LENIN'S TOMB

Monday, April 02, 2012

The privatization of the NHS posted by Richard Seymour

My latest for ABC Australia:

The rich want healthcare. Believe them about this. They want hospitals, doctor's practices, insurance, patient care, pharmaceutical provision, all of it.
Last year, four out of the 10 most profitable industries in the US were healthcare-related. This was due to the fact that these industries were providing services rather than more tangible products, thus keeping overheads low, and the fact that the services were, in the sickly phrase of Forbes magazine, "need-to-have". That is, compulsory. Need to have, or you'll die.
This is why healthcare is such a prized asset for businesses, and why they are desperate to crack open health sectors globally. And it is one reason why the British coalition government is undertaking the most fundamental demolition job on the National Health Service since its foundation in 1948.

Labels: capitalism, health care, neoliberalism, new labour, NHS, privatisation, tories

Thursday, March 29, 2012

A short history of privatization in the UK posted by Richard Seymour

My latest in The Guardian explains the course of privatization over the last thirty years or so:

Royal Mail is being auctioned, and not necessarily to the highest bidder (and stamp prices are going up). The London fire brigade is outsourcing 999 calls to a firm called Capita, at the behest of the oleaginous chair of the capital's fire authority, Brian Coleman. Multinationals are circling hungrily around NHS hospitals. Schools are already beginning to turn a profit. In the technocratic nomenclature of the IMF, this would be called a "structural adjustment programme", but that doesn't really capture the sweeping scale of the transformation. We can see this through a potted history of privatisation in the UK...

Labels: accumulation-by-dispossession, austerity, capitalism, education, fire brigade, neoliberalism, new labour, NHS, privatisation, public services, royal mail, tories

Monday, May 16, 2011

The Tories and the NHS posted by Richard Seymour

The NHS has always been a vulnerable point for the Tories. They neither like nor trust what it stands for, how it works, but cannot assemble a viable coalition in favour of its destruction. Today, David Cameron has attempted to justify the present government's privatizing measures by claiming that they are the only way to meet a funding crisis that will hit the service in the next few years. That is, they intend to underfund the system by at least £20bn by 2015, and claim that the dire effects of this can only be avoided through their 'reforms'. But note what they're not saying. This is David Cameron's explanation:

"If we stay as we are, the NHS will need £130bn a year by 2015 – meaning a potential funding gap of £20bn.
"The question is, what are we going to do about that? Ignore it? No – because we'd see a crisis of funding in the NHS, over-crowded wards and fewer treatments. Borrow more so we can chuck more money at it? No – because we can't afford to.
"Ask people to start paying at the point of delivery for it? No – because, as I said, the NHS must always be free to those who need it. There's only one option we've got, and that is to change and modernise the NHS to make it more efficient and more effective and, above all, more focused on prevention, on health not just sickness.
...when I think about what our NHS will look like in five years' time, I don't picture some space age institution, a million miles away from what we have now. Let me make clear: there will be no privatisation, there will be no cherry-picking from private providers, there will be no new up front costs people have to pay to get care."

This is obviously disingenuous. There will be privatization, and it will not make the service more efficient, either in terms of cost or patient outcomes. And the claim that this new system will look anything like the one we have now is a ham-fisted insult to reason. But the Tories are not seriously attacking the 'common sense' of the NHS. At the level of discourse, they are not making any inroads whatever into the principle of a taxpayer-funded, free national healthcare system. They dare not even try. Instead, they depend on a manouevre pioneered by Thatcher, that of exploiting a crisis of underfunding to argue for the reforms they want to see, which are then coded in apparently neutral, anaesthetizing phrases: not privatization - good heavens no! - efficiency. This is Stuart Hall writing back in 1988:

Mrs Thatcher has personally taken charge of the crisis - always an ominous sign. 'The impression which the prime minister was trying to create was that she was pleased that talk of crisis by the opposition and health professionals had opened up the NHS to her radicalism. Her spokesmen countered the impression of government panic by stressing that she was "seizing the tide of public perception"' (The Guardian Jan 27). The talk is now exclusively about 'alternative ways of funding' (which every post-Thatcherite child of nine knows is a code-phrase for the massive expansion of private medicine and privatisation within the NHS) and 'breaking the barriers to greater efficiency' (which we know is a codephrase for destroying COHSE and NUPE).
...
the balance of ideological advantage slowly turns Thatcherism's way, because the specific issue of the NHS is secured for the Right by a deeper set of articulations which the Left has not begun to shift. These include such propositions as: the public sector is bureaucratic and inefficient; the private sector is efficient and gives 'value-for-money'; efficiency is inextricably linked with 'competition' and 'market forces'; the 'dependency culture' makes growing demands on the state - unless ruthlessly disciplined - a 'bottomless pit' (the spectre of the endlessly desiring consumer); public sector institutions, protected by public sector unions, are always 'overmanned' (sic).; 'freedom' would be enhanced by giving the money back to the punters and letting them choose the form and level of health care they want; if there is money to spare, it is the direct result of Thatcherite 'prosperity'; and so on.
...
We may have to acknowledge that there is often a rational core to Thatcherism's critique, which reflects some real substantive issues, which Thatcherism did not create but addresses in its own way. And since, in this sense, we both inhabit the same world, the Left will have to address them too. However, squaring up to them means confronting some extremely awkward issues. One example is the fiscal crisis of the welfare state - the ever-rising relative costs in the NHS as the average age of the population rises, medical technology leaps ahead, health needs diversify, the awareness of environmental factors and preventive medicine deepens and the patterns of disease shift. The fiscal crisis of the welfare state is not simply a Thatcherite plot, though of course Thatcherism exaggerates it for its own political ends.
The Left's answer is that there is more to spend if we choose; and this is certainly correct, given Britain's pitiful comparative showing in terms of the proportion of GDP spent on health amongst the industrialised countries. But only up to a point. At the end of this road, there are limits, which are not those set by Thatcherism's artificial 'cap' on spending but those limits set by the productivity of the economy itself. What the Right argues is that, once this limit is reached (even at the USA's 10.7% rather than the UK's miserable 5.9%) there is then not much to choose between rationing by price (which they would prefer) and rationing by queue (which is what has been going on in the NHS for decades). Naturally, they prefer rationing by price, since it increases the incentive to the patient to save on costs and puts pressure on the 'health market' to become more efficient.
...
simply 'spending more on the NHS' comes up against the barrier of the failure of the Left so far to elaborate a strategy for an expanding economy. On the other hand, where it hits the road block of the unpopularity of higher taxation in the form of that entrenched figure (which, at the moment, belongs exclusively to the Right) - the 'sovereign taxpayer'. Thatcherism is also held in place by this ideological figure of 'economic man', the measure of all things, who only understands cash-in-hand, readies-in-the-pocket, and who apparently never gets ill, doesn't need his streets cleaned or his children educated or to breathe oxygen occasionally. Clearly, the NHS issue cannot be won in terms of the NHS alone. If Thatcherism wins the argument about 'wealth creation', 'prosperity' and 'taxpayer freedom', it will, sooner or later, win the argument about privatising the NHS.

Now, it so happens that Hall exaggerated the popular appeal of Thatcherism, and over-estimated their ability to erode public support for socialised health care - but discount for it and the same issue looms before us. Look at that last sentence from Hall again. If the Tories win the wider argument about austerity, they may not win the argument for privatising the NHS, but they will certainly make their case for this vandalism more plausible. The austerity narrative says that the state has over-extended itself and must contract to a more manageable scale; that the productive capacities of the economy are being over-burdened by the high taxation needed to support the welfare state; that prosperity can only be restored if business is allowed to get on with investing under relaxed conditions (albeit with some safety barriers built in to the financial sector in a vain attempt to protect the system from its instability). Naturally, therefore, "we can't afford" to pay for the NHS. The obvious lessons are that the Left, to counter this, has to have an alternative growth strategy, and; this has to be elaborated in an unabashedly ideological way, because what is at stake isn't just a bureaucratic-managerial matter of efficiency but rather of the priorities and direction of the whole society. I think there may be some in the Labour leadership who understand this, but they are no more able to act on this understanding than Gordon Brown was capable of being the 'secret socialist' of reactionary nightmare and centre-left masturbation fantasy.

I select the NHS to focus on because, apart from the fact that Cameron has made this intervention today, it's the Tories' weakest point, the issue on which we can assemble the broadest social forces. The middle class suburbs are up in arms about what's being done to healthcare every bit as much as working class boroughs. The Tories have already had to retreat on this, and the issue divides the coalition somewhat. We have them beating a tactical retreat before a serious shot has been fired. Yet, if what Hall referred to as the "political-ideological thematics of Thatcherism", which today are concentrated in the politics of austerity, remain in place, then they will be able to continue to come back for more. Even if the Tories do not succeed in getting all that they want, they will gradually get some more of what they want; and more importantly, they will find that their occupancy in power is not disturbed by their losing an election. New Labour, operating within a broadly Thatcherite mode, took the logic of privatization and marketization in the health service further, faster, than the Tories had been able to. Labour's leaders today cannot think or articulate a politics outside of austerity, which leave us with a desperate need for a counter-hegemonic campaign to do just that.

Labels: coalition, counter-hegemony, david cameron, hegemony, labour, neoliberalism, new labour, NHS, socialism, thatcherism, the meaning of david cameron, tories

Tuesday, February 01, 2011

Exactly posted by Richard Seymour

"If we listen to lulling consensus from the career-oriented left the best we will get in 2015 is a slightly kinder, gentler neoliberal party presiding over a country dominated by a bloated and larcenous financial sector. The NHS will have been privatized and the rest of the public sector shattered and opened up to profit-taking by corporations on a vastly greater scale."

Labels: capitalism, finance capital, left, neoliberalism, NHS, privatisation, socialism, tories

Tuesday, August 10, 2010

NHS shock doctrine posted by Richard Seymour

The NHS support federation has a statement on, and petition against, the government's NHS white paper. Here's a video that roughly explains what it's all about:

Labels: 'free markets', capitalism, health care, neoliberalism, new labour, NHS, socialism, tories

Tuesday, July 13, 2010

Tory shock therapy for the NHS is an attack on democracy posted by Richard Seymour

This is the shock doctrine in action. What with the recession and the barrage of propaganda misdirection, and with relatively little militancy in response to job losses and pay cuts so far, the Tories are hoping that people are too busy worrying about their jobs and houses to notice most of what they're doing - such as the latest example redistribution of wealth from the poor to the rich, and the neoliberal reforms of the NHS, which are tantamount to a massive privatization drive. Last year, when the NHS was under attack by the American right, David Cameron had to defend it. Now, the government is on the attack:

Announcing his plans, Tory health secretary Andrew Lansley this week said that he wants 80 percent of the NHS budget to be allocated to businesses run by groups of local GPs.

Local primary care trusts and strategic health authorities, which currently buy services for patients, would be abolished.

“These proposals have nothing at all to do with patient care, and everything to do with the needs of big business,” says Gill George, a health worker and member of the Unite union executive.

Lansley claims that his changes would benefit ordinary people by removing key decisions from “faceless bureaucrats” and decentralise power.

But far from making the NHS more democratic, the Tory plans are a ruse for handing yet more of the health service to private firms.

Indeed. The manner in which the ConDem government is attempting to sell neoliberal measures - which are profoundly anti-democratic in taking more and more of the public sector out of the sphere of democratic accountability - as progressive, empowering and democratising, is one of the most insolent and absurd aspects of modern political communication. Privatization, and the neoliberal praxis in which it is embedded, is an attack on democracy. As I have argued elsewhere, this adaptation of the language of progress for regressive ends has a prehistory in the origins of conservative thought, and particularly in the roots of neoliberal ideology.

In this case, the Tories argue that doctors know better than bureaucrats how to run healthcare, and that they intend to entrust decisions over treatment to healthcare professionals. Leaving aside the fact that it will be private firms rather than GPs that take over the running of health trusts - most doctors aren't actually specialists in procurement and health management - this defer-to-the-experts line is in fact a technocratic, rather than democratic, argument, and it runs counter to what makes the NHS a relatively democratic institution. It is because the National Health Service is one of the great achievements of socialism that it has been one of the more democratic aspects of the British state since its inception. This is because democracy is inherently collectivist and egalitarian. Everyone from whatever background has access to treatment when they need it. Relatively impartial information about medical choices is freely available. There is no bill at the end of treatment that would dissuade anyone from seeking treatment just because they're poor, and the tax system that pays for it is modestly progressive. And the NHS is a public good subject to the oversight of elected officials - that's democracy, and it means that 'bureaucratic' oversight is a good thing. In all, for all its flaws, and for all that it has been run down by mismanagement and under-funding, the NHS probably represents the zenith of democratic collectivism in Britain. This is why the NHS is arguably Britain's most popular institution.

The introduction of various charges and, more significantly, various market-based mechanisms has undermined the democratic element of socialised healthcare a bit. The market-based mechanisms contributed to the creation of a 'postcode lottery', for example. But this only marginally undermines the NHS and not nearly enough for the Tories and their Liberal allies. Luckily for them, New Labour began to lay the ground for a new way of running things when they published their plans to break-up and privatize NHS delivery back in 2008. The New Labour argument was always that as long as the treatment was high quality, and as long as it remained free at the point of delivery (well, they did dabble with the idea of charges for appointments with GPs), then there was nothing to worry about. So, they introduced Private Finance Initiatives, using private capital to build new hospital projects, and allowed private firms to compete for cleaning contracts etc. PFIs massively increased costs and ultimately caused the fiscal crisis of 2006, while the privatization of cleaning services led to MRSA. Not to be deterred, Lord Darzi signalled New Labour's determination to continue with privatizing, allowing the funding base to be administered by private firms, and by abandoning the principle of universal coverage set out to entrench legislative principles that would allow them to introduce charges and levies, and restrict care - a freedom which the NHS does not presently have. The basis for restrictions was provided by the disaggregation of NHS service provision into three levels of care: core, additional, and enhanced services. There would be nothing to stop a commercial provider restricting access to care classified as 'additional' or 'enhanced', or charging for it.

Now, radicalising New Labour's proposals, the Tories are going to allow commercial enterprises to administer up to 80% of the NHS budget. They can't very well sell their policy on the grounds of efficiency. Market-based reforms previously introduced have already created new layers of bureaucracy, resulting in - as I pointed out previously - a rise in administrative costs from about 5% of overall budget to 12%. In the private hospitals, administrative costs account for 34% of their total budget. The more the NHS is forced to imitate the private sector, the more administrative costs will rack up. This means less and less funding available for patient care. This is 'efficient' in the sense that Nick Clegg is Noam Chomsky. Coming alongside cuts (don't be fooled by the claims of 'ringfencing' - all local trusts know that cuts are coming and are preparing for it), these reforms mean that the NHS as a service free at the point of delivery, providing quality all-round care for all, is under serious attack. This is being promulgated alongside Michael Gove's attempt to roll back a public, comprehensive, democratically accountable education system. This isn't happening because of the deficit, it isn't happening because people want it, least of all is it happening because of the result of the 2010 general election - please let us be spared that insult. It's an attack on the welfare state, it's an attack on the working class, and it's an attack on democracy. It's time for a democratic revolution.

Labels: capitalism, democracy, health care, inequality, neoliberalism, NHS, socialism

Friday, August 14, 2009

America needs humanitarian intervention posted by Richard Seymour

One enjoyable side-effect of the campaign by lefties, liberals, celebs and so on to defend the NHS against the American right is that even the Tories have to come out for it. In truth, the Conservative Party likes the NHS as much as Harold Shipman doted on old ladies, but it is good to see them whipped into line. One doesn't have to be press-ganged into any sentimental bullshit about 'our national treasure' to see the good in this. But it's not enough to just defend the principle of socialised medicine from afar. The Fabian blog 'Next Left' has been digging up some interesting facts on health outcomes in the US and UK, and has found the following:

US residents are much less healthy than their English counterparts and these differences exist at all points of the SES distribution ... The US population in late middle age is less healthy than the equivalent British population for diabetes, hypertension, heart disease, myocardial infarction, stroke, lung disease, and cancer ... These differences are not solely driven by the bottom of the SES distribution. In many diseases, the top of the SES distribution is less healthy in the United States as well. [Emphasis added by Next Left]

And more:

With the sole exception of cancer, there exists a sharp negative gradient across both education and income groups in both countries ... As a result, country differences are larger and tend to be more statistically different at the bottom of the social hierarchy than at the top. Level differences between countries are sufficiently large that individuals in the top of the education and income strata in the United States have comparable rates of diabetes and heart disease as those in the bottom of the income and education strata in England."

It's not just that the NHS outperforms the US on most health outcomes. What leaps out at one is the way in which class amplifies the differences. America's psychopathic healthcare system is sacrificing tens of thousands of lives, mainly working class and African American, for the sake of profit. Health advisors and boards of trustees routinely kill people, knowingly, to defend the bottom-line. Right now, those who are scaremongering about the NHS are lobbying vehemently to ensure that nothing about this vile state of affairs ever changes. They aren't stupid enough not to understand the consequences of what they are doing, but the current rate of death and misery is part of creating an optimal investment climate. This is social sadism. This is a humanitarian catastrophe. To remedy this intolerable state of affairs, I propose a lobby or solidarity group to 'Save America' (or 'Save America From Itself', or 'Stop Them Before They Kill Again' - you get the picture). There should be rock concerts in Hyde Park to raise money for the millions of Americans who have no healthcare. Bob Geldof and Bono - and here's the excellent thing - would be totally uninvolved in any of this. Funds should be available for those who have been told by their insurance companies that their life is less important than shareholder value, to pay for an airline ticket to any country where they can get treated properly. And all support should be given to those heroic freedom fighters taking on the inhuman monsters who have been getting away with killing their people for far too long. I bet negative PR like that would get some reforms going pretty fucking quickly.

Labels: capitalism, health care, humanitarian intervention, NHS, socialism, tories, us politics

Wednesday, August 12, 2009

How the socialistic collectivist totalitarian NHS ate my hamster posted by Richard Seymour

Actually, that title is a tad misleading. What the NHS actually did was stop me from bleeding to death (this was years ago), stitch the wound shut, and give me a course of antibiotics to stop infection. I didn't pay any money or fill in any insurance forms. I stayed the night in the hospital, and went home the next day. I had the stitches removed later in the week, and I was all better.

Now, this may seem like, if anything, a feel-good story. But readers will surely apprehend the quiet menace of the totalitarian state machine behind it all. After all, as I have been hearing people say in shrill American accents for quite some time now, it means that some bureaucrat gets to decide whether I live or die. I mean, don't you think they call their bosses in the nanny state before operating? How the hell else are they supposed to check whether you fit into one of their communistic quotas? And, on top of being menacing and diabolical, the system is also an inefficient shambles. First of all, the toilet seats are always up, there's no flat-screen television, and you have to share a dormitory with other people. And these nurses - talk about attitude. Eat this, drink that, swallow these, would you like some water, etc etc. Ooh, la-di-fucking-da, look at you. Don't they realise who they're working for? If there was any concept of customer service in these wretched hospitals, they would say 'you have no insurance, so as soon as you can walk, you're out the door'. This so-called 'service', by the way, isn't free: you pay through the nose with your hard earned tax money. In a single year it costs $2815 (or £1706) per person. I could have bought a new nose with that. How dare some bureaucrat tell me how to spend my money? And... wait a minute... someone has just told me that America spends $6719 (or £4072) per person on healthcare every year. You fools! You bloody fools! You've only gone socialist without realising it!

Well, so much for that. In the drive to crush Obama's extremely modest healthcare proposals, much of the US health industry and the Republican right have struck on the original idea of saying that any offense against the holy profit is both foreign and communist. Hence, the debate becomes a spurious, contrived contest not between the actual proposed changes and the actually existing system, but between America and the UK. For example, one of the points that American rightists make about the NHS, amid much paranoid drivel, is that in some of its health outcomes, the NHS underperforms compared to the US system. The obvious answer is: so what? One could retort that on the most important health outcome that matters - health adjusted life expectancy - the UK outdoes the US. But this is beside the point. The NHS is not perfect, and has suffered long periods of underinvestment. Germany and France spend approximately 12% of their GDP on healthcare, but Britain only rose above 6% to approx 8% in the first half of this decade, and you can be sure that's about to fall again. To prove that free and equal access at the point of delivery is a superior system, it is not necessary to prove that the NHS excels on every point. There are also some comical misconstructions, as when Sean Hannity warned viewers about some poor sod from Merseyside who had to resort to supergluing the crown to his tooth because he couldn't find an NHS dentist. Hannity warned that Obama would reduce Americans to such a state if his proposals were passed. He did not realise, or did not care, that the reason for the dearth of NHS dentistry is because of the expansion of the private sector in dental care. Dentists are allowed to operate privately, and make far more money doing so (because they can charge more for basic operations). The reason the guy was looking for an NHS dentist is because he couldn't afford the exorbitant costs the private dentists charge for routine work. Another comical moment arose when a right-wing US investors magazine tried to claim that Stephen Hawking would be considered 'worthless' by the NHS, because of his physical handicap. Hawking retorted: "I wouldn't be here today if it were not for the NHS. I have received a large amount of high-quality treatment without which I would not have survived."

Of course, there is another way of approaching this, which is to consider why the private sector is so scandalously inefficient and wasteful. The NHS has historically had very low administration costs, with about 5% of the overall budget going to admin. Only after the internal market was introduced did it rise significantly, to 12%. In Britain's private hospitals, the administration costs are closer to 34%. (David Rowland, Allyson M. Pollock & Neil Vickers, 'The British Labour Government's Reform of the National Health Service', Journal of Public Health Policy, Vol. 22, No. 4, 2001)

In the United States, 'after exclusions', administration costs amount to 31% of total expenditure, although the overhead is much lower in schemes like Medicare than in private insurance. (Steffie Woolhandler, M.D., M.P.H., Terry Campbell, M.H.A., & David U. Himmelstein, M.D., 'Costs of Health Care Administration in the United States and Canada', New England Journal of Medicine, Vol. 349, No. 8, August 2003) The reasons for this vary, but one indicative example is the massive overheads incurred by US insurance companies, most of which are spent on functions (such as underwriting and marketing) that are totally unnecessary in a public system. Extensive legal bureaucracies and the duplication of capacity also suck up resources. And, of course, the fact that someone has to walk away with profit is important - the top ten US health insurers saw their profits rise 428% between 2000 and 2007, from $2.4bn to $12.9bn, mostly paid for by increased premiums. (See this report for figures, [pdf]).

One last thing. How much of this bloated administrative cost goes into denying treatment, and then relentlessly pursuing those who have received treatment to try and get the money back? A congressional probe looked at three companies and found that between 2003 and 2007, 20,000 people had their insurance policies rescinded, so that they could be denied necessary treatment. The saving to the companies would have been hundreds of millions, so undoubtedly this counts as 'efficiency' by their evil standards. Nonetheless, from the point of view of health outcomes, it does seem more than wasteful that there is a bureaucratic apparatus that is designed to kill people, that acts on the perverse incentive to deprive people of mastectomies and chemo that is necessary for their survival. Admittedly, this does call into question the idea that Americans, with their lavish freedom, will never run up against a heartless unfeeling bureaucrat in healthcare. But it does partially explain why no one in the UK, apart from a few cranks on the far right, has any intention whatsoever of emulating America's system.

Labels: 'free markets', capitalism, health care, NHS, profits, socialism