Category Archives: Lobbying for social change

Self-evident truths

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Two hospitals could be privatised and another will lose its accident and emergency department in the first test of the government’s determination to deal with bankrupt NHS trusts, it has been revealed.

Plans for South London NHS trust were outlined on Monday morning by the special administrator Matthew Kershaw. He said that without action the trust, already losing £1m a week, would accumulate a deficit of more than £240m by the end of 2015. (The Guardian, 29 October)

With the risk of sounding like a moral relativist – even though the self-restraint of dispassionate analysis usually eludes me – all assumptions at the heart of how human society is run are mere conventions – moral, intellectual and often purely accidental. What they are not is universal truths external to human endeavour. They are alive and tacitly accepted for as long as no one successfully challenges them (enter here the 20th century social revolution of your choosing).

So there is nothing self-evident therefore about our requirement to accept a public life permeated by the utilitarian and economistic language and assumptions of the free market system. Its unquestioned aura of scientific authority is our golden cage, comforting us with its promise of trickling prosperity and rigorous efficiency but also locking us into an inescapable logic. A logic of measuring the value of everything primarily and inflexibly in financial terms, with the narrow ideal of pecuniary profit as our only guidance.

This is not a lecture on money being the devil’s eye, as the Eastern European saying goes. It’s an expression of concern that the only thing that remains where social purpose used to exist is the unforgiving orthodoxy of neo-liberal capitalism.

“Bankrupt” NHS trusts, hospitals “losing” money, profit-driven private sector service providers beckoned to impart their wisdom on efficient delivery… This language has no place in the healthcare system, because it represents a set of values that belong to the world of business transactions. The NHS has one sole purpose, of an entirely moral nature: that of keeping us all alive and well, irrespectively of who we are.

I agree that this is a moral convention, not an immovable truth. Therefore, when it is being challenged, we need to acknowledge it overtly, so that we can soberly explore whatever new moral conventions are being put in its place.

I have just re-read Nye Bevan’s “In Place of Fear” (Heinemann, 1952) after many years, wanting to better understand the moral order that produced the NHS and public service as we know it today. As an aside, it’s remarkable how little ground we’ve covered in public debate over 60 years – we are slaves to the same political dichotomy, but we have, rather tragically, given up on arguing morally about our social purpose.

You may like to contrast and compare with the Guardian quote above, bearing in mind your own ideas about the purpose of society:

“The field in which the claims of individual commercialism come into most immediate conflict with reputable notions of social value is that of health.” (Pg. 73)

“[Contagious diseases] are kept at bay by the constant war society is waging in the form of collective action conducted by men and women who are paid fixed salaries. Neither payment by result nor the profit motive are relevant.” (Pg. 74)

“They do not flow from [competitive society]. They have come in spite of it. They stem from a different order of values. They have established themselves and they are still winning their way by hard struggle. In claiming them, capitalism proudly displays battles it has lost.” (Pg. 74)

“The collective principle asserts that the resources of medical skill and the apparatus of healing shall be placed at the disposal of the patient, without charge, when he or she needs them; that medical treatment and care should be a communal responsibility, that they should be made available to rich or poor alike in accordance with medical need and by no other criteria.” (Pg. 75)

“The National Health Service and the Welfare State have come to be used as interchangeable terms, and in the mouths of some people as terms of reproach. Why this is so it is not difficult to understand, if you view everything from the angle of a strictly individualistic Competitive Society.” (Pg. 81)

“[The NHS] is therefore an act of collective goodwill and public enterprise and not a commodity privately bought and sold.” (Pg. 82)

“A free Health Services is a triumphant example of the superiority of collective action and public initiative applied to a segment of society where commercial principles are seen at their worst.” (Pg. 85)

I am not quoting from Bevan for the purposes of argumentation in public debate. His aura and legacy may inspire, but do not serve as evidence. We do not owe the architects of our public services unwavering loyalty to their ideas. I am using his words to highlight the worldview that produced the services and guarantees we now take for granted. For we must put something in its place if we decide to bring it down.

There is nothing self-evident about requiring the NHS to be profitable or about assuming that private service delivery will bring with it increased efficiency. Both of these assumptions stem from a worldview incompatible with that which conceived the NHS. The latter is doomed to fail even against the criteria of its own neo-liberal value system:

“… the worst sort of ‘mixed economy’: individual enterprise indefinitely underwritten by public funds. In Britain, newly privatised National Health Service Hospital Groups periodically fail – typically because they are encouraged to make all manner of profits but forbidden to charge what they think the Market might bear.

[…] The result is moral hazard” (Tony Judt, Ill Fares the Land, Pg. 111-112)

But that’s a different debate altogether.

How we will miss the NHS…

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While I know from personal experience that the NHS is overly strained and groaning under the weight of keeping us all alive and well, I am enormously proud to live in a country where such a thing exists.

High-quality universal healthcare that is free at the point of use is a precious achievement and a guarantee of social justice at the most fundamental level.  For me, there is no clearer embodiment of the protection society should offer its citizens when they are at their most vulnerable. My determination to see the NHS cherished, protected and improved is almost visceral, as I know it is for many others.

A consultation process is taking place in my local area on the future shape and availability of NHS healthcare.  I have read very carefully the consultation document produced by the eight local clinical commissioning groups and have drafted a considered point-by-point response here. In a nutshell, the consultation highlights the strain on NHS services in NW London and proposes to address this by reducing the services available in four of the nine hospitals in the area and by diverting patients heavily towards care outside the hospital (be it at home or within a GP-led primary care network).

Opposition

I must confess from the outset that I was sceptical about the consultation process before reading the proposals, given the amount of anger and criticism it has generated in my local community. I am saddened to confirm that the groundswell of opposition is entirely justified and that I, like many others, will do everything in my power to prevent this organised shutdown of hospital care in my area.

We are dealing with a public consultation process based on a proposal document that makes repeated and significant use of leading language, contradictory argumentation, unsubstantiated claims, spurious statistics and faulty logic. It is accompanied by a profoundly dubious consultation questionnaire, formulated in such a way so as to imply support for the proposals even from objecting respondents such as myself. Both the literature underpinning the consultation process and the way in which responses are measured fall sufficiently short so as to warrant a legal challenge.

The changes being proposed are in effect a form of organised shutdown of existing services and very much a pre-determined outcome, i.e. that four of the nine local hospitals will be downgraded from “major” to “local” or “specialist” hospitals, losing their A&E, maternity and other specialised departments in the process. They fly in the face of logic and evidence (more on this later). Worse still, they strike me as being evidently ideological, consistent with the current austerity programme and designed to benefit the private sector. As this report shows, by moving patients away from hospital care and devolving much greater control and responsibility to the primary care sector, which falls within the remit of GP commissioning, an opportunity is created for billions to be made. Call me a cynic if you wish.

One immediately obvious problem is the omission of a comprehensive overview of the services currently being provided in the nine hospitals undergoing “reform”. This makes it very difficult to judge the impact of what is being lost though the proposed reduction in hospital departments. Deliberate or not, this omission is significant and can be misleading if it prompts patients to underestimate the scale of the hospital downgrades. It doesn’t fool me.

Here are some snippets from the consultation document, which I have grouped according to their various crimes against objectivity, logic and sadly, truth.

 Unsubstantiated claims

“The fact that there are a lot of big hospitals here causes more problems than solutions” (pg. 16)

“ In NW London however, as explained in section 2, not enough services have been centralised […] It is clear that by centralising certain services, patients will have better outcomes” (pg. 26)

“However, once someone is being treated by an ambulance, the time it takes to get to hospital is much less important” (pg. 26)

“Travel times are not as critical as they used to be in deciding exactly where services such as emergency care should be located” (pg. 27)

“The main parts of the proposed changes have all been delivered before, in this country and around the world, and so are known to be a successful way to reorganise health services to prepare for future demands” (pg. 71)

Spurious statistics

“At a public event in February 2012, 200 representatives of public and patient groups and clinicians ranked the most important criteria [for deciding which departments to close] as follows…” (pg. 52) – this is a survey with zero statistical value, which is used as evidence and granted the whole of page 52.

“Around 38 multi-disciplinary groups across NW London, covering 1.9 million people with care plans for all long-term conditions and elderly and case conferences for complicated cases [would result in] 17,000 more diabetics, 200 fewer amputations and 880 fewer deaths” (pg. 39) – apart from the evident speciousness of these statistics, they are also nonsensical (more diabetics?!) and completely out of context (compared to what, over what period of time, why, etc.).

Leading language

“This means delivering more care in surroundings which are better for patients – for example in community facilities, GP surgeries and in the home” (pg. 13)

“Local (i.e. downgraded) hospitals will offer better nursing, therapy, rehabilitation and community services…” (pg. 41)

And even some poetry:

“It will mean all these organisations, their leaders and workforces working across boundaries and without barriers and, as a result, patients in NW London receiving better care” (pg. 30)

Dubious logic

“We have recommended that Central Middlesex Hospital should not be a major hospital but an elective hospital with local hospital services. This is because it is already providing these services, its major A&E services are already under pressure (A&E emergency round-the-clock care had to be suspended in late 2011 because not enough senior emergency care doctors were available on site)”… (pg. 56)

Translated, this means we propose to shut down the A&E Department at Central Middlesex because demand outstrips service supply.

Contradictory argumentation

The insufficient number of consultants to cope with A&E demand (pg. 15) cannot be rectified by hiring more consultants (pg. 16), because they would not see a large enough number of serious cases to maintain their skills. This flies in the face of the admission that there are not enough consultants to cope with the urgent cases that require their expertise (pg. 15).

A declared benefit of “local hospitals” is that they will provide clinicians with training and professional development and act as centres of research (pg. 40), despite a clear indication that training and research should be centralised around specialist sites to improve the quality of research and education (pg. 27).

Daring fibbing

“To give women in NW London more choice about where they give birth, the new major hospitals would also have a midwife-led maternity unit.” (pg. 45)

The truth is that women in NW London will not have more choice, but rather a lot less choice following the closure of maternity departments at Charing Cross or at Chelsea and Westminster, for example.

Saving the best for last…insults

“Of course this will not be easy [delivering the proposed closures], nor will it be very popular among certain groups of people or communities.” (pg. 32)

“So while people do feel strongly about local health services, this does not mean that it is wrong to change the services.” (pg. 32)

What next?

In the face of these dangerous proposals, it saddens me to see my local hospitals effectively compete with one another for their survival – understandably, as either Charing Cross or Chelsea and Westminster will lose their A&E and maternity departments depending on which option becomes the preferred one. Given what is at stake, I would prefer to see a coordinated approach that challenges the consultation and its proposals on the legality of the process and on principle. Otherwise I fear my local hospitals are falling into the trap of the false choice being offered (i.e. whether to cut services in hospital A, B, or C), rather than demanding the opportunity of examining options that are absent from the consultation document – such as addressing chronic NHS underinvestment without hospital closures, lobbying for suitable funding and achieving savings in any area except the frontline services.

One thing is certain. If we fail to act now, we will truly miss the NHS before too long.

On recklessness

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Having just returned from a week in a once thriving fishing community in Portugal, I read an article about a much-needed campaign to improve the access of small-scale fishermen to EU-regulated fishing quotas. EU fishing quotas were introduced in the 1970s and 1980s to help protect European fish stocks and the livelihoods of European fishermen. Perversely, through bad design and questionable implementation at national level, they have ended up exclusively favouring the big fishing industry, who are trawling the seas unsustainably, depleting fish stocks and destroying centuries-old small-scale fishing communities all over the EU.

In short, the quotas are blasting into oblivion the very things they were designed to protect.

The Common Fisheries Policy reform expected in 2012-2013 will be a real test of how willing and capable we are of prioritising sustainability and the survival of traditional communities over the interests of big business. The Fair Fishing Manifesto published by Greenpeace and Nutfa  is not some tree-hugging pipe dream. It’s the illustration of multiple tragedies taking place right now in front of our very eyes. They require us to pay attention and take urgent action.

I married into a Portuguese family with a proud fishing heritage in Peniche, a tiny windswept rock of Atlantic wilderness and mind-boggling human resilience. Two generations back, they earned their living exclusively from fishing, along with most of the people of Peniche. Arnaldo, my husband’s paternal grandfather, went out to sea in his own small boat, while Zacarias, the other granddad, worked on traditional ‘traineiras’, finishing his career on the charmingly named ‘O Atleta’ (The Athlete). Grandma Isabel spent her days mending fishing nets with other fishermen’s wives, uncle Arnaldo was a fish auctioneer at the Peniche fish market, while my wonderfully brave and wise father-in-law started his working life building fishing boats on the beach at the old Peniche ‘estaleiro’.

These days, the only family member involved in fishing is uncle Urban, selling fish from his little refrigerated van and finding it increasingly hard to make ends meet because of fish stock depletion and decreasing profit margins. Peniche itself is faced with an employment crisis, with the only opportunities on offer being a handful of food processing plants and an emerging tourism industry fuelled primarily by young Northern European surfing enthusiasts. The ocean has been fished to within an inch of its life.

Two generations ago, the people of Peniche knew not to fish all year round, to allow stocks time to reproduce, grow and replenish. Nowadays such practices are deemed commercially unsound. Our trawlers are merciless and relentless, our technology unbeatable, the few who profit are drunk on greed, while our oceans lie increasingly empty and communities wither away.

There was nothing unavoidable about any of this. But it takes courage to keep greed and recklessness in check, even when not doing so means spiralling uncontrollably towards disaster. Us humans have real trouble imagining alternatives to ‘business-as-usual’.  By next year the EU’s decision making-process will be complete and we will know if the CFP reform is anything more than another collective failure of the imagination. I wholeheartedly hope that it is.

Democracy CPR

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Business secretary Vince Cable says the financial sector is disproportionately influential in policy circles. This shouldn’t surprise anyone. I touched on this in Amplified’s first blog post. There are important questions to be answered here about the quality of democracy and the fair representation of social and economic interests.

It is unrealistic to expect the private sector to curtail the amount of investment it makes into lobbying. What we can and should do is enrich public debate in a way that puts pressure on the policy agenda. It has not been sufficiently clear for a very long time that the financial sector or indeed any other big business stakeholder are not by default guardians of the public interest or of widely shared social goals. This has however long been an underlying assumption of political debate and policy output.

The tide seems to be turning. Nef’s Andrew Simms is pulling no punches: “This looks like full-scale mobilisation for an economic war of attrition with the finance industry on one side, and the rest of society, business and industry on the other.” This new narrative is sorely needed, belligerent though it may sound. Only a couple of years ago, Big Society guru Jesse Norman was framing social conflict in entirely different terms, personifying the state as a life-sucking force quashing all conversations: “In conversational terms, one might think of the state as the domineering bore at the table, whose loudness overwhelms the talk of others. But a better parallel might be that of the patriarch whose favourites thrive, but in whose unspeaking presence others feel robbed of air and automatically fall silent”.

When Norman was writing about this in his guide to the Big Society, anti-statism was if not the only game in town, then certainly the biggest. What the emergence of new narratives does is help ensure that the “ills” that are being addressed in policy output correspond to the values and preoccupations that best represent us a society. It may sound obvious, but variety has long been missing from the narrative palette underpinning debate, at least in its mainstream manifestations. With an obviously depleting effect on democracy. Vince Cable may have just administered some much-needed CPR.

Ambition

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A few months ago I offered advice to a humanist organisation doing great work to promote human rights and equality in Europe and beyond. We spoke at length about their impression of being denied access to the key discussions taking place within the EU institutions on matters to do with faith and inter-cultural dialogue. I couldn’t help but agree that inter-faith debates in Brussels frequently exclude secularism. This is a significant systemic failure that deserves to be addressed – for its influence on political debate and project funding, if anything.

I spent a long time before our meeting reflecting on the reasons why EU debates on matters of faith are not as inclusive as they ought to be. I have direct experience of running inter-cultural conferences in the European Parliament. So I understand the influence that external actors can have at every stage of the process. Such external influences can be a fundamentally positive way of keeping political debates relevant at a societal level. If they retain a sense of balance, that is.

The question is who is responsible for ensuring balance and fairness. The institutions themselves have a lot of power in this respect, naturally. But, from my experience, they are also fairly responsive to external pressures. Some humanists fear, for example, the conspiratorial influence of the Catholic Church. It’s certainly true that many MEPs and EU civil servants do not disclose their allegiance and links to particular faith organisations. But the reality is that most lobbying by churches takes place overtly, using professional strategies and established channels. The Catholic Church are a good example of successful lobbying that results in influence on political debate and a seat at the discussion table.

Amplified makes it its mission to help social progressives gain access to the corridors of power via the same established channels used by conventional interest group lobbying. They must overcome their outsider complex and be armed with the knowledge, confidence and contacts that are needed to have an impact. The balance of influence often tilts towards established interests, but their wheels also squeak much louder. This can and should change.