an authoritative body on accrediting health care institutions).‌⁹

Needless to say, this report was dismissed and deep-sixed by the Department of Health. David Nicholson regarded it as ‘insignificant’, which makes his very long tenure as CEO of the NHS easier to understand. It was exhumed only in response to a request under the Freedom of Information Act. Managers on the ground – many of whom are deeply committed to patient care – are themselves equally the victims of the ‘top-down and bullying culture’.‌¹⁰

These trends have been exacerbated by the casualisation of the medical workforce and those pressures that Colin Leys identifies to make them become businessmen and -women, and which are described by Stewart Player in chapter 2 (Ready for Market).‌¹¹

‘Corporatising the NHS’ requires instilling the corporate ethos into its workforce and replacing the fundamental idea (or at least ideal) of the professional as one who is bound by covenant to those he or she