Today, the BMA and the Junior Doctors begin unprecedented industrial action against the highly controversial contract – a full 48-hour walk out across all departments.
Let’s make one thing clear from the start – this in no way will affect emergency patient care. As Roshana Mehdian calmly and succinctly conveyed on “Newsnight” last Friday (and NHS England hurriedly confirmed an hour later) full contingency plans are in place, and there is now a specific website containing signposting to services on strike days.
So we can disregard the nonsense surrounding junior doctors being “militant” and their action being a “danger” to patients, and cut to the chase - the real reasons behind their industrial action and the objections to the contract. And the real reasons behind the Conservatives’ intransigence and unrelentingly bombastic attitude towards the BMA and its members.
Speaking to me, Dr Ben White, one of the 5 doctors from the “Justice for Health” group challenging the legality of Jeremy Hunt’s actions and who resigned as a doctor live on television Monday morning over the contract, said:
“Despite concerns from public, patients and professionals, he has refused to listen and instead pushed on with a politically motivated agenda for an unfunded "7-day NHS".
White continued: “We already have seven-day emergency services staffed by junior doctors. Trying to stretch staff further would tip an NHS on the brink over the edge into the abyss. He has proffered a scenario which would be a perfect storm for patient safety.”
Indeed. In layman’s terms, we are witnessing a Government attempting to impose a wholly unsatisfactory contract by using an un-costed and untested regime as leverage for the argument – ignoring the recommendations from professional bodies and individuals.
In its evidence-scraping, the Department of Health has used studies and consultations from numerous institutions and experts (most notably the “NHS Services, Seven Days a Week Forum” document, authored by Sir Bruce Keogh), which all point to the fact that it is consultants working patterns that need to change if we were to realise a “7-day NHS” – not junior doctors.
The doctors pay review board said in its recommendations: “We note that junior doctors are already working across seven days: indeed, they play a vital role in the delivery of services, particularly in the evenings, at night and at weekends”. They go further, saying “reform (of the contract) is not directly linked to enabling 7-day services” – but stipulating that the removal of the non-emergency weekend working opt-out clause for Consultants, was.
The contract will also lead to longer shifts and reduced rest times, creating more dangerous conditions for doctors to be working under – and is fundamentally discriminatory against women. The evidence that a “7-day NHS” would decrease “excess deaths” at the weekend is at best tenuous (and at worst nothing but cynical propaganda).
The BMA officially states that “We could not agree to the unsafe and unfair preconditions proposed” but have repeatedly tried to make headway with Jeremy Hunt, while a cross-party delegation led by Shadow Health Secretary Heidi Alexander attempted to broker a deal at the weekend – both to no avail.
So why do the Conservative Government still insist on forging ahead with this contract, even when it flies in the face of mounting clinical and professional evidence?
If we look at how right wing think tanks have been intimately involved in both designing and imposing the contract, and examine the agenda of this right wing in a bit more depth, we begin to see that this is not really about a “7 day NHS”, nor is it really about the junior doctors..
One phrase: privatisation-by-stealth. A purposeful agenda, which requires considered analysis and historical context. Things that are sorely lacking in most of the debate surrounding the Junior Doctor’s contract.
Rewind to 1988. Conservative MP’s Oliver Letwin and John Redwood published a document entitled “Britain’s Biggest Enterprise: ideas for radical reform of the NHS”, via the right-wing think-tank Centre for Policy Studies. Comparing the health service to a “slightly wayward and much loved pet”, Letwin and Redwood alluded to the “establishment of the NHS as an independent trust, which increased joint ventures between the NHS and the private sector” – something unheard of then, but is exactly what we have now have had within the NHS for some time.
Both Oliver Letwin and John Redwood are still MPs, with Letwin currently being responsible for Government policy, and Chair of the Conservative Policy Review from 2005-2010. Both have, or have had, vested interests in private healthcare – Letwin being a former executive director of an investment company that specialised in healthcare, and Redwood? Pretty much the same.
In 2005, a pamphlet by Tory ‘modernisers’ including one Jeremy Hunt, called “Direct Democracy: an agenda for a new model party” was released.
On the NHS, the pamphlet spoke of the ambition being “in effect denationalising the provision of health care in Britain”, and described the NHS as a “a centrally run, state monopoly designed over half a century ago” which is a “fundamentally broken machine”.
Fast-forward to the near-present, and in 2012 the “Health and Social Care Act” was introduced, and was a step on the path towards this vision.
The 2012 Health & Social Care Act removed the legal obligation on the Secretary of State’s to provide and secure comprehensive and universal healthcare. It handed a weaker duty to local Clinical Commissioning Groups (CCGs), meaning they can decide whether to take away services, or even start charging for them.
The Act also effectively said CCGs had to let private firms bid to take over any bits of the NHS they fancied, strengthening previous non-statutory guidance and entangling the NHS further in EU competition law.
So, what is the next step in the privatisation-by-stealth of the NHS? The answer probably lies within the “Reform” think-tank.
While Conservative cheerleaders provide the doctrine, institutions like Reform provide the mechanisms to implement it. The think tank Civitas recommended the scrapping of the nursing bursary; Reform endorsed “reducing centralisation” (“Why let a good crisis go to waste?”) and they also pushed for the takeover of “failing” hospitals by private companies (remember Hinchingbrooke?).
In a document from this month entitled “Who cares? The future of general practice”, Reform suggest that (in terms of the NHS) the current commissioning system is too fragmented, and a “healthcare system that acts as one” was needed, that should “cover the whole care needs of defined populations. Integrated commissioning bodies should replace today’s fragmented commissioners. Whole-population-care contracts should be capitated, with commissioners able to attach bonus payments to incentivise improved care in specific areas. Contracts must also be time-limited and the appropriate size to incentivise competition between providers”.
Translated? Whole geographical areas could be offered up to one private company to operate.
This leviathan approach ties in nicely with the Governments current mission of integrating health and social care, with the devolution of overall power relating to budgets in Manchester being the test model for this, and more than 20 other authorities lining up to follow. Could the centre of the Northern Powerhouse be the first place to have its entire health, primary and social care provision operated by one, singular (private) provider?
Key individuals from the private sector have been moved into public office: Simon Stevens – formerly a president of American healthcare firm UnitedHealth, now CEO of NHS England; Nick Seddon – former director of Reform think-tank, now Cameron’s personal advisor on health; Stuart Rose – board member of Bridgepoint Capital who own Care UK, drafted in by Cameron as an NHS consultant; the list goes on.
So is this why administrations like the Conservative are seemingly hell-bent on selling off public assets, and reshaping them so it’s easier to do so? The blurred lines between big corporations and big governments are foggiest when it comes to the revolving door into the House of Lords. Around 25% of Conservative Peers have vested interests in private healthcare.
“Corporatism” – those blurred lines I mention above – is at the heart of the Government’s strategy surrounding the NHS, and pretty much every other policy decision we see in the modern world – because ultimately the winners are corporations (with profits) and politicians (with careers).
Jeremy Hunt is the current public protagonist of this stealth privatisation policy. But he’s merely another puppet in a long line of ministers on strings (including his private health-promoting cousin) from both Conservatives and Blair-era Labour.
But how is the battle over the Junior Doctor’s contract and a “7-day NHS” related to all this?
We are now seeing the end game of a targeted strategy that has been decades in the making. Chronic underfunding, “top-down reorganisation”, the crippling ‘Private Finance Initiative’, CCGs... The drip, drip approach has been essential. The NHS is the 5th largest employer in the world and an organisation of epic proportions, it couldn’t have been privatised in just one parliamentary term. As the director of the right wing Adam Smith Institute admitted a few years back, when asked if the government would really turn the NHS into nothing more than a franchise, a kitemark - "It's been 20 years in the planning,,, I think they'll do it".
Earlier this year a Department of Health draft report (leaked to The Guardian) stipulated that the 7-day NHS proposals would cost £900m more per annum and require 11,000 more NHS staff. The Department admitted it couldn’t “evidence the mechanism by which increased consultant presence and diagnostic tests at weekends will translate into lower mortality and reduced length of stay”.
Fundamentally, the imposition of this contract will be irreparably damaging to the health service - a fact the Junior Doctors are acutely aware of.
By instigating chaos via an unfunded, unnecessary and unworkable policy, the Government will be able to claim that they’re out of options; that the only remedy left for a crippled NHS is to put it out of its misery and allow the private sector to step in – and with contracts worth around £25bn having been put out for tender in recent years with anything from 33 to 70 percent going to private companies, some worrying signs appear to already be there.
This is classic right-wing “shock therapy”: damage and destabilise a public service so much that you can present privatisation as the only way to revive it. The corporate vultures can move in to pick over the remaining flesh on the bones. Time and time again this strategy has been used around the world, not just on public assets but in some cases on whole countries – note Pinochet’s coup in Chile, mentored by laissez-faire economists like Milton Friedman.
British Rail, a pertinent and similar example, had its funding more than halved between 1982 and 1990 from £1.3bn to just over £500m, and suffered numerous “top-down reorganisations” including the “Organising for Quality” initiative which aimed to decentralise power and put control of budgets into regional cost centres, It was the target of think-tanks like the Centre for Policy Studies (see Letwin/Redwood) floating ideas around about privatisation from the mid-eighties onwards. It was generally scorned by the Government and the press, projecting an image in the public’s minds of an outdated, cumbersome and failing public sector monolith that couldn’t even produce a good sandwich.
The end result? The fire sale of British Rail in 1993 – and the exact same technique is now being applied to the NHS.
The dispute we are witnessing is a microcosm of what’s really going on in the NHS: A Government which has little regard for either staff or patients; whose only concern is fattening the clinical turkey up for a corporate Christmas, and who ultimately are showing no signs of relenting from an agenda which has been in the making for three decades.
While the public currently support the industrial action, fickleness and manufactured consent via a complicit media are never far away – and once their backing has gone, then the Government has won.
Simply put, the battle surrounding the contract is just another weapon in the Conservative’s (and their corporate bedfellow’s) armoury in the war against a public health service. Historical context sorely needs to be considered in this, otherwise history will judge us and our actions – and it will not be favourable.
While Oliver Letwin and his ilk appear to disdainfully consider the NHS a “wayward pet” whose only hope is to be put out of its misery, the thoroughbred that is our health service is by no means ready for the knacker’s yard, yet – and the fight for its life must continue, well beyond the next two days.
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