A process of marketization has infested U.K. public services, much like the virus we are tackling today, write Dr. Sarah Gangoli and Dr. Bob Gill.
By Dr. Sarah Gangoli
and Dr. Bob Gill
Special to Consortium News
When news broke of an outbreak of a novel coronavirus infection in Wuhan, China, the world was unsure what impact this would have. We have all, most likely, been exposed to coronaviruses at some point in our lives, yet this was different. This novel pathogen had a high mortality rate, and appeared to cause acute respiratory distress. Wuhan shut down, rapidly increased critical care capacity, instituted established pandemic control measures of rigorous testing, contact tracing, quarantine and practiced social isolation and disinfection. Global travel, however, continued unhindered, as country after country reported cases and deaths.
The U.K. is now in the early stages of an exponential growth in caseload and deaths. Italy, has been ravaged by this merciless foe, its death toll exceeding China’s. Lockdown is in force in Italy, but the death rate shows no sign of abating. The army is now removing the dead from Italian cities, as people die alone, isolated and undoubtedly, terrified. This, in a country with twice the intensive care unit (ITU) capacity of the U.K.
While the U.K. government fails to heed the warnings coming from other countries, and places responsibility on confused and frightened individuals, we examine the current peril and how our National Health Service (NHS) has been left diminished and ill-equipped to deal with a challenge of this scale.
The Tory election victory in 1979 installed Margaret Thatcher as prime minister, and with her, the newly imported ideology of neoliberalism. This breathed new life into the idea that any state intervention was an assault on the rights of an individual to be poor and sick, should they so desire. Adam Smith’s invisible hand was amputated, and replaced with the uneven and unfeeling robotic limb of the market. Prior to their election, and again in 1982, papers were presented to cabinet which floated the idea of NHS privatization, in line with the mass privatization and anti-union policies laid out by Nicholas Ridley.
During a special cabinet meeting in 1982, a plan commissioned by Thatcher and her chancellor, Geoffrey Howe, suggested charging for state schooling and compulsory private health insurance. The plan explicitly admitted that the proposals would mean the “end of the NHS.” A similar document advocating NHS privatization was presented in the same year to cabinet by the right wing think tank, The Adam Smith Institute, based on the policy platform of Thatcher’s key ally and friend, Ronald Reagan.
Rather than abandon the proposals, as many in cabinet believed to be the case (such was their opposition to the suggestion that the NHS should be privatized), Thatcher embarked on a program of privatisation by stealth. The process of marketization began with the introduction of an internal market and outsourcing of non-clinical services. This normalized a market within the public sector, creating a layer of bureaucracy and necessitated expansion of management within the NHS. New Public Management infested public services, much like the virus we are tackling today, destroying them from within, and undermining public confidence. One by one they fell, the NHS left standing for yet more assaults in the coming decades.
After suffering from underinvestment under Thatcher, and an increasing administration bill, the NHS was crumbling. It required significant investment. Governments, first under Prime Minister John Major and then Tony Blair, were keen to demonstrate their restraint and prudence. The weakened NHS was to be rebuilt courtesy of the Private Finance Initiative (PFI), an instrument of financialization which ultimately serves to transfer ownership from the public to the private sector. This has proven to be a costly venture, while preserving the appearance of restraint in public spending. It has been a deliberate millstone around the neck of the NHS and resulted in debt crises for several hospitals and trusts.
Clinical Services Outsourced
Servicing the debt took priority over patient care, as further legislation during the New Labour years installed hospitals as separate business entities (Foundation Trusts), which like any other businesses could go bankrupt (Unsustainable Providers Regime). For the first time clinical services were outsourced under Blair. Profitable, routine surgical procedures were performed by the private sector, paid for at higher cost by the public purse. Bevan’s publicly provided, publicly funded NHS, was now a hybrid. The “party of the NHS,” led by someone who venerated Thatcher, was ensuring that the NHS would end up in private hands.
These years also mark an important turning point in the balance of power from clinical professionals to management. Medical training was changing. A powerful profession is not easily bullied, so doctors’ careers were to be micromanaged. Every moment of self-doubt, every small error, every attempt to draw attention to an increasingly toxic working environment, recorded, or worse. This micromanagement was introduced under the guise of improving regulation. Its purpose was to enfeeble and fragment the potential opposition from doctors. Power was now in the hands of managers, and those medical professionals who, in a desire for career advancement, would join the managerial ranks. The clinical team structure, so important to the development, support and education of doctors was eroded, while decision making power was placed in the hands of a new army of managers and bean counters.
The single most dangerous piece of legislation was yet to come. The 2012 Health and Social Care Act, passed by the Tory-led coalition government, devolved the responsibility for running the health service to a QUANGO, or quasi-autonomous non-governmental organization, now called NHS England, and decimated public health. More destructively it broke the NHS up into clinical commissioning groups (CCGs), which were now required, by law, to put their services out to tender. The structure of CCGs resembles private insurance funding pools and was an essential catalyst for the mutation of primary care into Primary Care Networks replicating the American Health Maintenance Organisations (HMO). As President Richard Nixon was told by his adviser, John Ehrlichman, in 1971:
“All the incentives are towards less medical care because the less care they (HMOs) give them (patients) the more money they (HMOs) make.”
With privatization enshrined in law, the desires expressed in that 1982 document presented to Thatcher’s cabinet, were never so achievable.
We now have an NHS in a perilous state. Administration costs have increased as the plans for privatization have advanced. From less than 5 percent of the annual NHS budget pre-1979, to now more than 20 percent, this represents a significant drain. Money being syphoned off by private providers, another drain. PFI debt repayments are crippling many hospitals, forcing bed closures and sale of land and assets. All while our population, savaged by inequality and 10 years of austerity becomes sicker. Diseases of despair, mental health problems and chronic diseases representing a deeply unequal society, place great strain on the increasingly and deliberately scarce resources of the NHS
This long process is littered with the careers of those who have tried to speak out. Professionals, either reporting a deterioration in their working conditions, or expressing concerns about patient safety have been silenced or persecuted. Silencing dissenters and deterring others is vital to ensure staff compliance through a culture of fear. As staff are silenced, patients are left without their natural advocates.
Viral epidemics are relatively common, and it has been proposed for sometime that a viral pandemic would pose a threat to human survival. In 2016 a pandemic preparedness exercise was conducted by the then chief medical officer. She reported that the U.K. lacked the necessary ventilator capacity and could not cope with the excess deaths associated with a significant pandemic. Despite this, the actions set out in pandemic preparedness reports were not implemented. So, not only are we faced with a deliberately defunded, parasitized by PFI and market bureaucracy, denuded of genuine medical control, fragmented and weakened NHS, but when told that the U.K. was unprepared for a pandemic, the government knowingly failed to act.
As this pandemic has unfolded, the newly re-elected Prime Minister Boris Johnson, who has himself tested positive for the virus, has demonstrated incompetence and misanthropy. First, the problem was ignored. When it finally became apparent that the U.K. would be significantly impacted, we were told that the strategy was to allow people to suffer and die in the interests of herd-immunity. Not only was this strategy in contradistinction to the strategies of containment adopted in other countries, it was against World Health Organisation (WHO) advice. The government then decided that this wasn’t their strategy afterall, and gaslit the population with a new plan for containment.
With mixed messaging came confusion and panic, resulting in empty supermarket shelves and fights breaking out as people struggled to understand the scale of the threat. In addition, it was becoming clear that clinicians were not being furnished with the necessary protective equipment, and the WHO’s recommendation to “test, test, test,” was being ignored. At the time of writing we are hurtling towards catastrophe, with over 1000 deaths and an unknown number of cases. We are already receiving reports of intensive care units in London at capacity, and staff at breaking point. Several healthcare workers now lie, ventilated, in those intensive care units.
When the trajectory of this epidemic is examined, it appears that we are two weeks behind Italy, which recorded its highest daily death toll on 21stMarch at 793. Italian doctors had been warning us, that their ITUs were overwhelmed, and contrary to initial reports, young people were also affected. The mortality rate in Italy is now around 9 percent. Italy has an advanced and well-equipped health service. In contrast to that of the U.K. with six ITU beds per 100,000 of the population, Italy has 12 per 100,000. Germany, which has embarked on a rigorous program of testing and containment, is reporting a mortality rate of 0.3 percent. Just as it did in 2016, the government has failed to adopt an evidence based, scientific approach.
The consequences of this are grave. There have already been deaths, and there will be many more. Healthcare workers will be dealing with exhaustion and psychological trauma, our emergency services stretched beyond their limits. Many have already lost their jobs, and many more undoubtedly will.
Johnson’s decision to prioritize the economy over people has failed both. The Sunday Times reported on March 22 that his senior aide, Dominic Cummings, said at a private engagement in February that the government’s strategy should be “herd immunity, protect the economy and if that means some pensioners die, too bad.” [Cummings has since denied he said this.]
The non-scientific, reckless and catastrophic programme adopted by the U.K. government potentially resulted in millions more COVID-19 infections, than a more evidence-based approach. Other governments chose to save lives. Johnson’s government chose to save face.
Where will this leave the health service and society? With a government introducing draconian criminal justice and immigration legislation, there can be little doubt that they will use this crisis to justify further crackdowns on civil liberties, enhanced snooping, and a fire sale of public assets. Just as climate and disease have provided opportunities for disaster capitalists in the past, so will this current challenge. The raison d’être of neoliberal overlords is to transfer assets and freedoms from the public, to the few. The end game is authoritarianism, control ensured through maintaining fear and precariousness. If we do not respond as a society, challenge the narratives of unquestioning support for government policy, and present an alternative vision for society, we will be left with a dystopia. At a time when so many are in insecure and exploitative employment, when professionals are being usurped by Machiavellian managers, we must make the case for egalitarianism and genuine social justice.
In contrast, South Korea embarked on a well-organized program of mass testing, isolation of infected people, tracing and quarantine of contacts. Health workers wearing protective equipment achieved impressive suppression of the outbreak, reducing the deaths from COVID-19 without the country resorting to a draconian lockdown. In the U.K., hospital staff working without basic protection risk becoming infected or infecting their patients, working blind due to lack of testing. Suspected mild cases sent home to potentially spread the virus to their families. The U.K. needs to immediately adopt the rigorous and effective measures undertaken in South Korea and Germany to control the spread of the pandemic and prevent the loss of life of the public but also health professionals.
Analysis and exposure of how the health service has been betrayed must continue. There should now be no doubt that a publicly funded, publicly provided, rationally organized, universal healthcare system is absolutely vital. At this time of crisis, attention of the public has been drawn to that precious jewel, now our only defense against the invisible, deadly infectious enemy. When this virus has done its worst, the fight to restore and renationalise the NHS must continue. No one should be allowed to forget that it was the principle of care without prejudice, based only on need that saved lives.
Dr. Sarah Gangoli is a Returning NHS doctor. Follow her on Twitter @SarahGangoli
The views expressed are solely those of the author and may or may not reflect those of Consortium News.
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