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Hostle Intent


Posted by Dr No on 08 May 2011

lansley04.jpg“So, first of all, let me assert my firm belief that the only thing we have to fear is fear itself…”

—Franklin D. Roosevelt: First Inaugural Address: Saturday, March 4, 1933

Now that the elections and referendum are over, and the results have knocked the egg out of Clegg, the talk has turned, as it will, to what the Lib-Dems must do to lay themselves sunny-side up again. The general thrust is that they need to get tough, rattle a few sabres, perhaps even fire a few arrows, and so assert their identity in the face of their coallusion partners, the Tories. A top candidate for the sabre rattling treatment is of course the NHS reforms.

Now the notion that the severity of the pasting meted out by the Tories to the Yellow Tribe might back-fire on the Tories, by provoking a Lib-Dem health service strop sufficient to scupper Broken Arrow’s NHS reforms, may be enticing, but the reality is likely to be rather different, more, one might imagine, in the manner of Mowgli standing up to Baloo:

Nick: Leave me alone.

Dave: Well, now, that's pretty big talk, little britches.

Nick (slugging Dave): I'm big enough.

Certainly, on past performance, and here tuition fees spring to mind, Lib-Dem opposition has a habit of Macavitating once Lib-Dem ministers are safely bedded in behind Number 10’s door, as the naïve opportunism of opposition collides with the rock-face of Tory – and fiscal, not to mention governmental – reality. Dr No suspects that much the same fate awaits Lib-Dem opposition to the Tory health service reforms. Today’s huff will become tomorrow’s puff, all too soon to be blown away on the winds of political expediency.

The fact is that all political parties, once in power, are inclined to show, as our American cousins might say, hostle intent, sometimes covert, sometimes not so covert, towards the National Health Service. Labour, once seen as the party of the NHS, spent most of its last term punching private holes in the public NHS; and the Tories, now in power, have ditched their manifesto ‘NHS safe in our hands’ slogan for proposed reforms so radical that if implemented would see the National Health Service as we now know it hollowed out from the inside, and left a shallow shell of its former self, a branded franchise to be flogged to ‘any willing provider’.

The standard explanation for Tory zeal for privatisation is of course that it is all about bungs for buddies, and no doubt there is some, perhaps quite a lot, of truth in that knee-jerk response. But such an account does nothing to explain why all parties, once in power, set about carving up the NHS. There must be, Dr No supposes, some other underlying reason; and on reflection it appears to Dr No that that reason is fear.

Indeed, for some time now, the bean-counters have been frightening the pants off whoever is in power. They warn of an avalanche of the elderly swamping the country, of a silver cesspit draining the life-blood from the economy. And so it is that all parties of all colours, once burdened with the mantle of government, look at these predictions, and brown-trouser themselves; and it is from this fear that hostle intent towards the NHS is born: a crazed determination driven by fear to ‘risk-manage’ future health service expenditure by dumping it, lock stock and barrel, into the private sector.

And so it is that Dr No believes that, rather than attacking the Tory health service reforms as bungs for buddies, we should instead attack the underlying fear that drives all governments to want to ditch the NHS. We might want to point out, for example, that privatised health care on the American model is likely, at a national level, to double costs, and yet deliver worse outcomes. And, perhaps most of all, we might want to point out that this governmental fear may in fact be nothing short of an outstanding example of fear of fear itself. What if, for example, far from sucking the life-blood out of the country, the elderly in fact are net contributors to the economy, even after allowing for the burden they place on the NHS; and so the fear imaginary?

8 comments:

“The most important reasons for the uniquely high costs of the US health system are its commercialization and the effects of business incentives on the provision of care. The US has the only health system in the developed world that is so much owned by investors and in which medical care has become a commodity in trade rather than a right.”

Health Care: The Disquieting Truth Arnold Relman New York Review of Books Sept 2010

Be afraid, be very afraid ...

JT - couldn't agree more with the quote you provide. The fundamental problem with any private/insurance based health service is that it turns the public sector-patient marriage into a three-in-a-bad situation - and that third person is a greedy avaricious marriage wrecker!

Commercialisation and commodification (and knowing the price of everything but the value of nothing) are the sinister destructive tools the marketeers uses to turn a public service into a profitable business. The trouble is, the marketeers can't even be trusted to run profitable businesses. Look what happened when they started recklessly securitizing (ie repackaging (in effect a form of re-commodifying) and reflogging) the mortgage markets...

On another note, Dr No was pleased to hear the current Chair of the RCGP, Dr Clare Gerada, talking some very welcome sense on the Today programme this morning.

Dr No, you are probably right about fear being the predominant force driving the health care reforms rather than personal greed or status. Nevertheless, there will always be a few politicians and their hangers-on (some doctors included) who will be fearless and more concerned about the latter!

Politicians probably genuinely want us all to live happily to a ripe old age, contributing to society, but in the end die upright with our boots on. They are continually being advised, largely by the medical profession, that the dire consequencies of obesity, smoking, drinking, dementia, cancer will lay us all flat on our backs bootless for prolonged periods of time gobbling up all the countries resources and that there will not be enough fit younger people to care for those rendered supine. It is no wonder they are afraid.

But there is another fear much bigger than this. China. The balance of world power. They know we are not manufacturing enough. That frightens them too. They are looking for all sorts of commodities to sell locally, nationally and globally. Healthcare, largely untapped in the UK, as one of these commodities is just too tempting. Politicians will never give up on this. For this reason, the time may have come for coal face doctors to tell them in detail how to address present waste within sections of the NHS and how to differentiate between patients and clients. As doctors, our main concern must first be patients. Patients must be prioritised before clients, because, unlike patients, the health clientele reside in a bottomless pit so they need to be further down the list. If clients and their perceived or insoluble problems can boost the economy, so be it.

How to differentiate clients from patients can be so difficult though, and probably involves the “R” word. I sometimes wonder if those is some sections of government are already quietly setting up the differentiation between patients and clients for economic purposes. If they are, can they be trusted with it?

PFI is a clear example of wickedness in my book. If NHS is run on Insurance principle than the next year's 'premium' could well be based on the previous year's spent. On the other hand, a govt. run NHS Lottery will cover all NHS cost as long as there is no more silly Pavlovian style reward system. The govt has not learnt that when a Payment for Performance is set up, the 'wicked' people moved in. Money is not saved!

If it is the same pot of money, how can we allow private companies to make money and still deliver a better health service?

The trouble is: do they really care what we say?

The Witchdoc:

"in the end die upright with our boots on."

Way to go, count me in.

"They are continually being advised, largely by the medical profession, that the dire consequencies of obesity, smoking, drinking, dementia, cancer will lay us all flat on our backs bootless for prolonged periods of time gobbling up all the countries resources and that there will not be enough fit younger people to care for those rendered supine."

Only I don't think that our generation will live as long as our mums and dads have. Precisely because of the very problems the politicians are being advised on; smoking, obesity ... etc. Because our parents were not as indulged as we are. Already, I hear of fifty and early sixty year olds dying when their parents lived to their late eighties, even nineties.

"But there is another fear much bigger than this. China. The balance of world power."

Exactly! The world is changing to a new order and Britain can not and MUST not get left behind, the real reason for all the 'modernisation' and the reason why 'Health' too has to move with the times. But that is not neccessarly a bad thing, only, as you say, the new reform must not be allowed to neglect the need of the needy. Why you should all list your concerns while the government is 'listening'.

Already The Academy of Royal Colleges has made it's very well thought views clear on the reforms and on training. Now Clare Gerada of The RCGP has too, and well done as well. Consultants are swimming somewhere in the middle, they are not as loud as the rest! They need to be ... and the juniors need a voice and a place in that reform too ... they are the ones going global after all, the new 'human commodity'!

Which brings us to Andrew Lansley, Dr No has him with an arrow in the head. Well, I personally think it is not a good idea at all if he was to be replaced. Not in the interests of doctors either. Because if we decide to move in with the times, then best to 'negotiate' with the man who spent 7 years formulating the new recipe and not a fresher. To be fair, this is his right too. Afterall, the bill is the longest in the history of the NHS with around 350 pages to read and digest! So, get a fresher and you lose this power of negotiation as you both get lost in the maze of understanding the material as well as the new character who will not have a clue about Andrew's work and just impose what could have been 'negotiated'! Andrew is your man, and he knows now that he needs to make a few U turns. A new SoS and this would get lost in the maze too!

... Andrew ... Andrew :-)

Sam - you are right - that image is not one of Dr No's best, and it only won over two other equally indifferent ones because of the look on Cameron's face...

You are also right to point out we should be careful what we ask for, and indeed Dr No made the same point several times in private yesterday, and it does no harm to repeat it in public today. What if Broken Arrow does get fired into the long grass, and is replaced by BATman, who of course has an 'association' with (wrecking) the NHS that goes back for two decades - three times Broken Arrow's association? Of course that wont happen - BATman has bigger cigars to smoke - but there are plenty of other nasties who could become SoS for Health.

Dr No begs to differ on life expectancy - the current evidence is that it is increasing, not decreasing, and at present shows no sign of abating; although there is debate about whether there is a natural 'ceiling'. There is some interesting epidemiology on the increase in life expectancy changes over time, but most of it can be simply summed up by saying greater wealth means greater health (and so longer life span), even if, as shown in the above link, there has been a small increase recently in later years spent in poor health.

Dr No also begs to differ on Darwin. He didn't say "Adapt!" as an imperative verb; instead the concept was part of an observational essay on the origin of species. It was only later that others have used Darwin's theory as 'evidence' that failure to adapt means extinction - and that is distinctly questionable as an absolute proposition. Even those icons of adaptive failure the dinosaurs lasted for over 160 million years (not bad going really), and current thinking is that their extinction (along with many other species at the same time) happened not because they failed to adapt, but as a result of a catastrophic global event.

The other problem with the HSCB is that it isn't evolutionary, it's revolutionary - and history tells us that revolutionary change has a nasty habit of imploding sooner or later. So what Dr No is asking for is not so much that the SoS goes, but that the Bill goes, because it is the Bill that is broken, and can't be fixed.

WD's observations are astute as ever. The distinction between clients (and their near cousins consumers) and patients is crucial - and the government's obsession with the choice and change agendas plays into the hands of the former at the expense of the later. The two groups can glibly be distinguished by saying patients have needs, and clients and consumers have wants, but that hides the much thornier real problem: one person's want may be another person's need.

And had the WD's black cat had her say too yesterday, she would no doubt have predicted today's news, picked up by Dr G, that universities are to be allowed to flog degree courses at full cost on the global market - and where education goes today, the NHS may find itself tomorrow.

Dr No would only add that the predominance of fear as the driver doesn't rule out greed ('The standard explanation for Tory zeal for privatisation is of course that it is all about bungs for buddies, and no doubt there is some, perhaps quite a lot, of truth in that knee-jerk response.'). Dr No's point is that fear is the primary driver, and unless we tackle that head on, any government (Labour started doing it while in power, The Tories are trying to do it now, and even the Lib-Dems had plans to do it in their Orange Book) is going sooner or later to nuke the NHS.

"it only won over two other equally indifferent ones because of the look on Cameron's face..."

Actually, it's the look on Lansley's face that attracted my attention ....

"BATman has bigger cigars to smoke"

Only, reputable cigar smokers would race to light the fire on that big one Dr No. However, no BAT threats at the moment because PM has decided not to reshuffle Andrew now or in the forseeable future, as per an interview with The Mirror published yesterday, which is good news for Andrew and good news for you and for us patients too. Andrew now needs a friend and you do too so be friends, sort it out and we will be happy too. No losers, perfect.

"that is distinctly questionable as an absolute proposition"

But doesn't this statement apply to everything unknown and the prediction of same? If so, isn't this a contradiction to what you said on life expectancy? What makes your theory on that better in your eyes and the eyes of the politicians is because yours is based on 'numbers' as evidence, while mine is based on 'my own eyes'. So, although I have evidence, I can't gain your, or the politicians 'trust' because I did not document. Fair enough, but then you look at your numbers and 'assume' they will remain constant forever in the future, will they? Where is your 'evidence' for that? Why then are you disregarding 'my' evidence completely when I should at least raise some doubt you may be wrong? Evidence re nature is as changeable as nature itself and you can't take just an academic view on that! Isn't that a blinkered approach to 'nature'? A biased view, specially if you also believe that 'doctor Always knows best'. In which case, you have created two distinct assumptions and that in turn 'can' create an infinite number of doubts! Consider them, or how else do you propose to tackle and remove that fear 'you' inflected upon 'the poor trusting' politicians then?! Unless of course you admit to yourself first that you may not be 100% sure and that there is a chance Sam may be right. Otherwise you won't be able to change the politicians mindset - and the imposition of dramatic and panic driven policies will continue! Maybe the reason for the defiant look on Andrew's face in your picture above! Of course, when it comes to health matters, politicians too believe that doc is always right, but they 'choose' not to admit it, but they do act upon it ... poor SoS ....

Which brings us back to Darwin, of course Algae are the most adaptable, they've been around since life began and are still going the strongest despite the bombardment that wiped out the dinosaurs as you said. Why? Because they are so simple, the reason why they can accommodate 'change', 'adapt' - and live forever. There must be a lesson somewhere in that.

"WD's observations are astute as ever. The distinction between clients (and their near cousins consumers) and patients is crucial"

Yes, hence you need to ensure the provision for the needy is not harmed as I said in my previous comment.

"and the government's obsession with the choice and change agendas plays into the hands of the former at the expense of the later."

We've agreed this was because of that 'fear' you mentioned. As for what is happenning to universities maybe moving over to health, you and I discussed that before on my blog and I gave you Egypt as an example. The simple answer of course is 'yes', because you are either 'trendy' or you aren't - Britain has decided that she wants to be trendy. You can not say no to that, but you don't want her to end up looking like that lady gag either, although you hope for a similar success story

"So what Dr No is asking for is not so much that the SoS goes, but that the Bill goes, because it is the Bill that is broken, and can't be fixed."

Bill goes, SoS goes - and that would be the revolution Dr No, and a good chance of that implosion too. Implementation is so far gone already so, Kill the bill, then what?! Go backwards, or forwards? Eitherway, killing hurts so isn't a good option, 'heal' is always better than 'kill' ... and that's where you come in ...

Sam, I visited a cemetery recently and saw some of my ancestors’ graves..... great, great (or was it three greats) grandparents and some of their children. Although several children had died from TB and other infectious diseases, the grandparents themselves and some other children lived into their nineties. On the other hand, in todays world, I don’t have enough fingers and toes to count the number of friends, relatives and colleagues who have died prematurely of various causes, so from my point of view also, death seems to take its toll some way or another.

However, My Black Cat is of the firm opinion that within the next fifty years science will discover so much about the language of cells, that all types of malignancy will be able to be completely switched off, the ageing of cells arrested, and many other pathological conditions completely controlled at cellular level. If she’s correct (but Black Cats are often wrong), then governments will be very afraid indeed. How for example, how will they stop crammed populations of relatively healthy members The Humankind from firing the modern equivalent of bows and arrows everywhere? There has not been much success in controlling wars so far.

I suppose the clever bacteria and viruses that mutate much quicker than we do will come to the rescue again and wipe hoards of us out at a young age before we can catch up with them!

It’s a funny old life!


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