download a pdf here   NHS SOS

How the NHS was betrayed – and how we can save it    Editors  Raymond Tallis and Jacky Davies. Forward by Ken Loach.

 The contributors to this book are passionate opponents of the Health and Social Care Act, and succeed here in giving a very vivid description of their frustration at not persuading others to be more effective in opposing its passage through parliament. They clearly aim too to convince us of its dangers for the NHS .

Now a clear description of the dangers of the Health and Social Care Act and of what we can, constructively, do to oppose it or to mitigate those dangers, would be hugely valuable, but despite, or perhaps because of, their passion, this is not that.

There are many useful aspects to the book.

The history of Multinational Managed Care Organisations  (MMCOs) is thought provoking. The authors observe that it was when these US based companies (including those we know of as HMOs) ceased being ‘the darlings of Wall St’,  due to pressures on health care costs in the US , that ‘a transition from national to multinational managed care began to take place. With the support of the World Bank and other US led multilateral financial institutions, the industry now aimed to export managed care initiatives that convert public health care institutions and social insurance funds to private management, private ownership or both, around the world. ‘

I enjoyed seeing a number of prevailing myths being countered. For example that :

·          ‘headline stories about hospital and other health service deficits only mean that resources are being unfairly distributed, not that the NHS is unaffordable overall’;

·          the NHS is not over budget, that it  returned 2 billion to  the Treasury in 2012;

·         the NHS is unaffordable in today’s straitened times: ‘Proponents of  the argument that tax financed health care is a privilege we can no longer afford  are unable to explain why universal health care was instituted when the world’s economy was very much smaller than it is today. If the UK could create an NHS when the country was literally bankrupt, why in England can the government not sustain the NHS today?’

It is also timely and very heartening to be reminded of  the basis of a national health service – that it is about pooling risk, and that that can only happen when the pool is big enough – national indeed.

Sadly though, very sadly, the book fails to  inspire and often irritates. I had the disconcerting experience on several occasions , of momentarily opposing views I strongly hold, because I had become so enraged at the previous paragraph.

What is wrong? Well it is badly written, lazily argued, and atrociously referenced – and full of just this kind of sweeping generalisation!

Worse, it is an example in writing of exactly the dynamics that are  one of the fundamental problems of the NHS: the complacent, self righteous, sanctimonious, refusal of many of the medical profession to bring their proper (and genuine) concern for patients and engage with the  challenges of offering comprehensive care to meet the changing needs of the UK population, preferring instead to dish out blame to those who do.   

Time and again here we hear how doctors are the most trusted group in society, and politicians one of the least. No reflection on why that is, merely the implication that doctors are good and politicians bad. In fact this book can best be enjoyed as a rollicking tale of battle between heroes and villains. Nick Hornby used a recurring phrase in one of his books: I’m a doctor I’m a good person. That is the underlying stance here.

But let’s reflect for a moment on these levels of trust. Apart from the fact that we all want and indeed feel a need to trust our doctors, politicians have given doctors the most fantastic privilege of being able to dispense back to us our own generously, collectively, donated largesse. Of course they are trusted more than the politicians whose role is the inherently unpopular one of reconciling different interests, and who also have to subject themselves to re-election by an electorate who don’t have the patience to explore the complexities of an issue and instead make their choice based on sound bites.

This is something for doctors to celebrate and enjoy, it is the most fantastic privilege, and they can revel in it as long as they also aim to earn it. Using it  as a weapon just isn’t right. Especially against those doing a job they themselves could very valuably  participate in – making difficult decisions, with no right or wrong answers, about how best to use resources.

The heroes  and villains? Well the chief saint is Clare Gerada, and the demons include, well anyone who supported the Bill, all of whom apparently have vested interests (money, honours…) in its safe passage into law. There is no room here for the idea that people you disagree with may be similarly values driven; genuinely convinced by different logic, different evidence from yours, trying to achieve ends just as desirable as your own.

And yet….and yet….

Having had the thoroughly enjoyable chance to challenge, irritate and provoke doctors out of just this kind of attitude for the last twenty years, and made many firm friends along the way, I find it helpful, when confronted  with demeanours and attitudes as irritating as those on display here,  to keep in mind two quotes and an idea.

The first quote is from  the brilliant book ‘Audit Cultures’ edited by Marilyn Strathern, where M Mc Donald observes that ‘ For anthropologists, resistance to reforms is not to do with complacency, backwardness, laziness, inefficiency etc. Opposition is encapsulated in a whole symbolic complex through which people can feel their realities traduced.’ [1]

The second, is from John Ralston Saul’s  book ‘Voltaire’s Bastards’ where he describes how logic and reason now trump practical experience in arguments about policy or management, and  a logic -based technocratic elite imposes its unexamined untested ideology across the West. He observes that now, whenever there is ‘expression of any unstructured doubt[2]…’ it is ‘automatically categorised as naïve or idealistic, or bad for the economy or for jobs’.  Saul conveys a  sense of these ‘doubters’ being thought emotionally child- like among reasonable grown -ups.

The idea is the  Buddhist one that ‘emotions  are energy with a story attached’.

So if we look underneath the goodie/baddie story that these authors are presenting here we find a very vivid insight  into the frustration of being dismissed as naïve and idealistic, by the BMA, the Royal Colleges and the Academy of Colleges,  or by the leadership of their own political party. These are rich and useful descriptions of how members of the technocratic elite gather others into their fold, and help them neutralise dissent, by conversing with them as adults dealing with problem children.

We can usefully reflect, too,  on what is the ‘whole symbolic complex’ through which the authors  see their realities being traduced. And we can consider how their beautiful, valuable, energy (and ours) can be used to best effect, once we dispense with the story of heroes battling villains.

So what are the issues that are energising these authors but that they are not articulating?

The first , I suggest, is that there is a battle of ideas being conducted all around us, and that it matters very much which ‘side’ wins; that the battle is being won by seduction and willing enslavement, and is often sold as ‘freedom or liberation’, and that the only way to fight back is to expose this battle and the methods of the currently winning side to wider public view.

Sadly, instead of seeing this as a bigger battle and drawing this to our attention the authors here take it ‘personally’, as a marginalisation of medicine, when this is merely one example of a much wider ‘commodification’ or ‘McDonaldisation’ of the richness of our lives.

The  insidious idea is that logic is more reliable than experience, and one of the most pernicious examples of this is  neoliberalism, the theory  that markets and trade are the most efficient way to allocate resources and hence that the good of society can best be pursued through the indulgence of self interest. (It is not the only example  but it is perhaps the most dangerous). The weapons it deploys in this battle are those of fear and blame (think any media headline).

But it’s an argument that needs exploring too, after all, while it has been the dominant paradigm for world trade millions have been ‘lifted out of poverty’. So we need to examine and explore it not simply condemn it. We need to see what benefits it confers and on whom. It often offers goods and services more responsive to consumer preferences, for example. It can drive standards up and decrease variation. It doesn’t always, and it also exacerbates inequalities and leads to market concentration with the resulting oligopolies little more responsive than state monopolies. So we need to think about different circumstances and not treat every economy as a market one but consider carefully where gift economies must be allowed and encouraged to flourish. 

And in doing so we must not waste energy blaming others, but recognise that the people who believe this idea will mostly do so entirely genuinely, and will want good affordable health care for all, just as fervently as the authors here. So it is the idea that needs opposing, not the motives of its exponents.

The second  is that professions play a vital role in society. They are the only means we have of dealing with situations that are complex and uncertain. If, instead , we treat and educate our professionals as expert technicians we rob society of the ability to ‘muddle elegantly’ through any situations that are so complex that pre-prescribed protocols cannot help. Of course we sometimes need expert technicians and sometimes need elegant muddlers, and professionals must be expected to embrace being both and knowing when to be which.  

The Act continues the general direction of policy travel over the last two decades which has been to use the opportunity afforded by the digital revolution to drive judgement and wisdom out of health care (and social care and education and….) and reward only efficient technicians. There are many benefits of this, to be sure, but many losses, far too many losses, as well, and it is another good reason to oppose the Act.

It feels to me that this book is fuelled by these vital concerns, but incoherently. The authors’ impugning of the motives of those involved simply distracts from the really important arguments and, worse, fuels opposition to them. Indeed it is precisely behaviours and demeanours like this that lead policy makers to believe that doctors in particular and heath care professions in general are part of the problem rather than part of the solution. The failure of doctors to ‘get this’,  and to continue to behave in these ways, often amazes and amuses observers new to health care.

There is at the moment an opportunity, while the government is responding to the Francis report, for us to re-open minds, for us to persuade governments to trust professionals in ways they have not for years. But for that to happen professionals have to behave well enough to be trusted. They have to demonstrate that they are able and willing to  think widely enough and  interestedly enough, about the kind of decisions we as a society need to make, to make valuable contributions to a national debate. And that is the real danger of this book – that it prevents us using this opportunity by giving an example of the professions being unable or unwilling to do so.

There are many others of us who  are already engaged in this battle for ideas, I truly hope these authors will bring their passionate energy to join us.

Valerie  Iles

July 2013