Cameron’s ‘Predator State’ vs Junior Doctors

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RK on social media wrote (with a little editing):

An item on the news, said that teacher assistants were increasingly being used to teach full classes, some up to 30+ hours. PCSO staff are taking over much more of the standard police work and someone I know has just left a job taking bloods on wards, after little training, left alone to do the job on her own… and paid the same wage as a hospital porter.

I believe that by stealth, fully trained, higher waged professionals and semi professionals are being weeded out of many working environments.

Perhaps (just as nurses are taking over some doctor tasks) we will eventually only find the fully qualified in executive positions and barely trained, poorly paid staff will be undertaking most of the work.

Is this part of Hunt’s plans for the NHS, with doctors supervising a collection of underpaid individuals to deliver our health service?

We are fast heading to a worker bee situation, where cost cutting determines a very basic Health Care, Education and security for the masses except for those that can afford to pay. The rich will have the very best of care, education and security… further dividing an already horrendously divided nation.

This constant undermining of skills has been happening in industry for decades, where apprenticeships have ended and Mickey Mouse schemes qualify someone in a trade, after a six week course in a tech college.

It’s the bottom line that always matters most under capitalism. Skill, pride in workmanship, ethical standards of delivery, knowledge of the tasks, are all obstacles in the way of maximising profit. Perhaps that’s why we have so little of our industrial base left.

The argument is always: ” If we can’t be competitive, then we will take our manufacturing abroad to the third world”.

They can’t do that with health, welfare and education, so it has to be de-skilled to make it competitive. It’s also an attack on organised Labour, good pension schemes and secure employment. We all have to live in fear of the sack, or a wage freeze or as Public sector workers have long known, the gradual drip of outside tendering, ripping up of service agreements and eventual wage cuts and overtime payments.

While the working population is under increasing attack, there is a mirror image… one of unbridled growth in profits, bonuses and executive pay, for those that are ruining our nation.

 

I fully recognize the point RK is making and I think most of us could add even more examples of de-skilling of the workforce, whether in the public or private sector. However, he specifically puts the question:

Is this part of Hunt’s plans for the NHS, with doctors supervising a collection of underpaid individuals to deliver our health service?

Dr Bob Gill provides an answer:

The reality is that more qualified staff are being driven out in preparation for the de-skilling that is always part of healthcare privatisation and corporate takeover. For the UK, this is mapped out in the Five Year Forward View by Simon Stevens, the head of NHS England. Stevens used to be an executive of the US based private health care company, UnitedHealth.

http://koshh.org/the-connection-between-the-junior-doctors-contract-and-the-american-corporate-takeover-of-the-nhs

Motions at the BMA conference raised similar concerns that the future training plans could reduce the standards of patient care and safety; that by de-skilling doctors, de facto ‘sub-consultants’ would be introduced who could be paid less, and be subject to more rigid terms and conditions of service; that unacceptable power would be given to local hospital managers to determine training and workforce planning; and limit the career aspirations of many hospital doctors to a sub-consultant grade.

So how does this fit with ‘The Predator State’ of the title?

It is the term used by economist James Galbraith (2008 book) to describe this phase of capitalism in which politicians have colluded with the corporate and financial sectors to privatize public services, using …

‘The state as monopoly collector of taxes and corrupt distributor of the spoils to the private sector.’

This is certainly what is happening to the NHS. Only this week, Richard Branson took over the NHS Children’s Services in Wiltshire. He will be paid by the state for that provision and will doubtless introduce the usual cost-cutting measures to increase its profitability ie reducing the wages bill, weakening union representation and paring the service back as much as possible. Using under or unskilled labour to do the work of a highly trained professional is the obvious way to reduce the wages bill – wages will be the biggest drain on his profits. The UK government will pay Branson for taking on the service (probably with a huge subsidy) and in return, we will get an impoverished service.

So what, where, why?

Aren’t we told that the Tories are all about ‘free-markets’ and competition … but that sounds just like a rigged ‘market’.  How can Richard Branson possibly lose? Just as with the banks and care homes for the elderly, if the private company goes bust or gets fed up, the government will have to step in to pick up the pieces.  In other words, it is yet again …

‘Privatisation of profits and socialization of losses.’

 As Max Keiser pointed out, privatizing health, education and other public services provide great investment opportunities to hedge against more risky speculative ventures. And with another banking crisis predicted for the near future….

So why are the politicians going along with this rip-off of the nation?

Historically, we need to go back to Margaret Thatcher’s election in 1979, and even further back to Hayek on Mount Perelin in 1947.  Put simply, Margaret Thatcher couldn’t bear the Welfare State and wanted Britain to resemble Churchill’s wartime fantasy of pre-WW2…   The Austrian economist Hayek and his book ‘The Road to Serfdom’, offered her a political philosophy and economics that was an intellectual vehicle for her dreams.  The fact that his ideas were so diametrically the opposite of the Welfare State and a mixed economy meant that there were limits to how fast radical dismantling/restructuring could occur without provoking riots.  The ‘Boiling frogs’ strategy was adopted (put frogs in saucepan of cold water and gradually increase the heat – the frogs don’t notice until it’s too late).

The annual release of Margaret Thatcher’s Cabinet papers after the 30y rule confirms all this, and it is notable that this year, Cameron has stopped the release of a majority of the minutes from 1986.

But Margaret Thatcher was egged on and undoubtably manipulated by much bigger vested interests than her dreams of an England fit for Miss Marples and Agatha Christie. The City of London provided experts and consultants who saw the opportunity to return wealth and power to its ‘rightful heirs’ (and themselves) – those who we now call the 1% but more properly should be called the 0.1% or even the 0.001%.

It is highly significant that after the Great Depression, and in that short window of 1945-1979, the rich were not so rich and that has now been reversed back to ‘normal’.

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http://gabriel-zucman.eu/files/SaezZucman2014Slides.pdf

 

Sadly, the LP lost its way in the 80s and bought into the idea that there was no alternative (TINA). Many actually believed in The Third Way. However as Tony Blair said recently, he had seen his role as to build on Margaret Thatcher’s achievements, and ironically, it seems that New Labour politicians continue to believe in ‘the wisdom of the markets’ when it is quite clear that George Osborne and the Republicans in the US do not.

James Galbraith insists that the original Monetarists like Milton Friedman were serious economists but after deregulation, market solutions were abandoned in favour of Crony Capitalism ‘in all important areas of policy-making’.

 For them, [a market solution] now serves as nothing more than an enabling myth, used to hide the true nature of our world. Ironically, only the progressive still takes the call for “market solutions”

http://economistsview.typepad.com/economistsview/2008/05/the-predator-st.html

In other words, we’re being spun a load of economic lies (like austerity, the deficit drama and competitive efficiency) which are intended to persuade us that the impoverishment of the next generation, to benefit the global over-class of super-rich, is unavoidable. And as it happens, we have a government of Old Etonians and aristocrats who belong to that over-class, as do their cronies, friends, relatives and future employers.

‘Cameron himself went to Eton, and the many Old Etonians in his inner circle include Oliver Letwin, minister for government policy; Jo Johnson, head of his policy unit; Ed Llewellyn, chief of staff; and Rupert Harrison, George Osborne’s chief economic adviser.’

http://www.theguardian.com/politics/2014/mar/14/gove-attacks-preposterous-number-old-etonians-cameron-cabinet

“What did the new class… set out to do in political terms? The experience of the past decade permits a very simple summary explanation: they set out to take over the state and to run it — not for any ideological project but simply in the way that would bring to them, individually and as a group, the most money, the least disturbed power, and the greatest chance of rescue should something go wrong. That is, they set out to prey on the existing institutions of the [ ] regulatory and welfare system.”

http://forensicstatistician.wordpress.com/2011/05/23/a-predator-state-the-worst-bits-of-capitalism-communism-and-feudalism/

So where does this leads us with regards to the junior doctors’ contract and Jeremy Hunt?

Jeremy Hunt’s behaviour really doesn’t make any sense if he wants a ‘seven day’ NHS. No-one can imagine that it is feasible, not without more doctors, more hospital porters, nurses, radiographers etc… and expecting 20bn worth of cuts to the NHS budget at the same time? The old adage is that if something doesn’t make sense, ‘Follow the Money’.

After the last 5y of Lansley’s Health and Social Care Bill reorganization and cuts, it is no surprise that hospital doctors feel demoralized, undervalued, over worked and now they are being threatened with a substantial pay cut. Hunt’s imposition of the new contract on the Junior doctors is particularly criticized for driving doctors to work abroad.

Thousands are set to quit the NHS in protest over plans to shake up hours… more than 6,000 requests have been made for the paperwork needed to practise medicine outside the UK.

http://www.mirror.co.uk/news/uk-news/junior-doctors-fleeing-country-after-7367186#ICID=sharebar_facebook

 

Well, the resulting shortage from a mass exodus of doctors would be a perfect reason for using under-skilled staff … and it could be even be spun as unreasonable doctors, disloyally abandoning the NHS.  Hence, the conditions of the NHS could be harmonized with the expectations of private health care providers.  And all who could afford it, would be tempted to go for private treatment… as in the two tier system of the US.

Hunt has good reason to want to upset and alienate the Junior doctors.  It seems all too likely that he would love the awkward squad to go.  Then he can move on to the consultants…

As James Galbraith writes:

There is no common good, no public purpose, no shareholder’s interest; we are the prey and governments as well as corporations are run by and for predators. The “failures” enrich the proper beneficiaries even as they “prove” government is no solution.

 

Fortunately, we’re not told the truth about how the economy really works… and there is no economic reason why a new courageous state could not (in time) restore the NHS to being an improved, truly nationalised service….  And it just so happens that Jeremy Corbyn supports full re-instatement of the NHS.  Fingers crossed.

http://www.nhsbill2015.org/jeremy-corbyn-supports-the-nhs-reinstatement-bill/

 

 

 

https://think-left.org/2012/02/16/the-nhs-and-tina-mrs-thatchers-ideological-anti-democratic-political-legacy/

http://www.taxresearch.org.uk/Blog/2014/05/23/this-mornings-political-landscape-is-a-victory-for-the-cowardly-state/

 

Jeremy Hunt’s Plan for the NHS

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It may not look like it, but Jeremy Hunt DOES have a plan for the NHS – Caroline Molloy  First posted 23 October 2015 on openDemocracy/OurNHS

The Tories would have us believe that they are backing away from NHS privatisation.  In fact, they’re stealthily laying the groundwork for maximum profit opportunities – and comprehensive healthcare may be their first casualty.

Don’t worry about the fact that 82% of GPs are planning to leave or cut their hours in the next five years. Don’t worry that junior doctors aren’t any happier. And don’t worry that every week reveals another NHS hospital deeply in the red – even ones we thought were ok.

Don’t worry about any of that, because Jeremy Hunt has a plan.

It’s the NHS’s own plan, he repeats in every media interview. It’s the plan it would be a ‘disaster’ to deviate from, he told us before the election.

But what is this plan?

We’ll get to that in a minute.

First, let’s look at what we’re being told it’s not.

It’s not like that toxic Andrew Lansley stuff, the pro-competition 2012 Act, the “reorganisation so big you can see it from outer space”. No, that was Cameron and Osborne’s “worst mistake”, they’ve let it be known. It wasn’t really their fault, of course – they didn’t have “a clue” what the then Health Secretary was up to.

They were so cross with him, they made him a Lord. And he was such a fool, he’s just landed a job at private equity firm, Bain, advising on healthcare privatisation.

But let’s not worry about that. Lansley’s Act is “being ignored” anyway, the pro-market Health Services Journal tells us. Forget competition, forget the idea of external takeovers and internal dog-eat-dog competition between standalone trusts and powerful CCGs – under current Health Secretary Jeremy Hunt and NHS boss Simon Stevens’ plan, it’s all about collaboration now. Even KPMG (who’ve just poached another former Health Secretary, Steven Dorrellsay so.

So what is this plan? And, er, collaboration with whom?

Has Stevens – long-time Blair advisor and former United Health Vice President– really sent the private sector packing? And – after a few brand-damaging failures – have private health firms really scuttled away defeated from the £120bn “unopened oyster” of the NHS budget, deciding the NHS would be ‘shown some mercy’ after all?

It would be nice to think so. The more naïve sections of the liberal media have certainly bought that idea. When Simon Stevens launched his “Five Year Plan” last year, Andrew Rawnsley in the Observer said he had “only one fundamental objection” to the “generally excellent” plan – that it had the wrong picture on the cover. Polly Toynbee in the Guardian told us it was great because “the word competition doesn’t appear once in his 37 page document”. Shadow Health Secretary Andy Burnham appeared to sort of welcome the Stevens plan, then to sort of welcome it not quite so much.

Aside from this site, one of the few mainstream commentators to nail what the Stevens’ plan was really about was Fraser Nelson, in the Telegraph. “Like the best revolutions, it came carefully disguised,” Nelson observes. Yes, “the c-word didn’t appear once” but (like Nelson himself) Stevens still “firmly believes” in the competition/choice agenda – he’s just experienced enough to know that “the secret of successful radical reform is not to announce it with any fanfare.”

Nelson nails it when he says: “Stevens’ Grand Plan is to have no more Grand Plans but, instead, lots of smaller plans.”

So what are these smaller plans – and what do they mean for the future of the NHS?

Whilst even Jeremy Hunt and his regulator Monitor have tacitly admitted that standalone, competing Foundation Trusts aren’t working, Hunt and Stevens see more privatisation, not less, as the answer.

‘Collaboration’ turns out to mean hospital mergers into ‘chains’ – a theme developed in the Stevens report. The man tasked to develop the ‘chains’ plan, Sir David Dalton, has suggested it could lead to more private takeovers. Junior health minister Lord Prior wants private takeovers of hospital chains, too – and he also thinks they should close lots of beds.

As Circle have found in the UK with their disastrous Hinchingbrooke foray, at the moment it’s hard to make a profit from competing to provide full service local hospitals.

As United Health, Kaiser and others have found in the U.S. – profit opportunities are much bigger if you integrate both the purchasing and provisionof healthcare under private control or influence, enabling you to ration or deny more expensive healthcare interventions. And it’s much easier to do that if you use your control or influence to reorganise provision away from full service local hospitals, towards a chain of disparate community-based clinics and far-flung specialist centres. Of course you have to claim all the while that this is all about integration, prevention, empowerment, localism, personalisation, specialisation, reducing ‘variation’, and ‘care closer to home’.

Stevens is pushing this approach through a range of supposedly ‘integrated’ new ‘smaller plans’. Like the new multi-billion pound lead provider framework to ‘help’ with purchasing healthcare (which United Health subsidiary Optum has won a sizeable chunk of). And a ‘prime provider’ framework to ‘integrate’ purchasing and providing (which both Circle and Virgin have won contracts worth billions for already). Not to mention the the array of ‘local’ NHS ‘Vanguard’ projects, which Stevens explicitly suggests could be modelled on US firm Kaiser Permanante’s ‘Accountable Care Organisations’ or similar Spanish companies. The tech-heavy projects are full of private sector opportunities and partnerships – particularly outside of unprofitable acute care. Meanwhile, tariff cuts leave the sword of Damocles dangling over many local full service hospitals.

Profit opportunities also expand if firms set their own easily-gamed ‘outcome based’ success measurements. Out go what Stevens calls ‘mechanistic’measurements (like the requirement to have enough nurses, properly trained healthcare workers, and hospital beds).

Since the general election, Stevens and Hunt have been busy tearing up such requirements.

And in come easily gamed ‘outcome’ measures – exactly what we see in the new style contracts.

Profit opportunities also expand if co-payments (ie, patient charges) are permitted. The right are getting more confident in calling for such chargesLord Prior has tried to launch an inquiry to consider it – and the government has still not clearly disavowed such an inquiry. The growing number of exponents of charges and co-payments are usually keen to stress it would only be for freshly defined ‘non-core’ services which, if you look closely, turn out to mean things like a bed to recover in after your op (£75 a night please!).

And there are many other attempts underway to undermine the comprehensive, universal, publicly funded core values of the NHS, by bringing the ‘undeserving’ narrative from benefits, into the NHS. An early sign is the attempt to refuse people care if they smoke or are obese, for example (cavalier to the fact that it is poorer people who will be disproportionately hit by such clinically uninformed decisions). Whilst Devon’s attempt to do this failed, experts saw it as a sign of things to come.

Stevens has just given all of this a big boost by pushing integrated health and social care budgets (and indeed integrated benefits budgets in some devolved areas, like Cornwall). All of this may be nice in theory, perhaps, but it’s pretty terrifying in a climate of ‘austerity’, where social care users already can, and have to, top-up or co-pay for services (and benefits are already heavily conditional).

And integrated personal budgets – which Stevens has been pushing since day one in the job – are now being rolled out to millions. No-one has yet managed to explain how these are any different from the old Thatcherite voucher plan (which would basically finish the job of destroying the NHS).

Lastly, as a big bonus, once firms nabbing all these contracts have their hands on the patient data needed to commission healthcare (or obtained by delivering it ‘digitally’), they can also make a packet selling our information to data, insurance and pharmaceutical companies – or worse.

Of course this entire bureaucratic market nightmare costs a fortune to administer, though the scale of the fortune is a closely guarded secret. The Health Select Committee pointed all this out in 2010 (referring to earlier data – and we’ve had two or three more tranches of ‘marketisation’ since then).

So if that’s the Stevens plan, what’s our plan B to get out of this mess?

First, the NHS urgently needs a cash injection to get it through this current manufactured crisis (with the DoH handing billions back to the Treasury in ‘underspends‘ in recent years – ‘doh!’ indeed!).

Healthcare needs are not a bottomless pit, as the neoliberal ideologues claim – but the demands of health, insurance, pharmaceutical, data, consultancy and tech companies for profit streams, may well be.

Ultimately, all this destruction is possible, not because of Stevens himself, but because the Coalition government finally removed the duty to secure comprehensive healthcare which was offered to the nation in 1948 and persisted, just about, til 2012. We need to restore that duty.

And we need to recognise that hospitals have been brought low by a combination of PFI debt and the dog eat dog, beggar my neighbour nightmare of even the ‘internal’ market, let alone the external one. We need to get rid of that market – as Scotland has done.

The NHS Bill – sponsored by Caroline Lucas, signed by Jeremy Corbyn when he was a backbencher, and due for its second reading in March 2016 – is a serious attempt to do both.

The market, internal or external, disguised as ‘collaboration’ or not, is not an effective way to allocate healthcare – we’ve known that since the pioneering work of Nobel prize winner Kenneth Arrow in the 1960s. It forces hospitals to hammer down staff costs and offload unprofitable patients, and creates impossible choices between the bottom line and patient safety.

It’s only ideology and vested interests that would seek to persuade us that the answer is more of the same.

And if anyone – Tory, Labour, or ‘non-political’ – says they support the NHS, we need to ask – do you mean an NHS that is comprehensive, universal, publicly funded, high quality, timely and ethical?

If not, they are not defending the NHS as the public understand and love it. And that’s what we need to fight for.

 

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