Should politicians summer reading lists include 'unthinkable' ideas for the NHS?

Corporate think tanks hope their bravely unthinkable suggestions to "fix" (or kill) the NHS are on politicians' summer reading lists. But why are far more popular and evidenced solutions - like reversing privatisation - so unthinkable to the political class?

John Lister
18 July 2014


Labour leader Ed Miliband reading on the beach. Image: Jon Parker Lee. www.jonparkerlee.com All rights reserved.

“Thinking the unthinkable” is a fashionable phrase from people trying to get us to take on board policies that they know will encounter a lot of resistance.

Are their suggestions really 'unthinkable'? Or just ideas that are publicly and politically unacceptable?

How bad do things have to be to abandon all your basic values and principles and start to embrace completely different values? This isn't a question of timing - it’s a question of whether you really have any principles at all.

The fact is, no matter how mad or bad an idea may be, there’s normally somebody, somewhere, thinking it, whether they are sitting comfortably in one of the countless right-wing American think tanks, reclining languidly in the Adam Smith Institute, or chatting amiably with Lord Warner or one of the other leading lights of Reform.  They will already have been thinking it – in some cases for decades.

We know that whenever their ideas are voiced out loud, or put into print, they frighten and antagonise decent people. So who really wants to be aligned with this unsavoury group of co-thinkers?

Look at the recent example of UKIP. It’s a populist right-wing party with classical right-wing, neoliberal policies, apparently rejoicing in the image of being cavalier and politically incorrect.

But even UKIP was embarrassed when their Deputy Leader put out a letter saying that “the very existence of the NHS stifles competition” and that they wanted it franchised out. When they were challenged by Labour and other opponents to say where they stood on charges to see a GP, the party’s spin doctors saw the danger signs: this could cost them votes. (The letter has since been removed from the deputy leader’s website but a snapshot is viewable here).

UKIP was obliged to do an abrupt U-turn, and put out statements claiming to support the NHS.

So some ideas are unthinkable, even by unspeakable people, because they are unacceptable to the electorate – a political liability to any party that signed up for them.

Thatcher found the same. Party ideologues John Redwood and Oliver Letwin in the 1980s hatched plans so extreme that - despite her commitment to such plans - she couldn't include them in her 1989 'review' that spawned the costly and bureaucratic ‘internal market’ in the NHS. 

The plans remained, though - and resurfaced at the core of Lansley's 2012 Health Act. Cameron was canny enough to hide the plans from his 2010 manifesto, aware (as Michael Portillo admitted) they would drive away voters in droves. Even a majority of Tory voters are opposed - only 13% of Conservative voters say the NHS should be run privately.

So these policies had to be smuggled in after the election, without any electoral mandate.

It seems you can't keep a bad idea down.

Year after year the BMA debates some proposal or other to impose charges for GP consultations, and heavily rejects it at its conference. 

The King's Fund’s new Barker commission has now come back to this same old idea of charging as well. It's among the list of unpleasant options from which the commission urges us to select the least detested means to boost NHS finances or cut costs.

We only have to look to Germany for the impact. A €10 charge for a visit to a GP was imposed in 2004. It was designed to deter demand and thus restrict ‘frivolous’ attendances. But the charge proved counter-productive, too complicated and expensive to administer, and was scrapped some time ago. Why would it work any better in Britain?

So why even think about thinking the unthinkable?

The fountain of unthinkable ideas on the NHS and social care is the right wing of political and economic thinking. Its currency depends on us swallowing the myth of ‘unsustainability’ that has grown up since the 2008 banking crash, and ignoring any notions of social solidarity and equity.

As the banks crashed it was regarded as unthinkable not to bail out the bankers who had caused the crisis - but perfectly thinkable to dump the costs of the bailout onto health workers, patients, and other public sector workers and users.

We are told that increased health spending is 'unsustainable'. The King's Fund’s Barker commission – which studiously avoids looking at the costly trappings of the health care market itself – argues that it is politically impossible for any British government to allocate more than 42% of GDP to public spending.

Labour has ducked even questioning this arbitrary political decision, and seems to be dragging its heels over any commitment to release more money for patient care.

It seems no major party wants to promise more money. There is a determined effort to ignore the looming consequences of cash starvation.

The public aren't thinking along the same lines. Recent opinion polls show a very large majority fearing that the NHS is under threat from charges and privatisation, another majority willing to pay more tax to protect the NHS, and 80% wanting political parties to protect the NHS against austerity cuts.

Why is it thinkable to starve the NHS of cash to the point of near collapse, and unthinkable to increase funding, when that’s what the public want? The NHS will not survive in its current form unless more money is released for frontline services.

Despite the Barker commission assertions, other countries spend much more than us on health care: both as a share of GDP and on health spending per head we are mid-table of the OECD and EU.

Despite its limited budget, the recent Commonwealth Fund report showed that the British system – at least prior to the Lansley reforms - delivered astonishingly good value for money, resulting in the NHS coming out top of eleven comparable countries on most measures – with the high spending US bottom.

The issue is not the amount of money: it’s where it comes from, and where it goes. In the USA even the crazy Tea Party right wing has no ideological objection to high and rising spending on health – as long as the money flows into the private sector, and is not raised fairly through progressive tax. That’s what they dismiss as ‘socialised medicine’.

Some of the higher spending countries – such as France – are quoted as examples of good practice by people reluctant to commit to much higher French levels of spending to get them.

Instead, keeping state spending low just means making up the difference through more ‘out of pocket’ and individual payments for health care.

All of the various proposals to inject "new money" into health care – whether by charging, or charging more, for prescriptions, hospital care, emergency care or pressing more people to take out private insurance, or levying national insurance on pensions, or whatever reactionary idea is thrown into the mix, would, if implemented, actually increase overall spending on health as a share of GDP.

As Roy Lilley argues, tax payments may come out of one pocket, and individual charges come out of another – but it's still the same pair of trousers.

Those most likely to need to pay extra are those least able to - the sick, the elderly and the poor.

The result is inevitably a 2-tier system. A system that encourages the young, the healthy and the wealthy to opt out of the queues for declining public health care by buying themselves private insurance to cover any need for elective treatment. (Nobody ever talks about the fact that private health care will not and cannot properly cover the whole population for emergency care).

What about plans to contain or reduce spending?

Almost all involve exclusions – whether of particular treatments, through rationing of services, or maybe particular groups of patients, such as the elderly or those perceived as "undeserving" patients.

Some of this will in turn divert demand to the private sector, where it will be more expensively (and profitably) provided.

There’s also a lot of wishful thinking going on in all the main parties. No-one could really oppose “integration” of services, or “care closer to home” - but there is little if any evidence that it is cheaper to deliver services “in the community”. In the current conditions of budget constraints nobody seems willing to cost these schemes properly, plan them seriously, and spend a realistic amount of money or fight the political fight to ensure they are fully implemented.

Ideas that should NOT be unthinkable

There are options currently regarded as 'unthinkable' which are much more appealing to those who wish to uphold the values and principles of the NHS.

Why, for example is it unthinkable to get the big-time scroungers, the bankers and the big multinational corporations and the wealthy to pay the tax they owe? The tax gap is estimated at £120 billion per year.

Why is it unthinkable to scrap the costly and wasteful bureaucracy of the competitive market in health care created by the 2012 Health & Social Care Act?

Why is it unthinkable to stop putting thousands of contracts out to tender, given that tendering creates a field day for health companies, consultants like McKinsey and PWC, accountants and lawyers – but there's no evidence it improves services, as even NHS England admits?

Why is it unthinkable to force a renegotiation of PFI contracts on the basis of fair value and reclaim some of the money that has been wasted on unaffordable schemes?

Why is it unthinkable for Britain to implement a financial transaction tax, as supported by the Germans and French,  that even at low levels could raise billions towards public services?

Why is it unthinkable to reject the alien political priorities that have gained an unthinking political acceptance and instead defend universality and social solidarity?

Ideologically  opposed to the NHS since 1948

Cameron's government, with its millionaire ministers and its divisive and backward looking policies, is more ideologically committed than Thatcher's to shrinking the public sector. Osborne is determined to reduce NHS spending as a percentage of GDP, and he is on course to do just that, wiping out the increases pumped in by Labour in the 2000s.

The financial crisis created by bankers irresponsiblity in 2008 was not really a problem for the Tories: it was an ideal opportunity and an excuse to drive their plans forward.

A wing of the Conservative party has never been reconciled to the principles of the NHS. It’s establishment in 1948 was itself  'unthinkable' to Churchill's Tories – who, along with the BMA, fought tooth and nail against it right up to it’s birth on July 5, 1948.

The NHS achieved much more than establishing services free at point of use funded from taxation: it established a qualitatively new and superior way of delivering healthcare.

·        It linked the patchwork of small hospitals together for the first time, enabling collaboration and creating the basis of modern medicine.

·        It created career paths and a national training system for doctors, nurses and health professionals.

·        For the first time it allowed resources to be planned and allocated to meet local needs and health requirements, not dictated on the basis of the availability of charitable funds or the possibility of securing profitable returns.

It completely superseded the failed market it replaced.

It really should be unthinkable to contemplate any policies that might threaten to turn the clock back to the chaos and inequality that prevailed before 1948.

We don't need the zombie ideas, the desperate, defeatist, unthinkable solutions that are being proffered, often masked by half-hearted denials that the Department of Health ‘has no current plans to do this’, by the King's Fund Barker Commission, by the NHS Confederation, 2020 Health, Reform and others.

We need to move forward, not backwards.

·   We need to put our NHS back together, along the lines of David Owen’s and subsequent Bills to restore the service and the duty of the Secretary of State, and scrapping the whole wasteful apparatus of competition and market mechanisms.

·        We need the NHS properly resourced from progressive general taxation – and kept firmly in the public sector, so the benefits of 1948 can live on, and grasping multinationals are kept out.

·        And we need a similar change of course on social care, to halt the spending cuts, relax increasingly tight eligibility criteria, reverse the destructive privatisation that has wrecked home care, and establish a new public sector provision of nursing and residential care homes.

We need a clear alternative in place of the timid and evasive gestures from the Labour Party leadership. They must commit to bold changes that have become regarded as unthinkable – to decisively undo the damage and scrap many of the more costly, wasteful elements of the Act.

The prospect of restoring and further improving the NHS could be a popular one, if politicians had the courage to embrace it and promote it. If not, and Labour somehow wins in 2015, they will carry the electoral burden of presiding over the demise of their Party’s most historic progressive achievement.

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