Future historians may well look back at the passage of the 2012 Health and Social Care Act as the pivotal moment in the conversion of England from a collectivist society framed by the post-war welfare state to an individualist society in which people are responsible for securing their own welfare, and state provision is not only minimised but stigmatised.
By 2012 local government had long been converted from a democratic agency for providing collective services, including housing, schooling, and long-term care for the old and frail, to an administrative dependency of Whitehall, stripped of most of these functions and obliged to implement an unremitting contraction of those that remained. Universities had already been converted into a system of training institutions, through replacing state funding with loan-financed fees which from 2010 were set at a level that made it quixotic for a student without superior family connections to regard getting a degree as anything than a means to a job.
The list could easily be extended. But the conversion of health care from a free public service back to a commodity ought to be specially remembered as symbolic of the overall transformation, because the NHS serves everybody, and—to a greater extent than any other public service—makes everybody equal. This unquestioned right of access to care, regardless of your social status or social condition is what underlies the public’s refusal to stop loving the NHS, and even being willing to pay more tax to keep it. In health care alone people still are, in David Cameron’s famously inept phrase, “all in it together”.
Yet a transition from the provision of care by public providers to provision by for-profit companies is going ahead rapidly, the scope of free services is contracting and the reintroduction of charges, long favoured by neoliberals, is now being actively canvassed (on the false pretext that there is no alternative way of closing the NHS funding gap). From start to finish the process has not merely lacked an electoral mandate, but breaks an explicit pre-election promise not to undertake further ‘top down’ reform of the NHS. Yet it is going ahead.
There are practical obstacles in the way; as both UnitedHealth and Serco have found, you can’t make a profit out of primary care by cutting costs, because 90% of patient interactions with health care are with primary care so the public quickly sees what is happening. But the large-scale outsourcing of community-based specialist services such as speech therapy, physiotherapy, and post-natal, mental health and elderly care that is currently under way is unlikely to be reversed; in these sectors the negative impact of profit-driven cost-cutting will be less universally felt and resented. It is also a fair bet that more and more NHS hospitals will be put out of business as Monitor requires specific hospital services to be “unbundled” and contracted out to private companies. But will future historians see the Health and Social Care Act of 2012 as the same kind of watershed as the repeal of the Corn Laws of 1846, or the Trade Disputes Act of 2006? Are they any more likely to do so than editors and journalists today, who have shown little inclination to frame the Act in these terms?
As Oliver Huitson and others have shown in NHS SOS (2013), very few newspapers, and among broadcasters only Channel 4, maintained a serious critical interest in the HSC Bill during its prolonged parliamentary passage. The huge investment by the private health industry in lobbying for the Bill (exposed, along with other similar scandals, in A Quiet Word: Lobbying, Crony Capitalism and Broken Politics in Britain (2014)); the many undeclared interests in the private health industry of MPs and numerous Peers; the central role accorded to McKinsey and KPMG in drafting legislation which promoted their business clients’ interests (as also revealed in NHS SOS); the manifest untruth of the government’s claim, which opened the preamble to the Bill, that its aim was to empower GPs - little if any of this was consistently commented on. Nor was there much appraisal of the opposition case advanced by a growing segment of the medical profession. The government cited the support for the Bill of, in particular, certain active pro-market GPs (notably in the National Association of Primary Care and The NHS Alliance), but their history and commercial interests were rarely noted.
The point of all this is not to reproach either print journalists or broadcasters but to ask why most of the media failed so comprehensively not only to provide a critical account of the aims of the Bill and the forces behind it, the flawed legislative process, and so on, but also any “external” critique, framing this measure in its historical context and pointing out what it meant for English society.
It is no doubt a major oversimplification, but from the standpoint of someone engaged in the effort to defend the NHS, the explanation appears over-determined. Most newspaper owners support business and competition. Even the Guardian, which supported the Liberal Democrats in the 2010 General Election, did not oppose the Bill unequivocally, or highlight the way in which Shirley Williams, the Lib Dems’ “national treasure” and self-styled defender of the NHS, enabled the Bill’s passage. In addition most papers are losing money and cutting editorial staff, so journalists have no time to do investigative work, or even double-source, and have little option but to use government press releases for an estimated 80% of their output (as revealed by Nick Davies in Flat Earth News (2008)), even when they know that these releases—and not least the Department of Health’s—are often shamelessly spun.
Less predictable was the way in which the BBC failed in its task of public education on the Bill, especially by including virtually none of the Bill’s best informed critics in broadcast debates. Again, there seems to be a superabundance of causes, from the Corporation’s bruising conflict with the Labour government over the David Kelly affair to the ongoing fear of cuts to the licence fee, of being required to share it with competing broadcasters, and of being subject to increased regulation by Ofcom.
And this kind of fear links the reticence of the BBC to that of both the medical profession and university-based health policy researchers. Once NHS hospitals became trusts, paid on the basis of patient throughput and obliged to compete for patients, it was inevitable that, like any other business, they would require their staff to avoid public criticism, not only of their own particular hospital but also of government policy. The independence of medical professional bodies has also been increasingly circumscribed and the BMA leadership, traditionally and understandably anxious not to find itself at odds with the government, did not seriously oppose the Bill and could not be looked to for much support, as pointed out in NHS SOS. As for health policy experts, academic careers now depend on publishing and on securing funding, including from corporates and the Department of Health. Outspoken criticism of the Bill carried a risk that many did not feel in a position to take.
In short there was a comprehensive alignment of incentives to conform that embraced not just the media but most of the active participants in the story too. And perhaps more important than anything else, in the long run, is the difficulty of continuing to see as objectionable something which has become accepted by everyone around you as at least inevitable, if not positively reasonable and satisfactory. This is most obvious in the case of the BBC: defining its commitment to political impartiality in terms of standing mid-way between the views of the major parties now means standing near the middle of a neoliberal consensus, one which has been internalised by its staff. What would have been a mainstream critical standpoint 20 years ago gradually comes to be seen as eccentric, marginal, unrealistic, “political”, “ideological”, and so on. But the same process is at work everywhere, to a greater or lesser extent. In the Department of Health, in the NHS, and in the commentariat, the post-war political culture—in which social democracy contested conservatism, liberalism and communism—has been increasingly replaced by a single neoliberal culture. Reinforced by lobbying and spin, and enforced by sanctions, it has become increasingly naturalised.
The relevance of liberalism (paleo-liberalism) to all this is not easy to discern. It belonged to the early years of capitalism, when political liberalism supported private property as a counter to political absolutism, and saw congruence between economic freedom and freedom of expression. Through the new absolutism that has resulted from the triumph of neoliberalism, this congruence has disappeared. The fate of the NHS at the hands of the media is an example of the consequences.
This article is part of the Liberalism and the Media strand of the Liberalism in neoliberal times series that OurKingdom is running in partnership with Goldsmiths, supported by the Department of Sociology. You can read Gholam Khiabany's introduction to the whole series here.
Liberalism in neo-liberal times - an OurKingdom partnership with Goldsmiths, University of London