Sunday, 5 March 2017

The day after the NHS march...

As most people in the UK are probably aware by now, there was a rather large march for the NHS in London yesterday. Most people know this because it actually was covered by the much-derided mainstream media, including the BBC, ITV, Channel 4, the Mirror, the Daily Mail, the Daily Express, the Evening Standard, the Guardian, the Telegraph, Sky News and Metro.

This did not stop the internet lighting up with people claiming the march was not covered or seeking out conspiracies where none exist.

"It's the mainstream meeja's fault!"

On the Big Up The NHS Facebook page, one person thought it was suspicious that the Evening Standard and the Mail Online used the same photograph, even though it was an agency photo which would be available to any major news outlet with a PA subscription, which is all of them. 

On the same page as well as on Twitter, multiple people pounced on the inverted commas used by the BBC in an online headline about the march, with "hospital cuts" in inverted commas. If anyone bothered to read the story, they would see that the inverted commas are used to refer to quotes from the protesters rather than any specific cuts and it is, therefore, accurate journalism, but the left-wing media bashers are not interested in accuracy or learning about how journalism works. They'd rather scream about media conspiracies, as if we journalists spend our spare time in a darkened bar, smoking unfiltered cigarettes, drinking whisky neat, and colluding with each other about how to create a Tory dictatorship. 

This is a shame because such paranoid nonsense only serves to distract from the very real issues facing the NHS. And speaking of distractions, one of the biggest and dumbest banners at yesterday's march, bafflingly, said: "SICK OF MEDIA LIES ABOUT JEREMY CORBYN". 

Firstly, Jeremy Corbyn's address to yesterday's march was very well covered, including by the right-leaning Daily MailExpress and Telegraph. The brutal truth is that marches are usually not that interesting to cover unless violence breaks out. In terms of media coverage, you have images of marching, shouting people with placards and banners, footage or quotes from the speeches and, er, that's about it. From a journalistic point of view, it is pretty limiting as to what can actually be said about a march before it gets repetitive. So for yesterday's march to glean the coverage it did should be seen as a positive. Whining about media conspiracies makes campaigners look certifiable.

Secondly, that banner is absurd at a march specifically about the NHS. Campaigners who want people to seriously focus on the many things that are bringing the NHS to its knees and want to attract people of all political persuasions - as well as the apolitical and apathetic - need to look outside the Corbyn-loving echo chamber in which many of them are stuck. These people (and I hasten to add this is not all NHS campaigners) need to realise that NHS campaigns which come across as Corbyn fan clubs, when he is simply not resonating with people outside the Labour Party and Momentum in particular, will not be effective.  

And then it gets complicated...

On top of all this, the Health and Social Care Act 2012 devolved all responsibility for health services to local Clinical Commissioning Groups (CCGs) and that is where the real lobbying and engagement needs to take place, with elected MPs and local councillors along to ask hard questions about where money will be spent in their regions. In theory, CCGs make sense - the healthcare needs of a seaside retirement town will be vastly different to an inner city borough of young families, for example, so one size does not fit every area. 

That said, the basics such as accessible A&E, cancer treatment, and GP services should be available to people equally across the country - although in the case of GP services, this also varies between different areas. The retirement town won't have the same demand for GP services on evenings or weekends that the inner city area full of time-poor working people will. 

If the message that engagement is required locally at CCG level as well as nationally has not been properly communicated to the wider community as a result of the march, better communication from campaigners is required. This is also needed from Labour at all levels if they are serious about being a proper opposition and forming a government at the next election. 

Yes, the future of the NHS is about adequate funding at the Westminster level, where plenty of MPs have vested interests in private healthcare, just as much as it is about CCGs being financially responsible and lobbying the government if there are local shortfalls, particularly if people cannot be discharged from hospital because of inadequate social care. The financial interests of CCG members are as important in this equation as that of MPs because right now there is nothing to stop members commissioning from businesses or non-profits in which they have an interest.

It is complicated and it is not simply about throwing money at the NHS if it will only end up mismanaged at a local level and the CCGs are not held accountable. 

Do not be naive - we will have a Conservative government in this country until at least 2020 and therefore we will have CCGs at least until then.

So, what next for the NHS?

What happens next for the NHS will depend on what is seen as politically expedient because, like it or not, the NHS is political. 

It is pretty clear that there is an appetite for destruction when it comes to the NHS under Theresa May's government. If she genuinely cared, one of her first orders of business would have been to ditch Jeremy Hunt, the failed marmalade mogul who has been play-acting at the Health Secretary job since September 2012.

The government is smart enough to know that British voters will not stand for a complete replication of the American system. While there are always calls to charge so-called health tourists for NHS services, the free-at-the-point-of-use mantra has been effective. Except it has been effective for the Conservative Party and this is a hurdle for the opposition.

The privatisation conundrum

As long as health services remain free at the point of use and people are not filing for bankruptcy because of medical bills, it is really hard to get people to care about whether the services are being provided directly by the NHS or the NHS has farmed it out to a private company.

On top of this, Corbyn's rhetoric about stopping all NHS privatisation is simplistic. For starters, GPs have always been privateers. Any attempt to nationalise GP services, forcing GPs to work certain hours and potentially reducing the flexibility for GPs to work part-time, will result in a shortage, particularly among GPs who are parents - this will disproportionately affect women GPs so hardly a great victory to be had there. 

The big financial pressure here is the cost of administering the tender process, with estimations between £4.5 billion to £10 billion per year. But if we keep farming out services - which can be anything from cleaning the loos to cancer treatment - the government has to run a proper tender process, which is not cheap. Thus the government needs to acknowledge that this will be the case as long as services are open to tender - this is not an expense it can pretend doesn't exist.

Additionally, the NHS is not subjecting private companies involved in bidding for contracts to the same freedom of information rules that government departments are subjected to - so this makes transparency much harder. Indeed, I tried and failed to get solid information from my local hospital trust on whether the rise in MRSA infections had anything to do with farming out the cleaning services to a private company, but I was stonewalled. This government is not going to do anything about this given it already has form in trying to restrict existing FOI access. 

Similarly, there doesn't seem to be any bans on companies being able to bid for or keep contracts after catastrophic events. G4S should have been banned from any government contract after the Olympics security debacle and they continue to run the patient transport services at my local hospital despite killing an amputee in one of their vehicles owing to insufficient staff training. Virgin, meanwhile, has also done an abysmal - and lethal - job of running the Urgent Care Centre at Croydon University Hospital, yet continues to hoover up NHS contracts, including a £700 million contract over 200 hospitals late last year. 

These are fundamental problems with the way things are run at the moment but even if all NHS services were returned to the NHS, the NHS still has to procure stuff it can't make itself. 

It is absurd to expect the NHS to set up its own factories for bedlinen, cutlery, crockery, windows, uniforms and the thousands of other things it needs to purchase in order to function. 

While one idiot once said to me with a straight face that the NHS will indeed make all its own things once the workers control the means of production, that is clearly ridiculous. Instead, the NHS should use its huge purchasing power to get the best possible deals on all it procures. There is no excuse for waste here and the NHS will continue to buy stuff from private companies. Sorry, it will. It's just that the procurers should do a better job of it.

The technology conundrum

Actually, this should not be a conundrum at all. If there is good technology out there that can contribute to saving lives, money and time in the provision of healthcare, the NHS should look into procuring it for the best price possible. 

I have noticed a rejection of technology among elements of NHS campaign groups. There was a placard at yesterday's march that said "TECH IS CHEAP BUT AN APP CAN'T WIPE YOUR BOTTOM". This is very true - there will always be a need for human beings in hospitals to perform such tasks but if there are apps that can improve the way care is provided, this should be looked into.

I've seen NHS campaigners complain about advances such as telemedicine, even though it can be used as a way to improve access to care and relieve pressure on GP surgeries. Again, it cannot always be used as a substitute for an in-person physical examination but it can play a role and this sort of thing should not be dismissed out of hand.

I suspect nostalgia for the good old days of the NHS comes into play here instead of recognising that society has changed since the NHS was established in 1948, the population has increased, amazing advances have been made in medical science, and technological changes have happened and a modern NHS needs to be about making all this work for everyone.

And again, if there is technology that can be used to improve patient care, it will have to be purchased from private companies. Like I said, Corbyn's anti-privatisation rhetoric is simplistic.

The Australian model?

As I said, if services are still free at the point of use, there are millions of people who won't care if the services are provided by a private company.

What I do see happening is a move towards the hybrid Australian system rather than an all-American system, with a mixture of public and private services side by side. I dared to suggest this on a local campaign Facebook page last year and was howled down. I never said the Australian system was perfect in my comments, merely that, as someone who has experienced both the Australian and UK systems, I could see the trends happening over here.

It is important to bear in mind that just as we have postcode lotteries with care in the UK because of differences in how CCGs spend their money, the American system is actually multiple systems on a state-by-state basis - so to simply say: "We're going all American!" is also simplistic. We will see more involvement by American companies in the NHS, particularly if we are left wide open to this in a post-Brexit trade deal with the US. It is important to remember here that American companies are very nimble and thus good at adapting to trading in diverse markets. 

From McDonalds varying its menus across cultures to big oil companies making money in countries with a wide range of tax and regulatory systems, it's what American companies do. Healthcare is seen as no different by American companies.

Like America, Australia has differences in health systems between states but with public-private hybridisation across them all. I can see this Australianisation happening in microcosm form at my local hospital, St Helier.

St Helier could well lose its A&E department in the near future, which will be disastrous, forcing people to spend longer in ambulances or in traffic or on public transport seeking medical attention. 

But I predict it will keep its maternity unit, bolstered by its expanding assisted conception unit. Currently, IVF patients undergo pre-IVF testing and appointments as well as egg extraction at St Helier but the eggs are fertilised at Kings Hospital. The transfer of fertilised eggs also takes place at Kings. When St Helier's assisted conception unit expands to include its own embryology department, it will become a one-stop shop for IVF patients. Under local CCG rules, one round of IVF per patient is funded on the NHS but there is nothing to stop St Helier from receiving paying private patients - this should prove a handy source of income for the hospital and I suspect we will be seeing more and more of this across NHS hospitals all over the country. This sort of thing is not unusual in Australia and the funds raised from the private business helps keep the public services afloat.

The IVF example is an interesting one because, like privatisation but services being free at the point of use, it is also an example of what the public will tolerate here in the UK. In Australia, there are some Medicare rebates on fertility services but, by and large, it is an expensive undertaking with plenty of couples spending thousands in their quest to have a family.

It would not surprise me if, in the coming years, IVF on the NHS becomes virtually unheard of. I believe this is something the public will tolerate overall. Breast implants, unless they're for mastectomy patients, is another service I can see being chipped away, along with transgender procedures. Prochoice activists will also need to be vigilant about any attempts to limit abortion access - Jeremy Hunt has publicly said he'd like to see the time limit reduced to 12 weeks and if the government thinks it can save a few more pennies this way, or give the impression of being fiscally sensible, without taking too much of a hit on election day, I wouldn't put it past the May regime. Hunt was shot down in flames by people across the political parties last time but that was 2012. Britain has become a more conservative place in just five short years. 

I am not saying any of this is right - especially as such cuts would target women disproportionately - but it is the kind of thing this government can get away with if it doesn't anticipate harm at the ballot box. Hell, you've only got to look at Labour's catastrophic humiliation in the Copeland by-election, losing a safe seat to the Tories at a time when local maternity services are under threat to see what resilience this government has right now in terms of withstanding removing NHS services. 

The other Australian trend that has already gained plenty of traction here in the UK is increased take-up of private insurance. The advertising is ubiquitous, the deals often sound affordable, there is an increase in employers offering private cover as part of the package for staff. Around 50% of Australians have private health insurance, compared to an estimation of around 8.7% of people in the UK. Figures up to the end of 2015 show a surge in uptake of private health insurance in the UK. Again, plenty of people will not see this as a bad thing, especially if they find they can be treated faster if they go private.

Apologies for the long blog post

I have ranted for longer than usual this time but it is a complex subject. Just as there needs to be follow-up after the women's marches in the wake of Trump's election, there is a long road ahead if the NHS is to be preserved. I do not expect the NHS to survive in its current form and, despite yesterday's impressive march turnout, there is plenty that voters will tolerate in terms of cuts particularly if it doesn't affect them directly. Too old for an abortion? Not a woman? Intolerant to transgender people? These are the people who probably will turn out to vote in 2020 and they might not seek to punish the Tories over the NHS. 

It's a massive issue and none of it fits nicely on a placard.

Photography: Loco Steve/Flickr

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