Great tides of people press against me, hands outstretched, faces questioning. They wait for something - a doctor? Anguish ripples through the crowd. Those without the right colour passport are turned away. Countless others shake out their pockets: desperate for pennies; desperate for treatment. Their eyes fill with reproach once they recognize I am a doctor. Their searing gaze brands my guilt.
I try to wake up. This must be a nightmare.
Or worse - I ended up in America?
But no, I am awake.
And this is England.
While We Were Sleeping
The Health and Social Care Act 2012 crippled the NHS as we know it. Without any mandate from voters the government introduced a top down reorganisation that enables the rapid acceleration of NHS privatisation. The right of private providers to profit from illness is the key driver of the so-called ‘reforms’. For the first time since the NHS’s foundation, the Health & Social Care Act removed the government’s legal duty to secure a comprehensive health service. The law that once ensured that everyone receives the same health care - rich or poor, wherever they live - no longer exists. Universal healthcare free at the point of delivery may soon be a thing of the past.
Since the Act came into effect in April this year we have already seen its implications. Widespread hospital closures are leading to increasing mortality rates and delayed care, while thousands of nursing jobs continue to be lost. The Act harms patients, populations and professionals alike.
In abolishing one of the most successful models of healthcare in the world – both cost-effective and equitable – the Act is one of the most regressive pieces of UK legislation over the last 60 years. “Liberating the NHS” has cost us our liberty from ill health.
Many of us in the health profession feel as though we are just coming round from a blow to the head. As a junior doctor who grew up with the NHS – for whom working in a public health service has always been paramount – I find myself in a very different system to the one I signed up to. And one with which I fundamentally disagree. I feel ashamed and angry that I – that we – allowed things to get this far. A pernicious, anti-democratic policy was brought in over our heads. How could we have let this happen?
Doctors have a noble history of activism. Doctors were some of the most strident critics of nuclear proliferation in the 1970s. It was doctors who first raised the alarm about the genocide in Rwanda. And it was witnessing poverty, hunger and disease as a young doctor that radicalized Che Guevara.
Yet our generation of doctors has been slow to react to this particular crisis – one within our very own domain. Why?
One popular explanation has it that doctors are simply self-interested. But I have worked in the NHS long enough to know that this is just not true. There are other more complicated reasons for our silence and each one deserves attention if we are to rouse our generation from its slumber.
1. Not Being Taught a Lesson
A recent study investigating awareness of NHS reforms among junior doctors found that their basic understanding of health politics was poor. 1 in 5 could not name the health secretary. Even more concerning, almost 75% were unaware that the NHS reforms could affect their training.
The most effective way to stop people understanding what is going on is to keep it secret.
Traditional medical curriculums make little space for public health teaching. At Cambridge, I was taught next to nothing about the structure of the NHS, and even less about the importance of socialised care. Distanced from the horrors of an era before nationalised health, and unaware of the struggle that brought it into being, our generation took the NHS for granted.
Instead we were told tales about an unwieldy and inefficient NHS. We witnessed the fragmented and cumbersome state of the NHS on the wards. But our teachers neglected to mention that, far from inevitable, this was a side-effect of successive governments building on the privatizations of the last. “Continuous redisorganization” and multiplying layers of bureaucracy ensued. With the NHS looking increasingly incompetent – even to its own workers – it was easy to justify dismantling it from the inside out.
Instead of involving public and professionals in shaping the NHS, the government continually misrepresented what the Health & Social Care Act was about. It used feel good labels like “GP-led” and “patient choice” rather than more accurate ones - “market”, “competition”, “privatization”. It used the media to shake the public's faith in its favourite institution before presenting (yet more) market-based solutions to a crisis of its own making. For the architects of the Act, descriptive accuracy is of no value – profiting from illness is.
2. Not Rocking the Boat
Not all doctors were in the dark about the NHS reforms, however; many had an inkling of the changes afoot. Why then were so few of them present at the numerous demonstrations that laypeople organised against the reforms? Why, when asked about them, did nearly half of junior doctors say they were “apathetic”?
As well as belonging to a generation of diminishing political participation, what differentiates young doctors from their patients is that they may see themselves as having less to lose if the NHS dies. Medical students overwhelmingly come from families in the top quintiles of household income. Such privilege insulates them from the consequences of health privatization. It dilutes the urgency to protest.
Fear, money and disorganisation also play their parts. Doctors and nurses concerned about the impact of marketization on their patients have been suspended and even dismissed. Forced to accept gagging clauses, money buys their silence.
Prominence and success shield no one. Professor Allyson Pollock's excellent work, systematically destroying the economic case for the marketization of healthcare, threatened the government so much that they replaced her as special adviser to the Commons Health Committee - and then tried to discredit her in public. Dr. Clare Gerada, chair of the Royal College of General Practitioners, was similarly attacked for her vocal criticism of the reforms. Patronised and dismissed, Gerada has been on the receiving end of misogynistic rhetoric from both ministers and the predominantly male medical establishment. Though neither woman has been silenced by these tactics, the message is clear: shut up or get out.
When individuals do speak up they receive little or no organizational support. The British Medical Association (BMA) – Britain's foremost doctor's trade union with 150,000 members – failed to fight the Act, proving itself out of touch with its grassroots. Why would individual doctors raise their heads above the parapet without leading examples, when it is far easier to follow the herd? Even if one were to speak up, how to go about it? The fact that we are represented by multiple structures – the Royal Colleges, the BMA, hospital committees – means we have no united, common voice. Our conservative medical establishment is disorganized and shambolic - and it allowed us to betray our NHS.
3. Not Labouring for Love
Politicians stymied much of the political resistance to the NHS reforms by co-opting a layer of the medical profession to give a veneer of clinical leadership to the marketisation of health. As Director of Strategy in the Department of Health in 2000, Penny Dash was instrumental in opening the door to “more private sector provision of healthcare.” A medical doctor by training, she has also worked as an advisor to the pro-market Kings Fund, McKinsey & Co, independent healthcare providers, pharmaceutical companies and private equity groups [C1] - all of which stand to gain from the privatization of the NHS.
Ara Darzi, the face of ‘polyclinics’, was Paul Hamlyn Professor of Surgery at Imperial College London and pioneer of keyhole surgery. Darzi handed over general practices across London to private companies in 2006 on little or no evidence. In place of the promised high-tech, multi-purpose facilities, we got little more than “walk-in centres” for the young and healthy. Five years later - and at a cost of hundreds of thousands of pounds of taxpayer's money - the farcical project was wound up. Meanwhile, the mastermind was made Baron Darzi of Denham and a junior minister in the Department of Health.
But no one is asking for us to be selfless angels for the poor and needy. Doctors have the right for rewarding and life-sustaining work as much as anyone. Junior doctors should not take these reforms lying down, because – contrary to belief – we have almost as much to lose as our patients.
As the scandal at Mid-Staffordshire – which was racing to meet targets to become a market-friendly Foundation Trust - shows, increasing marketisation leads to an increasingly toxic work environment in the NHS. A system that places profits, throughput and results above patient care and staff satisfaction will not allow us to thrive.
Clinical services are now following the model first introduced by Thatcher for cleaning, catering, and laundry, outsourced to private companies in the 1980s. Cost reductions from outsourcing - and the profits pocketed by the private companies - were made possible by paying workers less. We can expect our jobs to be handed over to companies such as the notorious Serco, G4S and Harmoni. Forget your white coat and stethoscope. Your new work attire? Red Virgin uniforms. If we don’t lose our jobs, we will be asked to work longer hours. And the effect on patient care will play second fiddle.
For colleagues who think the dismantling of the NHS might work to their advantage - a word of warning. If not for your patients’ interests, then at least stand up for your own.
Junior doctor contracts are currently up for discussion, and pay-cuts are in the offing. With more shift-work, less continuity of care, and a higher emphasis on bureaucracy, we will become replaceable automatons in the healthcare machine – with obvious repercussions for our training. Professional autonomy will be eroded, our decisions based no longer on clinical need but corporate greed. As we-move from a taxation-funded model to an insurance-based one (via the underfunded, quasi-insurance structured Clinical Commissioning Groups) we will be expected to refuse patients and function as border control. The hallowed doctor-patient relationship will be jeopardized; who would trust a doctor that stands to profit from their illness as markets permeate everything?
If you are in any doubt, only look across the Atlantic for a glimpse of a future with privatized medicine. Exploitative working conditions for junior doctors and the worst health indicators of the industrialized world are on the horizon.
No Time to Sleep
Many of us turned a blind eye to the biggest reorganisation of the NHS in its 65 year history, fooled by Trojan horses of “choice”, “diversity” and “clinical leadership”. In doing so, we became the puppets of a free-market agenda. And we justified our inertia with platitudes.
But while we may not have actively tore down the NHS, remember this. Our ignorance, inaction and self-interest do not absolve us - they simply make us complicit in the crime.
But this doesn’t have to be the end. The NHS may have changed, but it’s not too late to save it. The most noxious elements of the reforms can be repealed without yet another expensive, disruptive reorganization. But just as the reforms did not happen overnight, it will take time and effort to overturn them. This is no time to sleep.
It's Time to Wake Up
We have been lied to. We should be angry. We need to act now. Let’s move from haplessness, hopelessness and helplessness. Let's really put “power in the hands of the doctors”. Here's how you can help.
1. Teach ourselves a lesson
a. Educate ourselves and others about the NHS, the reforms and the role we can play in it. There are a number of excellent books and resources on this topic (see below). Keep up-to-date - OurNHS delivers the latest news online.
b. Talk about it. Make sure your colleagues know what’s going on. Inform medical students that the NHS they will be working in is not the one they signed up to. Tell your friends and family how the reforms will affect them - more cuts, rationing and expense.
2. Start rocking the boat
a. Have an opinion. Rudolph Virchow said: “Medicine is a social science, and politics is nothing else but medicine on a large scale”. The NHS is a political issue, and espousing non-partisan sentiments simply isn’t good enough. Use your vote wisely in the next general election - support only candidates who favour repealing the Act, or vote for the National Health Action Party.
b. Speak up. We are only going to be able to influence the discussion if we first become part of it. Voice your concerns and encourage others to do the same. Listen to your patients - many of them will already have felt the effects of the ‘reforms’. Write to newspapers and local MPs with your stories. As doctors, our voices are heard where others are not.
c. Participate. Join local and national campaigns. Many hospitals are being damaged by the changes - show solidarity with your time, money or organizational abilities. Nationally become part of established groups such as Keep Our NHS Public or 38 Degrees. It doesn’t matter which - the key is showing dissent.
3. Labour for love and love our labour
a. Advocate for your patients. Performance measures are readily lost in privatized health systems. Make it your job to keep track how the Act affects your local ward, hospital or area. Spread the news with social media - make your time on Facebook and Twitter count.
b. Organize. We are so much stronger when we work together. During apartheid in South Africa, the Health Worker’s Society operated across professional boundaries to successfully oppose the racist state’s health policies and practices. Join the Medical Practitioners Union (MPU) - it’s the nearest thing we have to such a body in the UK. As part of UNITE, it offers a dynamic alternative to the BMA as a trade union for doctors.
c. Represent your interests. Whether at local or national level, in the BMA or in the Royal Colleges, there are meetings about your training going on now. Be there and demand to know what is being done to protect you and your patients.
d. Stand and be counted. Think of ways to make your dissent public e.g. GPs can put posters in their practices. But don't act alone; form local groups of like-minded doctors. Such cohesion is symbolic, and a powerful message to the government.
I am proud to be a doctor. Alongside our nursing and allied health colleagues, we strive to help people when their bodies fail. There is nothing more human. But we can only hold our heads high if we stand shoulder to shoulder with our patients. By educating, vocalising and mobilising we can add to the overall movement to combat the destruction of nationalised healthcare in the UK. The single most important thing for any of us who care about the NHS to achieve is to re-instate the Secretary of State’s duty to secure a comprehensive health service - a duty that the 2012 abolished for the first time since the NHS’s foundation, allowing Jeremy Hunt to wash his hands of problems in the NHS and pass the blame for government meddling and cuts, down to individual Trusts and doctors. Getting this onto the public, media and political agenda is crucial - and it needs our help.
Our power in working for the system comes from being in the system - and we must use this power wisely. As doctors we are more than just healers: we are our patients’ advocates, and we are also citizens. To care for the NHS is to care for the health and well-being of the people of this country.
The responsibility for leading the charge for the NHS lies with us. This is our NHS. It won't be Cameron, Clegg or any of their cronies who will be the inheritors of this mess – it will be us.
It would be easy to sit tight; as doctors we could probably weather the storm. But what about the others? What is at stake is not professional integrity or a job – it's people’s lives. And simply doing what is right. In years to come, when asked what I was doing when the state tried to wrest health from the hands of the people, I want to be able to say that I was fighting - tooth and nail - to pull it right back.
I'm doing whatever I can to reclaim our NHS. And I urge you to do the same.
Join me. It’s time to wake up.
Guddi Singh is a doctor training in Paediatrics in London. She also has a Masters in Public Health from Harvard University and has worked for the World Health Organization. She is passionate about social justice, human rights and challenging barriers to access to health.
Co-published with OurNHS openDemocracy