The NHS is now locked into a transformative process since the enactment of Andrew Lansley’s Health and Social Care Bill last year. My friends in the world of public health tell me there is a fair amount of confusion as to what is actually going on, with the dissolution of primary care trusts in favour of clinical commissioning groups. What is for certain is that a period of difficulty during and after a top-down reorganisation was entirely predictable and, moreover, predicted.
Meanwhile, we are supposedly anticipating a demographic crisis. With all of the doom-laden rhetoric around the burden that these oldies will place on working-age people over the next few years and decades, it’s a wonder we’re still trying our damnedest to shut our borders to economic migrants, who boost the birth rate, work more, consult healthcare less and generally ‘cost’ the state less. The basic argument seems to be that old people aren’t dying fast enough. I'm surprised nobody has drawn up a neoliberal economic argument for legalising euthanasia.
This is an apposite time to wonder about the public’s interpretation of what the NHS is. What is it? What is healthcare for? Is it simply there to improve our health? But then what is health? The WHO defines it as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. This isn’t really what most of our resources are aimed at. We spend most money on treating illness, not improving health. For many years, there’s been a running joke in the world of public health that it shouldn’t be called the National Health Service at all; it should be the National Illness Service. (Chortle chortle.)
But I would argue that it is neither a health service nor an illness service. Or rather, it is both, and more. The NHS is a symbol of the kind of society we are. Which is why people are so passionate about it, why it is the site of so much contestation. And as with many symbols, it works at a number of levels: at a national level, of course, although this is difficult to keep track of given the complexities of the beast it has become. But also at a local level. The local hospital is a symbol that the state cares, that if the shit hits the fan, the state can and will look after you.
For those who already visit these hospitals, they may well already be a literal lifeline. And what about healthcare workers? The symbol of state-provided care, equal for all, regardless of wealth or background, is massive for those who participate in its provision. Cheesy as it may sound, for many of us it is exactly this that gives us our sense of vocation. Doing this locally engages us in communities in ways that faraway super centres simply cannot.
So what happens when this symbol is forcibly taken away despite public protest? We interpret it as another sign that government doesn’t give a shit about normal people. More importantly, it really doesn’t give a shit about disadvantaged people. You’ll hear experts talking about how centralisation of specialist services improves quality and reduces morbidity. There’s a great deal of truth in this. If you have a car accident, the difference between being taken to the nearest district hospital or to a major trauma centre has been shown to be pretty significant. Put simply, you are more likely to live if the ambulance takes you straight to the trauma centre.
But the centralisation of resources in this way means investing more in those sites, which may mean investing less in peripheral sites. And what if is this evidence-based argument is used to justify closure of peripheral sites without increasing central capacity, as we have had in Manchester? The closure of Trafford A&E is a recent case in point, which led to Wythenshawe hospital being way over capacity at the end of 2013. It is quite clear that the expert-led argument which had aimed to improve services has simply been used to obscure a cost-cutting measure, thus reducing the quality of care. In other words, the justification for the change was saving lives. But the change implemented was not quite what was presented. And the final result may well be the opposite: increased morbidity and mortality.
In the field in which I work, mental health, all inpatient beds were recently closed in
central Manchester with the North and South Manchester sites expected to pick up the
slack. This has led to an acute shortage of beds, with inpatients having to be transferred hundreds of
miles to find a bed. I admitted a patient from a Manchester A&E department three
weeks ago who had to wait several hours for her ambulance to arrive. When it did, it
took her to the closest available NHS bed: in Sunderland. The reduction in mental health
beds has followed a slightly different argument to the centralisation of specialist
services discourse described above. In mental health there was a move to providing care
in the community, rather than in huge institutions cut off from society. Again, this was
based on societal change, on improving attitudes to the mentally unwell, on reducing
stigma and helping the unwell to re-integrate back into society rather than suffer in
isolation, separated from others. The arguments were all sensible, ethically sound and
often evidence-based. But instead of seeing adequate resources devoted to provision of
community care, we have just seen the closure of inpatient beds, with not enough done to replace the care they used
to provide. Like the local A&E as a symbol that the state will look after you when
you have a heart attack or break your leg, the mental health hospital serves as a symbol
that the state will look after you when your psychological suffering becomes so great
that you need respite. When you can’t get into that hospital because it’s
full, the meaning of that symbol changes.
The point here is that one argument has been used to persuade the populace that a change in the system is for the best. And that argument has obscured the fact that the change has not served the people whose health the NHS is supposed to protect. The only people who have gained from these changes are private providers of care who have been able to gain access to taxpayers’ money: a fail-safe, government-backed investment.
We have seen the Tory party, in particular Andrew Lansley and Jeremy Hunt, attempting to persuade us that we needed a huge top-down organisation of the NHS (months after David Cameron had promised us none of the sort) in order to improve ‘patient-choice’. Rather than improving actual care, this has simply opened the market to private providers. The common sense being appealed to here is that competition improves care. The evidence suggests otherwise, and there are very good reasons for this, as explained here.
More recently, Jeremy Hunt has attempted to persuade us that he needs to shut hospitals
and A&E departments, using the arguments described above. His arguments though have
not worked. He has forgotten the power of the local hospital as a symbol, and therefore
not anticipated the mobilisation against hospital closures. So what happens when
persuasion fails? The ruling class gets spooked and has to reassert its authority. It
resorts to coercion. And this is what we see with clause 118. Jeremy Hunt is trying to put through a bill that will give him ultimate power to shut hospitals at will. The rhetoric of patient choice and
public involvement is exposed as vapid bullshit as he tries to bulldoze public opinion
into giving him the ‘power to turn around failing hospitals quickly’. He is simply doing
‘tough but necessary things’, which ‘should be supported by everyone
who cares about the NHS’ or else ‘lives can be put at risk’. The
curiously transparent emotional blackmail (where does he find his speech-writers?) is
desperate schwarmerei, one last attempt at persuasion while he fiddles in parliament to
enact the coercive clause 118.
In a way this move is encouraging. It is a sign that people aren’t being persuaded. People aren’t buying into the bullshit. They, we, are not allowing the oppressive new order to be born, are not consenting to our own subordination, are forging our own common sense. It is under these circumstances that old Jeremy feels the need for extraordinary measures.
Don’t let him get away with it.
What you can do:
1.Sign a petition with 38 degrees
2. Get involved with Keep Our NHS Public. They have a number of local branches who meet regularly to plan campaigning and activism.
3. Write to your MP. You can find his/her details here.
4. If your local hospital is facing closure, it probably has a group of people campaigning for it to remain open. Examples are Lewisham, Trafford, Bolton.
5. Join the NHA Party, a newly formed political party formed by two doctors who are passionate about keeping the NHS as a publicly funded service free to all.
6. Educate yourself – read NHS SOS by Raymond Tallis and Jackie Davis.
7. Tell people, have a conversation with someone, start an argument/discussion!
Doctormagiot is a psychiatry trainee working in Manchester. He tweets at @doctormagiot.