Tag Archives: welfare

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.

The way we talk

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We must question the narratives that shape our public space if we are to have any certainty in the body of policies that guide us.

A political battle is won when your opponents adopt your framing of an issue in their own arguments. The way we talk about social problems, their sources and their dangers shapes our amenability to specific policy remedies. It primes us to accept a particular worldview as accurate, along with the social problems it identifies and the course of action it proposes. I have talked about this many times already. It is a key issue at the heart of what Amplified seeks to do and obvious though it may sound, it’s usually ignored – particularly in an age in which political debate is underpinned by a tacit consensus on the usefulness of neo-liberal economics.

Public debate is swamped with denials of the social causes of deprivation and disadvantage. Perversely, there is no such thing as society in the Big Society. The individual alone is the subject of praise and recrimination, the recipient of reward, incentive and admonishment. Individual responsibility and merit alone explain success and failure; they also justify coercion and recompense. Inequality of opportunity has all but vanished from the public space. All that remains is individual choice.

The worthy wealth creators and hardworking homeowners sit in one camp while the destitute, the invalid and the jobless are shown the error of their ways. If society plays no part in their predicament, the wicked must be shown the virtuous path through penitence. The law is no longer there for the vulnerable, but for the upright citizens and the paragons of success – for their economic and social advantages are a reflection of their own merit. No example is better than the abolishment of the so-called “squatters’ rights” to offer further protection than what already existed for hardworking homeowners. This riles me despite my own experience as a homeowner whose house was quite literally devastated by an unwelcome guest. The law should favour the needy, the vulnerable and the disadvantaged. It’s the very least it can do.

I write about the stories we tell in our public space because they are the mechanism via which ideology becomes indistinguishable from common sense. I make no secret of my own ideological bias in my writing – indeed, it would be very hard to. I truly fear that by denying the social causes of deprivation and disadvantage, we also remove our obligation to care, our very capacity for compassion, and ultimately the precious bonds that hold us together as a community with a social purpose.

The way we talk shapes the way we think and, in turn, the way we act. When ideology becomes common sense, there is little room left for manoeuvre and debate. That is why the right questions need to be asked at the right time. We must question the narratives that shape our public space if we are to have any certainty in the body of policies that guide us.

There is no alternative

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No words are more abused in politics than these. I touched on it already in my previous article here. I will keep highlighting this sort of language and its implications. Because everything in public life is constructed – through stories and language and imagined enemies and belief – and there is always at least one other way. The way that involves not taking the course of action presented as the only way.

Professor Terence Stephenson, chair of the Academy of Medical Royal Colleges (AoMRC), wants ministers and NHS bosses to downgrade some hospitals and push through major rationalisation of key services such as major surgery or intensive care, despite local campaigns to save units. He says this is the only way – yes, apparently there is no other way – to improve healthcare for the most seriously ill. He says too many hospitals provide the same services only miles between one another. There must be rationalisation. There must be cutbacks and hospital closures.

The same services. Yes. Of course they provide the same services. They provide healthcare. They are not department stores competing for market share. They are hospitals, keeping us alive and well in our hour of need. Healthcare provision must surely be one of the core goals of living together in organised society. Yet we are told that having less healthcare available will make everything better for us overall. As if nothing could possibly be changed about the way the NHS is run and funded apart from the volume of service provided.

For me as a citizen, universal healthcare provision is a moral question. Yes, it’s a collective financial burden. But it’s the price we must pay for civilisation. Yes, we live longer and treatments are increasingly complex and expensive. But if it needs funding, we must fund it. Some say that’s naïve. Yet we live in a world in which trillions of dollars are tucked away by the wealthy in offshore tax havens while governments claim that proportional taxation only increases tax avoidance. I am not sure what is more naïve.

The reason I keep writing about language is because it’s fundamentally normative. The pictures that are painted for us have a pre-defined course of action inscribed in them. They are not neutral, nor are they there (solely) to share useful facts. The chairman of a professional medical association speaks with a certain degree of authority. Yet he paints a rather skewed picture.

I will accept that healthcare provision must be reduced if it’s a collective and informed choice. I won’t see it as our only choice, but it will be our choice nonetheless. What I struggle to accept is that we can only afford a downgraded form of civilised society and that there is no alternative.

One of my local hospitals is going to lose its A&E department as part of this rationalisation drive. I guess you can have too much emergency care.

Four legs good

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The time has come for policy-making to be based on evidence rather than belief.

Recent stories about the corruption and incompetence of private sector contractors delivering public services raise important questions about key assumptions at the heart of political debate. For those who haven’t read enough about it already, I recommend Private Eye’s excellent series of investigations into companies delivering the DWP’s contested workfare programme. Polly Toynbee also asks some valid questions in the Guardian here.

I cannot help but view these stories in their broader context, against a backdrop of systemic change in the philosophy of public service delivery, i.e. the idea of opening up all delivery to any able provider. Here’s how the Cabinet Office’s March 2012 Open Service review frames the current debate:

“This means replacing top-down monopolies with open networks in which diverse and innovative providers compete to provide the best and most efficient services for the public. It means re-thinking the role of government – so that governments at all levels become increasingly funders, regulators and commissioners, whose task it is to secure quality and guarantee fair access for all, instead of attempting to run the public services from a desk in Whitehall, city hall or county hall.”

As always, the use of language tells us a lot about underlying ideological assumptions. What we have here is a typical story of decline (public services not up to scratch), with a cause and a perpetrator (out-of-touch central or local administration sucking the life out of public services from their bureaucratic towers) as well as an agent capable of taking the reins and reversing the decline (the diverse and innovative providers).

story of decline >> cause selection >> agent >> control

This simple narrative structure (story of decline >> cause selection >> agent >> control) underpins pretty much all political activity. It’s incredibly useful, as it creates a remit for action, with the promoters of the narrative as the agents. Its imagery juxtaposes vibrant (private) service providers to grey out-of-touch (public) bureaucrats – needless to say that in our collective imagination, vibrant and colourful beats stale and grey quite effortlessly.

This is an old mantra – the idea that the private sector is by its very nature an innovative and efficient service provider, as opposed to the state, which isn’t. Four legs good, two legs bad, in other words. Political language reinforces this mantra though stories of decline and control such as the one above. It has become so established that it’s taken as a given, in political as well as public debate.

But scandals such as G4S, A4E and Working Links show that analysis and reflection have not yet become redundant. The time has come for policy-making to be evidence rather than belief-based. I am fully aware of my own outsourcing-sceptic bias when I say this. What this debate needs is a body of research looking at quality of service and public accountability and inquiring whether the private sector, with its profit imperatives and commercial focus, is indeed inherently and demonstrably better endowed to deliver high-quality public goods and services. Then and only then will public policy be informed by evidence, as opposed to belief, ideology and other superstitions – my own included.

When that happens, we can all accept, as the case may be, the self-evidently superior nature of the delivery of public services by the private sector as the only available option and only feasible way, as the Open Service review would have us believe.

“Given the fiscal constraints, the only feasible way of making the gains in quality of service that our economy and society so urgently need is to make a step change in the productivity of the public services. And the only feasible way of achieving such a step change in public service productivity is to introduce competition, choice and accountability – so that the public services can display the same innovation and entrepreneurial drive that characterise the best of the UK’s economy and society.”

Until then, I will keep wondering.

Individual merit

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As a political communicator, I cannot help but find language a rich resource of insight into the preconceptions and moral priorities that underpin public policy. One of the most interesting aspects of Big Society discourse, for example, is its seamless combination of communitarian “let’s do it”, “we’re all in this together” language with individualist ideas of responsibility, merit and a reward/punishment moral accounting system. Of course, all language hides a moral system, with ideological elements that are accepted as common sense. And naturally, there is no such thing as common sense, or rather, there is nothing common about it. Our ideas of what constitutes common sense are very much tied in with the moral and ideological conventions we subscribe to.

Take poverty and inequality for example. They are universally deplored as unacceptable and in Big Society discourse their eradication is as much a priority as in leftwing traditions. Poverty is a moral issue, an immoral state of affairs or a moral failure – in that it is morally unacceptable for deprivation to exist in our broadly shared ideas about society. That may sound nurturing and communitarian, but a closer look reveals a different story. Welfare in Big Society discourse is a trap (this is actually a commonly used metaphor) and welfare dependency very much an individual issue. That is, a failure of the individual as opposed to a systemic deficiency. Here’s how deprivation is explained in the DWP’s Social Justice blueprint from March 2012:

« Though low income is a useful proxy measure, it does not tell the full story of an individual’s well-being. Frequently, very low income is a symptom of deeper problems, whether that is family breakdown, educational failure, welfare dependency, debt, drug dependency, or some other relevant factor.»

This is a story of individuals erring from the moral path of small-c conservative righteousness, which would stipulate strongly fused family units, educational accomplishment, economic self-reliance, thrift and a healthy and wholesome lifestyle. Therefore it follows that economic deprivation is a symptom of individual moral failure, as opposed to being an effect of societal inequality of opportunity.

Why does this matter? It matters because the moral assumptions underpinning the DWP’s current outlook may well end up monopolising the welfare debate, as they are pretty much unchallenged in mainstream political debate, at the level of narratives. Which means the idea of individual merit is likely to become a prevalent explanation of economic success and deprivation. And this will affect the way we look at poverty and the amount of sympathy we are willing to allocate to it for generations to come. We may one day not so long from now be talking about the “undeserving poor”. I can accept this, although it goes against my own ideological bias, as long as we are aware of it happening, and conscious of the moral choice we are making – for it is a moral choice, as opposed to something self-evident, belonging to the realm of common sense. This is why peeling the layers of the language of politics is a satisfying and worthwhile pastime.