SPOKESMAN BOOKS

Haditha Ethics - From Iraq to Iran?

The Spokesman, 91

Reviews

Alison Talbot Smith & Allyson M.Pollock, The New NHS: A Guide, Routledge, 206 pages, ISBN 0415328411, £14.99.   Dexter Whitfield, New Labour’s Attack on Public Services, Spokesman, 176 pages, ISBN 0851247156, £11.99

Now that owners of UK capital see little opportunity of making money in productive industries – mining and manufacturing – and the infra-structure of transport and power and water supplies is in their hands, they have turned their attention increasingly to the service sector. Distribution and retail services are theirs, apart from the struggling Co-op. But the public services remain to be captured, and with the enthusiastic help of New Labour that is what, under the deceptive name of ‘reform’, is now happening. The end is already in sight of any public services remaining – in housing, education, health, police or prisons – and with this the end of democratic control and social accountability to public bodies. The means adopted is that government – and increasingly central and not local government – commissions the provision and provides the funds and the private sector supplies the service, within some limited regulation of provision, such as is applied to private companies generally.

Dexter Whitfield has devoted his life to the defence of the public sector through research, writing, advice and organisation, not least through the Centre for Public Services, which he founded in 1973 and whose work he continues in the University of Northumbria. This the latest of several books and pamphlets he has written gathers together much earlier research in arguing the case against the drive of neoliberalism which is encouraging the marketisation of public services. Whitfield emphasises the central role of the state in creating the conditions for successful marketisation. The market cannot function without laws to enforce contracts, financial concessions to business, such as export finance, tax relief, public subsidies, local and regional grants, and above all the promotion of the ideology and value system of competition, personal greed and corporate power. Marketisation, moreover, involves the opening up of the in-house services of public providers not only to private suppliers at home but to giant transnational corporations.

What Dexter has done in this new book is to collect together the whole history of the way in which step-by-step the working of the market and the ethos of business competition has been brought into the public sector in the United Kingdom, replacing all practices and ideals of collective responsibility. The result is made abundantly clear in the growing inequality of provision for those who are well placed financially and those who are not. The emphasis on ‘choice’ simply means choice for those who live in the right places and know how to work the system, whether this refers to hospital treatment or school places. Only those who can see their way to affording or borrowing for university fees and maintenance charges continue into higher education. Business involvement in provision, whether in public private partnerships in hospital building and management or in the financing and running of schools, means that the bottom line is always profit. So-called parent power comes down to the influence of unelected managers and company executives.

The ideology of the market is based on the assumption that competition ensures that actions base on ignorance, domination or incompetence are simply ruled out. So it is argued that private is always to be preferred to public. Yet, the most extraordinary fact about New Labour’s marketisation is that nothing works. The total incompetence in the prison service, partly now privatised, is the most glaring example. Another was the famous computerisation of passports by a private company. But Dexter has drawn up detailed lists of the extra costs incurred in marketisation. These amount to £8.3 billlion in one-off costs and over £3 billion of annual costs. But it is not just money that is wasted. The inspector’s reports on the new flagship academies, with all their extra funding, are abysmal. Many of the private funders have simply not paid up. Some of the new public private financed hospitals are not working after long construction delays. While grotesque profits are made in land speculation, and managers are paid more than many of the medical staff, whole wards are being closed down and the staff sacked, because budgets have been over-run. Nurses are so badly paid that it is necessary to replace them with temporary staff and with recruits from poor developing countries. Even as respectable a body as the Royal College of Nurses at its annual conference shouts down a cabinet minister who claims that the NHS has had its best year ever.

The last thirty pages of Dexter’s book are concerned with outlining in some detail an alternative strategy. This emphasises improving community well being with preventive action, democratic accountability, involving NHS workers and patients, equalities and social justice as the basis for advances, sustainable development through care for local and regional needs, protecting the public interest locally and regionally as well as nationally, financial transparency and economies of scale in finance and, finally, training and intellectual capacity building. Dexter proposes a whole sheaf of strategies to oppose marketisation and to support alternative policies by mobilising alliances and campaigns around particular issues – many of them necessarily local. He does not forget at the end the important lessons for other European states, where marketisation and privatisation are less advanced than they are in the United Kingdom.

Much of what Whitfield writes will be criticised by New Labour as coming from an old Socialist, but, in relation at least to the NHS, everything he writes is supported by the conclusions of the new book by Dr. Alison Talbot-Smith, who once worked for the NHS, and Professor Allyson Pollock, who used to research and write for the British Medical Association and is now head of the Centre for International Public Health Policy at Edinburgh University. The book consists mainly of the most thorough description of the way in which, in their words, ‘a publicly-funded system of publicly owned and provided health care is being replaced by a health care market…’ Chapters deal with ‘Organisations with strategic roles’; ‘Organisations commissioning services’, ‘Organisations providing services’; ‘Funding and resources’; ‘Efficiency and standards’; ‘Research and development and research governance’; ‘The NHS workforce’; ‘Devolution of the NHS in Scotland, Wales and Northern Ireland’. They are full of valuable facts and figures.

When the authors come to looking into the future, they conclude that

‘The day when the NHS becomes mainly a funder of health care – a “logo” attached to the provision of health care by private hospitals and surgeries – no longer seems remote.’

Then they ask a series of key questions:

‘First, how far the new NHS will, or can, continue to serve the values and aims of the original NHS, namely services which are universal, comprehensive, and free at the point of delivery. Second how far the market-based system, adopted for the sake of efficiency, will actually be more efficient than what it is replacing.’

Their answers are given from here on in quotations from their last chapter. Universality, they argue, implies equity of resource allocation and service distribution, but they say that

‘Under the new system, control over resource allocation will be devolved to private or voluntary sector commissioners with no responsibility to meet the health care needs of a defined population … providers will try to concentrate on the most profitable treatments, services and patients and avoid the least profitable… Some commissioners and some providers will be liable to make losses and have to cut services…(Already) cuts are making existing inequalities worse, both across areas, and between and within patient groups.’

A related issue is whether any part of the NHS is now responsible for relating services to needs and ensuring universal access.

‘Second, as regards comprehensiveness, what mechanism will ensure that services for patients with conditions that are inherently hard to predict and relatively costly to treat – older patients with several chronic diseases or the frail elderly, for example – will continue to be provided? The NHS no longer provides truly comprehensive care

Third, as regards the provision of services free at the point of delivery; if many trusts and foundation trusts continue to find themselves in persistent deficits, what will stop this leading to a new demand (from all quarters) to find additional sources of funding in the form of ‘user fees’ – for so-called ‘hotel costs’ in hospitals, or for ‘enhanced services’? … Another proposal is vouchers, whereby every patient would receive an equal entitlement to a fixed amount of treatment, but have to pay for additional care. Vouchers are already government policy for the young disabled and the 2006 White Paper proposes to extend their use in social care and long term care … Once the market is in full operation then ‘topping up’ of one kind or another is likely to follow, undermining all the goals of the NHS.

As regards efficiency… Given that much of the healthcare budget is spent on staff and so much health care is labour intensive, depending on thousands of interactions between patients and highly trained and experienced clinicians, how far can ‘business efficiency’ be expected to improve the balance sheets without downgrading the service through reductions in funding of levels and quality of staff? … Second, do the gains from adopting a ‘business-like’ approach to service provision outweigh the costs of operating in a market such as making and monitoring contracts, paying for capital, invoicing and accounting for every completed treatment, marketing services and dealing with fraud …? Third, how will the answers to any questions about efficiency be known if the financial operations of foundation trusts, as well as of the private sector providers and commissioners, which are to become part of the NHS ‘mainstream’, are to be treated as ‘commercially confidential’ (as the independent regulator, Monitor, has already decided some of them will be).

All these questions raise the general question of public accountability … Will any avenue then remain for the public to challenge the decisions made by private bodies and shareholders on their behalf?’

The authors end by hoping that the questions they have raised will encourage others to ask questions. They provide an excellent starting point.

Michael Barratt Brown

Spokesman Books,

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Bulwell Lane,

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