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Hypocrisy, the Hoodie Tsunami and the NHS


Posted by Dr No on 11 August 2011

major_contribution.jpgDr No is not a hoodie; nor, so far as he knows are any of his friends, or even his friends’ children. He moves in the rarefied climate of relative genteeldom that is upper middle class Britain. Most of the sharks he knows wear suits, and work in the City, or the local private hospital; and the robber barons he knows wear wellies and tweeds. Those times in the past when his medical career has taken him into the sink estates and dumping ghettoes – he recalls once being advised to ‘put his doctor’s bag first through the door’, so that the waiting Rottweiler bit it, not him – have been brief; and despite the portent of his colleague, he conducted his practice in a spirit of Croninian naivety. He came not to judge his patients, but to treat them.

So it is with great trepidation that Dr No presumes to venture intimate observations on our broader society, let alone contemplate the day to day appreciation of the news by a hoodie. Perhaps he is even foolish so to do, but that is the privilege of the foolish blogger. So: his first observation is that the ‘hoodie’ is a curious partially sanitised icon of the underclass. Instead of the underclass, we now talk of hoodies, and of criminals and thugs – and so of isolated indivduals. The carbuncle on the underbelly of society is recast as a tiresome flea: a external parasite treatable by a blast of Tory flea spray, rather than a purulence at work within the body of society itself.

Dr No thinks this is bad mistake, for the underclass is still there, as it has always been. The hoodie tsunamis that have swept these last few days through our Cities are not so much, as our politicians wish us to believe, the simple expressions of individual criminality and thuggery (though such base motives do surely play a part), as the spontaneous welling up of the underclass through the widening cracks of a fractured society. To pretend otherwise is not just misguided, it is deeply foolish; for it is not individuals, or even small pockets of – as Cameron has it – of ‘sick’ society that need mending, but the whole of society; all society. We are all – despite Hacksaw’s infamous proclamation that there is no such thing – part of society, and we are all in this together.

Which brings Dr No to his second observation: that in the last few years much of the domestic news has been dominated by two long-running stories: the MPs expenses scandal, and the collapse of our banks, and their subsequent bail out by – ahem – those very same MPs, or rather, those same discredited MPs using our money to bail out their buddies who gambled with – and lost - our money; and then – to add insult to injury - collected eye-watering allowances and bonuses in reward.

Now, Dr No appreciates that the last paragraph might be a slanted account of recent events that ignores some of the finer points. He has put it so because he suspects that hoodies are not ones to over-burden themselves with finer points. Instead, they simply see sickness and greed at the heart of government, and of the City: a pervasive culture of - as Clegg put it this morning in the other context - of ‘smash and grab’, that all too often goes unpunished, and on occasions is even, by way of bent rules, bail outs, and bonuses, rewarded.

So the underclass hoodies say to themselves – not unreasonably, which is not in the slightest to condone it, but to finger the inescapable logic – if MPs and bankers can ‘smash and grab’ and get away with it – then why can’t we? It is, considered broadly, a hard argument to counter. A legal view might say that most of the MPs and most of the bankers did nothing illegal, and that might well be true; but that narrow view crumples in the face of the wider argument, for there was clear moral wrong doing. And so there is, rightly or wrongly – Dr No happily concedes there may be a few swans hiding in the duck houses - a perception of a double standard, of hypocrisy, of one rule for toffs, and another very different rule for hoodies.

This, Dr No suspects, is the Tories’ blind spot, and perhaps their Achilles’ heel, that may yet one day render them unelectable. They cannot see that it matters greatly how the underclass perceive the Tories; and so they are careless of appearances, and so greatly offend the underclass. That is why many of the roll call of major British riots of the last few decades - Bristol, Brixton, Toxteth, Broadwater Farm, and the Poll Tax, not to mention Wapping and the Miners’ strike, all happened under a Tory watch.

It now seems that, in spite of, or perhaps because of this blind spot, the current government is determined to force through its recklessly misguided Health and Social Care Bill. And make no mistake: if this Bill is enacted, we shall before long see the coming of a two-tier, double-standard health service: one for the vocal well-to-do, funded by insurance and co-payments; and, on lower plane, a state-funded corners cut ‘safety net’ service for the underclass – and the net will be large meshed, torn in places, and many will fall through.

It was ironically a Tory who once had the sense to recognise that the NHS is the nearest thing we English have to a religion. If the current government persist in driving a wedge into that religion, splitting it into a two-tier service, then it wont just be the NHS divided; the country too will be deeply divided, into the haves and have-nots, an over-class and an underclass. There is a real - and deeply alarming - danger, if this foolish Bill is enacted, that the riots of recent days will come in time to be seen as the early raindrops of a furious storm that is yet to come.

In the aftermath of that storm, there will be but one certainty: the Tories will have rendered themselves permanently unelectable. Far be it from Dr No to presume, but it does seem to him that were he a Tory MP, he might wish to contemplate the consequences, before mindlessly voting for a Bill that will surely become known as the longest suicide note in political history.

28 comments:

"Instead of the underclass, we now talk of hoodies, and of criminals and thugs "

But it's very unfair to say that 'hoodie' on the rampage kicking in shop fronts, areaking havoc without regard to any value whatsoever is representative of the 'underclass', or the poor, as I prefer to say.

My own experience of the poor, and believe me, I have met people whose children slept the night without even a piece of bread inside them, are very proud people they most of the time refuse even charity if they can get that bread for their families on their own. Maybe I should write about that ... but those 'rioters' were 'criminals' committing horrendous acts and the poor are innocent of their vicious doings.

I agree with the comment above that the criminals who took over our streets are not the same as the "underclass". What is more noticable here is the politicians failure to recognise the fear present in everyday people at the fact this was allowed to happen and with the economic situation. This fear was manifested by the vigilante groups and rampant protectionism that was seen after the riots and is all the more worrying. This is the first look at what a "small" state will provide. I can only imagine what it would look like applied to the NHS, on that point ... I completely agree with you about the hscb.

"This, Dr No suspects, is the Tories’ blind spot, and perhaps their Achilles’ heel, that may yet one day render them unelectable. They cannot see that it matters greatly how the underclass perceive the Tories; and so they are careless of appearances, and so greatly offend the underclass. That is why many of the roll call of major British riots of the last few decades - Bristol, Brixton, Toxteth, Broadwater Farm, and the Poll Tax, not to mention Wapping and the Miners’ strike, all happened under a Tory watch."

My own musings on the situation in my re-entry to the blogosphere do point out that there is a long history of British Rioting, and it is not only under Tory Governments (and the one we have now is a Coalition Government). In the 1997-2010 Labour Government we had riots in several cities, notably Oldham, Bradford and a particularly nasty one in Birmingham between British Asians and British Afro-Caribbeans. The 1976 Notting Hill Riot was under Harold Wilson's government, and the death of Blair Peach was under the Callaghan government. The 1968 Grosvenor square riot was under Wilsons first government, as were the Civil rights marches, demonstrations and intercommunal riots that led to the Northern Ireland Troubles.

One has to go back a little further for a Liberal Government but in both 1920 Clydeside and infamously at Tonypandy in 1910 where troops shot rioting Welshmen, there is social disorder.

It is simply not true that riots occur only or even predominately under Tory governments. I think it certainly true that riots in London get a lot more media attention and handwringing than riots in the Midland or Northern Cities. Who in the metropolitan media cares if Birmingham burns? it is too far from their cameras.

I think it likely that I shall post further on the subject of the recent disturbances. There is a long and interesting history of rioting in Britain as a form of political expression when citizens feel that their political masters are ignoring them. Sometimes the rioters have right on their side, sometimes the government, but it is rare for it to just be mindless thuggery.

I agree with much else in your analysis though. It is wrong to depict these hoodies as the underclass, they are our sons and brothers. As David Cameron said in 2006 "So when you see a child walking down the road, hoodie up, head down, moody, swaggering, dominating the pavement - think what has brought that child to that moment.If the first thing we have to do is understand what's gone wrong, the second thing is to realise that putting things right is not just about law enforcement.It's about the quality of the work we do with young people.It's about relationships. It's about trust.Above all, it's about emotion and emotional development."

Not much there that I do not agree with. The full "hug a hoodie speech" can be found at http://iaindale.blogspot.com/2006/07/hoodie-speech-read-it-in-full.html. Perhaps you should read it, it may open your eyes a bit to our Prime Ministers views, and modern Tory thinking.

Dr Phil

... for the link to David Cameron speech of 2006. It's sooo spot on, I feel I could've written it myself ... and it boils down to this point;

[Firm, when needed, is love ... and loose, when not needed, is 'we don't care', or no love]

For those looters, it's now time for 'firm', hopefully followed by 'we do care'.

David Cameron is a good man and a good PM

And we're awaiting your post on this topic :-)

I think it is important to differentiate between the ‘poor’ and the ‘underclass’ as they are not the same thing although it is a common belief that they are - yet it is possible to be both.

The underclass are categorised into four main groups –

1. The passive poor, usually long term benefit recipients.
2. The hostile street criminal, drop-outs and drug pushers.
3. The hustlers, dependent on the underground economy but rarely involved in violent crime
4. The traumatised drunks, drifters, homeless bag ladies and released mental patients.

In all cases there are two different sides of the argument as to why people exist in these groups and I would suggest further reading here.

I do believe that many of the rioters do [happily] exist in the underclass – I would reiterate that poverty and the underclass do not necessarily go hand in hand. I also believe that many were not – merely those who do not receive any guidance from their parents and therefore do not have a social conscience – this goes far to explain why children reported to be as young as seven took to the streets.

I would agree that in society we are ‘all in it together’ yet would contend that some ‘behaviours’ in some of these groups would be a difficult cycle to break and it is highly probable that the persons involved see nothing wrong with their particular lifestyle. Would we accept change ‘enforced’ by others who deemed that our particular lifestyle was ‘wrong’

I totally agree that the introduction of the HSCB will be further divisive and widen the divide between social groups.

Anna.

PS Keyboard injured – therefore ‘iffy’ punctuation

As it happens, Dr No is currently reading Oliver Twist. Not only is it as fresh today as it ever was, but it just happens to be in large part about the underclass...and on reflection Dr No thinks we are using the term somewhat loosely, as a sort of generic, and so too vague, umbrella term. So: how about this for a definition: it is that part of society which is excluded, for whatever reason, from the normal benefits of society. This definition is intentionally positional (as in placed outside normal society), and positional alone, and makes no judgements (deserving/undeserving), nor does it fix attributes (poor/not-poor) or causes (fallen on hard times/wilful benefit scrounging scum). It just says: these are the people who are outside normal society. They are the excluded (and, importantly, being sentient beings, most know they are excluded).

So - in this definition, the underclass will include hoodies, criminals and thugs, but it will also include - for example - the poor who have fallen on hard times through no fault of their own, patients incarcerated in institutions (who may by chance be quite wealthy, but unable to make use of their money), perhaps even immigrants who do not speak any English, and any other excluded group that comes to mind. It is clearly a large and heterogeneous group, perhaps so much so that in practice it is not often a very useful term...says Dr No, aware that he is ticking himself off for using sloppy language...

So the subset of the underclass that Dr No is talking about here is what we might call the disaffected underclass; and by dis-affected Dr No means a present state of feeling (ie 'affect' used in the medical/psychiatric sense), ranging from disgruntlement through pained and offended to frank and hostile resentment.

The line about 'Instead of the underclass, we now talk of hoodies, and of criminals and thugs' was Dr No trying to pick up on (a) the trend to avoid the term underclass (politically incorrect etc – but, as noted above, the term has little use without clarification) and (b) what he saw as a knee jerk response early on in the riots by politicians to 'encapsulate' the unrest as mere/simple 'criminality' and 'thuggery' (and so by implication ‘hood-ery’, or whatever the word is). Dr No's problem is that he thinks this is too simple an approach; to get a better understanding of what is going on we need to consider why so many 'criminal' and 'thugs' spontaneously appeared on the streets in so many English cities (there may be a clue here - why was Scotland so largely unaffected?).

En passant, there is also a secondary observation to be made here: not only is the crims and thugs response simplistic, it also grossly underestimates the size of the problem. Those we saw on the streets are surely only the tip of the iceberg: for every one that turned out, a dozen may have considered it, but stayed at home; and most of those who did turn up belong to 'families' - and by all accounts those families - perhaps numbering two or three to every visible crim/thug - did little to object to what was going on, and so were at the least passively complicit. The point here is that the disaffected underclass is almost far larger than we realise: and if - for example - they are provoked by the emergence of a two-tier health service, then we soon may find that 'we ain't seen nothing yet'.

The concept of a disaffected underclass also goes some way towards explaining a question that has appeared to baffle some: why did these people turn on their own communities? The answer, in this assessment, is that they didn't: they felt excluded, 'out-side-of', the community around them; have-nots sinking unseen in a sea of haves; outlaws. What we saw was not people attacking there own communities, but the have-nots attacking the haves.

Boots - a pleasure to see you back here, and even more so on your own blog. Dr No agrees rioting is not exclusively a feature of Tories in power (whether in majority of coalition), and slyly covered this by saying 'That is why many of the roll call of major British riots of the last few decades...'; but he does think the general observation - that recently rioting has often been triggered under Tory rule, because Tory politics tend to be divisive - holds enough water not to sink (so to speak). He also agrees entirely with your succinct observations:

'There is a long and interesting history of rioting in Britain as a form of political expression when citizens feel that their political masters are ignoring them. Sometimes the rioters have right on their side, sometimes the government, but it is rare for it to just be mindless thuggery.'

Indeed this is one of Dr No's key points: to dismiss the rioting as just criminality and thuggery is a grave mistake, a failure to read the political wind, and that is never a good thing.

The strange and/or sad thing about Cammers is: who is the real Cammers? The hoodie loving good Samaritan of 2006 (thanks for the link, and yes I have read the speech), or today's water-cannon/rubber bullet toting vigilante? Sam, and I dare say Boots: you will probably reply he is both (loving but firm etc) but Dr No remains confused, as he suspects will a lot of the disaffected underclass; and, as in the original post, a lot of this is to do with not just what the Tories are, but how they are perceived.

The answer to the ‘who is the real Cammers’ may lie in the difference between being in opposition, and being in power, for it is always easier to be compassionate from the opposition benches. But on one thing Dr No ventures to suggest we can all agree: that we are all in this together. And perhaps strange as it may seem (or not as the case may be), the closest Dr No gets to political affiliation is to that curious and probably hopelessly antiquated lot known as the one nation tories. And yes, the lower case 't' is intentional...

Anna – you posted your comment, and thank you for it, as Dr No was writing this – and I think it fait to say that we are both picking up on the point that ‘underclass’ unqualified is too vague a term.

A truly well written and disturbing piece.

I have been trying my best not to link the happenings of RBS/MP expenses/ Southern Cross with the current riots.

I must say I am very disturbed.

The real difference is that some of them do it whilst they are still wearing their ties. Thy did not physically threatened us either. Most did not go to jail.

No fire either and no broken jaws.

The riots are going to cost £100m which of course we will pay in the end as we did with RBS or the like. RBS cost a lot more.

But look at the Milk and Dairy Cartel:

Market Forces and Choice is suppose to give us better value with our shopping, the OFT judged that nine companies OFT colluded to rig the price of cheese and milk in 2002 and 2003. The scandal is thought to have cost consumers about £270m.
Perhaps we should be thankful that we were not mugged, jaws broken, or burnt. Yes they did rob some supermarkets and we are going to pay again.

What they are going to do with HSCB is worst.

So long as we talk about class we're talking about a fractured society. Most of the 'riot-talk' has been about how awful the under/upper/political/bankster classes are. As if we represent the class from whose collective bottoms the sun of righteousness shines. Am Ang gets closest to nailing the problems with a dizzying blog capturing the various ways capitalism has the game rigged. It's delusional to believe that somehow we're playing a different game, or able to take an objective position whilst all around are corrupted. As any first grade anthropologist will tell you, the point of learning about other cultures is in order to better understand your own. The sooner we realise we're part of the problem, the sooner we'll be part of the solution.

"to dismiss the rioting as just criminality and thuggery is a grave mistake"

Quite the opposite Dr No. By prioritising your response to grave happenings such as the terror England suffered during those riots, you are able to form a proper response and suitable punishment to deter from similar destructive actions in the future. Only then can you address other issues you may think are relevant to why all this happened. Tackle it any other way and you create the biggest confusion on earth! It's the same as a parent disciplining a child, punish for an offence, then address the cause. But neglect punishment ... and expect more and more offences to ceiling high! Maybe this is the reason for all the gang cultures around now; parents neglecting to punish their children until it totally got out of hand! ... then those kids got together, and together ... then Terror for all!

As for men in suits being corrupt, bankers, etc, well, they can always say 'we make the money, we are the economy, and we are entitled to some of it since without us you are all going to be poor', something which the looters can not claim because they only cost money! ... and please don't think I am excusing inequality or corruption, I am just making a point based on logic.

Which brings us to 'class' ... and there have always been class and hierarchy since humanity began - and that's not a bad thing as such 'if everyone is valued and respected' because society won't function if we're all doctors, for example, but you need a doctor and you need a porter and you need a cleaner for a hospital to function properly. Same with society - so no society without 'classes' ... but properly :-)

And when you value and respect everyone regardless of their class, then you'll have a fair system of reward, a fair system of helping the needy 'when in need' and a fair system of crime and punishment too, where regardless of who you are; big or small, black or white, etc, will receive the same reward or indeed punishment for your actions. So the key word here is 'respect' because without that 'responsibility' will melt, then as respect dies, responsibility will die too ... hence the riots, and the corruption, etc.

Of course, 'respect' and 'responsible' are just the other face of the same coin that tells you not to murder, or steal, or covet, or bear false witness, or cheat ... :-)

I do not like the term Underclass, because of its pejorative overtones. It is a word like Chav that I am careful to not use. Class is just one of many ways of putting people into boxes that constrict their individuality.

It is interesting to see the looters details in the papers: http://www.dailymail.co.uk/news/article-2025068/UK-riots-Middle-class-ri... Not at all the Underclass described, indeed many seem to have found short term pleasure (as well as blighted futures) in the riot. And all caught by the Panopticon. http://drphilyerboots.wordpress.com/2011/08/12/life-in-the-panopticon/

I am not convinced that Tory led governments are more divisive than Labour ones. I have never known the nation more divided than the late '70's, its just that the shift of power occurred in May '79 from one side of the divide to the other. Last year it was a Labour Minister who instructed his staff to issue different election leaflets to Asian and white precincts, with instruction to "make the white folk angry" in an area just a few years on from race riots. It was astonishing that after this that Ed Miliband installed Woolas in his shadow cabinet. He must have thought it acceptable behaviour.

I think David Cameron is socially Liberal, his attitudes spring from a very much more Libertarian mindset to the authoritarianism of the Hang 'em and Flog 'em wing of the party. I think that he genuinely wants the Tory party to be more tolerant, and his "hug a hoodie" speech matches very well with Ian Duncan-Smiths welfare reforms that are a central plank of Tory Policy. Otherwise he would not have found the money to back IDS. In the short term the changes are forecast to cost money, the savings (if they ever appear) being significantly down the line, possibly under another government.

Best wishes

Boots

I do not like the term Underclass, because of its pejorative overtones. It is a word like Chav that I am careful to not use. Class is just one of many ways of putting people into boxes that constrict their individuality.

It is interesting to see the looters details in the papers: http://www.dailymail.co.uk/news/article-2025068/UK-riots-Middle-class-ri... Not at all the Underclass described, indeed many seem to have found short term pleasure (as well as blighted futures) in the riot. And all caught by the Panopticon. http://drphilyerboots.wordpress.com/2011/08/12/life-in-the-panopticon/

I am not convinced that Tory led governments are more divisive than Labour ones. I have never known the nation more divided than the late '70's, its just that the shift of power occurred in May '79 from one side of the divide to the other. Last year it was a Labour Minister who instructed his staff to issue different election leaflets to Asian and white precincts, with instruction to "make the white folk angry" in an area just a few years on from race riots. It was astonishing that after this that Ed Miliband installed Woolas in his shadow cabinet. He must have thought it acceptable behaviour.

I think David Cameron is socially Liberal, his attitudes spring from a very much more Libertarian mindset to the authoritarianism of the Hang 'em and Flog 'em wing of the party. I think that he genuinely wants the Tory party to be more tolerant, and his "hug a hoodie" speech matches very well with Ian Duncan-Smiths welfare reforms that are a central plank of Tory Policy. Otherwise he would not have found the money to back IDS. In the short term the changes are forecast to cost money, the savings (if they ever appear) being significantly down the line, possibly under another government.

Best wishes

Boots

" Class is just one of many ways of putting people into boxes that constrict their individuality."

Not necessarily Dr Phil, because everything has an entry and an exit point; a birth and a death, including abilities and ideas, endeavours and achievements, etc. We've seen many people work hard and get higher with it, and the opposite is true too. 'Class' is also 'classification', in that you are a member of the professional class ie, you'll always be a doc, but that doesn't restrict you, on the contrary, it gives you the ideal platform to expand your talent, even outside your field, through your individuality and move as high as you want 'if you want'. Not everyone does though, and that's where all 'the boxes' come from.

... and I can't count the number of boxes I built for myself, we all do ... and we all get out of them again if we want too ... it does happen, sometimes

Sorry about the dual comment DN, it must have happened while editing in the preview box.

Dear Sam, The concept of class does have some validity, but class, age, race, gender, education, occupation, income, political allegiance etc are all just one face on the multifaceted, and often contradictory people that we are. Viewing everything through the one face gives a very poor view of what is really going on in the world. We need to look at things in the round if we want to really understand the problems.

There is a very interesting article in the telegraph http://blogs.telegraph.co.uk/news/tomchiversscience/100100666/uk-riots-l... that hits the nail on the head. We find what we want to see, and just confirm our own prejudices, me included.

Thanks Jonathan.
We were at the National Theatre for: One Man, Two Guvnors (http://www.nationaltheatre.org.uk/64476/productions/one-man-two-guvnors....)

All the classes were there from servant class to public school class to criminal class and the obligatory legal class were there. Hilarious production but, yes they were all “bad”.

"Viewing everything through the one face gives a very poor view of what is really going on in the world"

But I didn't though, that's why there are 'boxes' not one box, unless one goes to live on an island somewhere ... alone

Dr No is not sure we can get rid of classifications (which is what under classes, political classes, chattering classes all are), and even if we could, he is not sure that we would want to, because they are probably a flawed but necessary social shorthand. And of course as doctors we use a class system all the time, only we call it diagnosis - he belongs to the diabetic class, she belongs to the epileptic class.

Dr No used epilepsy as the last example because it seems to him much more important than avoiding the use of class based classification, is the need to avoid slipping into stereotyping, and then prejudice.

Dr No continues to believe we need a collective noun for the excluded, the dis-possessed, those who are unable (and perhaps sometimes unwilling - a nod to Anna) to avail themselves of the normal benefits of society. He supposes it possible (in keeping with his earlier remarks on the term being positional) that the term underclass arose not always to mean inferior in a moral sense, but also under in an unseen sense: that they were under normal society, and so not normally seen: the ones who, if the HSCB is enacted, will be less seen in the consulting rooms and clinics, as they are squeezed out and then excluded from normal medical care. This class already exists, of course, in America, where millions - over 50 million - of citizen-subjects are excluded from enjoying the benefits of adequate affordable healthcare.

The NHS, despite all its faults, has largely prevented the emergence of a health underclass here. It is undoubtedly one of our greatest post-war achievements: and it will be to our eternal shame if that universal comprehensive health service gets dismantled on our watch.

"in America, where millions - over 50 million - of citizen-subjects are excluded from enjoying the benefits of adequate affordable healthcare."

But this will never happen here Dr No, rest assured.

"The NHS, despite all its faults, has largely prevented the emergence of a health underclass here. It is undoubtedly one of our greatest post-war achievements: and it will be to our eternal shame if that universal comprehensive health service gets dismantled on our watch. "

Too true. I took me sometime to understand the ethos of this bill, if indeed I do, that the aim is to push those who can to go private, either through insurance or through introducing top ups. This way there would be a basic health service guranteed for all still [specially important for the poor], and if you want more, well, pay for it.

I don't find that principal too bad myself since there isn't enough money to answer to every health whim of everyone in the country anymore given the advance explosions in new treatments and procedures. Take cancer treatment for example, there are extremely expensive new medicines out there that prolong life by only a few weeks at the most. Well, I can see a rich person wanting them so that s/he can get their house in order before they die, but is it fair to ask the tax payer to pay for that? A poorer person won't have the same problem and is unlikely to want them, I think, or is that too simplistic a view?

As for the bill itself, it is currently going through the two houses and I trust it won't pass if it is found not fit for purpose, so, let's not jump horses. Better wait and see, the react accordingly ... because the two houses know people, of all sorts, have reservations, don't forget.

Is a subject that I can be a bit chippy about it, perhaps because of my modest background and some of the ribbing I got at St Elsewheres from the public school rugby crowd. I struggle to come up with a good alternative term to underclass without pejorative connotations. When I was a youthful Socialist I saw all issues via the issue of class. My comment was a reminder to myself not to fall back to those ways of thinking.

The combination of demographic changes and globalisation will force changes in the welfare state including the NHS. As you know I am not opposed to private provision per se, but the bill does not impress me. Like the tuition bill mess it is a compromise that suits no-one. I would rather have a system where small local providers could compete in a de-regulated system. The current conception is for large corporations to have the tables tilted heavily in their favour, against both the old NHS and against small independent providers with local roots. As I have often said: the worst of both sectors. I am too young, and probably too much of a workaholic to retire, so will do my best with whatever system emerges.

I don't think that it will provoke riots though. Riots are a form of protest of young urban men who feel that they are not being listened to. Health tends to be fairly far down their list of priorities.

Sam,

“Take cancer treatment for example, there are extremely expensive new medicines out there that prolong life by only a few weeks at the most. Well, I can see a rich person wanting them so that s/he can get their house in order before they die, but is it fair to ask the tax payer to pay for that? A poorer person won't have the same problem and is unlikely to want them, I think, or is that too simplistic a view?”

Getting their house in order may be the least of it and anyway, the poor may worry more about leaving things tidy than the rich. Can they even afford a funeral? Do they feel they need a few weeks to organize even that? But there are many more reasons why a cancer patient may want to be given the chance to live a few extra weeks. For example, any effective treatment, even if short-lived for the many, will have a tail to it for the few and give those patients much more than a few weeks, perhaps years. It is likely most patients will hope that they will be one of the lucky ones.

Regardless of their “status” in society, financial or otherwise, each individual may have very special reasons to stay alive for even a few weeks longer. They may want to see the safe birth of a grandchild, they may want to see a teenage daughter through her A level exams without her having to cope with the death of a mother during them, or a father may want to see a son home safely from fighting in Afghanistan. They may just want to see the snowdrops come through in their garden for the last time. Some may just want a few weeks or months free to savor time on this earth with their family because all through their life they have had such a demanding job that they have sacrificed a “normal” life. (The NHS, for example, may have stolen many years of normal family life from them and may owe them a great deal, and yes, the word “stolen” is carefully chosen.)

What we are really talking about is rationing. The NHS is first and foremost about diagnosing and treating the sick. There is still a lot of waste in the NHS although many will not admit it. In my view rationing in the NHS should not happen until wasteful and dubious practices have been eliminated as far as possible, and if then rationing is still necessary, those who are truly ill are normally (but not always) given priority over the healthy.

Oh dear, I could go on and on and on…..

Sam - Dr No can only fully endorse the WD's spot on comment. One of the core guiding principles of the NHS is that its provision:

"be based on clinical need, not ability to pay".

The two tier system you describe (poor left to get on with it and die; rich top up their treatment to 'get their house in order') ignores the point the WD makes so well - we all can have houses that we might wish to put in order, or reasons to want to stay alive a little longer. The family reasons the WD gives are very typical real life examples. Dr No believes the vast majority of good doctors, NHS or otherwise, would find such segregation on ability to pay abhorrent.

There is a very important debate to be had about rationing, and current waste in the system - take for example the patient who wants (and all too often demands) antibiotics for his sore throat, while the GP knows that antibiotics are most certainly not needed for a viral infection - and here we get not only into needs vs wants, but also the 'unfortunate' behaviour of the GP who does prescribe to keep his patient 'happy' - only to ensure the patient keeps coming back, so perpetuating the cycle of wasting both his and the doctors time, and NHS money...that could otherwise be spent on supplying those cancer drugs to the poor patient who would otherwise be left to die, never seeing his daughter married, or his grandson born.

Boots - I agree health is pretty low down the list of priorities for young/middle aged men who famously never visit their doctor anyway - but they are part of families - and what they will see is relatives dumped by the two tier system - and that will make them very angry.

First, allow me to thank you Witch Doc and Dr No for caring about you patients so much. I know you mean it too.

But from a financial perspective, this country, or any other for that matter, will not be able to afford all the treatments for everybody as and when they wish it, given also that there are new things appearing on a daily basis, and the current economic situation too - you have to be realistic and draw a line somewhere!

Financially restricting treatments to those 'in need' and even prioritising those as well doesn't mean a 'two tier system' emerging, because one can argue that this exists now already. For example, those who have no reason, like patients who have not suffered from a disfiguring accident or the like and need a face op, go private or not have it done at all, because the NHS can not afford it just for cosmetic reasons. Then surely, in the case of unrestricted spending on a terminal patient, the time will come when questions will be asked if it was 'right' to sustain a life coming to an end 'for sure' over, say, a 14 year old who needs a new Cornia or they'll go blind. I feel that the majority of tax payers would say the latter is more deserving. I know it is sad for a student to go through A level exams having lost a mother, but even with the best of drugs you can't 'guarantee' you can avoid that and that student may still go through the ordeal despite all your efforts!

And, I remember Dr Grumble, whom I miss very much because he hasn't written for aaages, once posted a video about an Australian woman who was artifically kept alive for months because her family couldn't bear to let her go even though she was very terminal. She died at the end but after a lot of suffering. So, it's not just about cost only but humanity and regard for such patients dignity too to let nature take it's course when it is time. After all, although one must also take the family into consideration, it's about 'the patient' at the end.

So, what we need in the future is a health service that will provide for everybody at the point of need without regard to ability to pay - providing there is 'real' need, not based on emotions, but based on 'need'.

For example, Witch doctor said that some cancer patients live for years with the expensive medicines, hence if that's the prognosis then that patient should be put on that medicine 'if they wish', and it is up to you docs to decide when you have such patient and give them those new drugs. A clinical decision bas on need not because one patient wants to see his grand child before they die and give priority to that over one needing a liver transplant who'd live for decades with the operation and definately die without it. So, as the experts say, the NHS needs 'collaboration' more than competition, and that's one of the reasons to prove this, another, as you both say, to reduce the waste in the system ... that needs to be drastically reduced too as you say, not only by saying no to patient's demanding medicines as of right but also by maybe charging patients who excessively visit their GPs for every minor thing and cost the tax payers lots of money that need not be spent, etc ... and this is where you all good docs come in too because you know where it wastes best and you know how deal with it ... but sometimes bureaucracy doesn allow, right?

Maybe it's time you 'insisted' on transparency in the NHS.

... and the majority of you do do a brilliant job, the reason why I hope that with whatever system we end up with, that people like you will not be replaced with semi everything quacks ... that's more important to me as a patient; to recieve' quality' care when 'in need', rather than being kept alive by force then end up suffering on the hands of don't knows.

The world around us is in a financial free fall and this country is in grave danger from that too. We need to take note of that and that the times of having 'everything' we want is 'gone'! ... so, if to achieve that 'quality' we all need something has to give because we can no longer afford everything ... and if that means rationing too, then be it.

Rationing has always been present in the NHS and often took the form of waiting lists. However, the problem with rationing, is not so much that it exists, but that it should be compassionate, stepwise and rational, should take account of the fact that each patient is an individual, and does not dictate that a doctor must turn their back on the needs of the patient facing him/her for the sake of the commune or indeed for the sake of an individual doctor's own preference or prejudice. The way the NHS runs, there is no guarantee that money saved from depriving a cancer patient from some extra time on this earth will find it's way to replacing a damaged cornea. It is more likely to find it's way into a communal purse which is dipped into to form yet another committee or something far removed from direct patient care.

My point is that the first step in the rationing ladder is to stop waste within the NHS. This waste is often the result of people (not just politicians and administrators but doctors too) pontificating on committees and often displaying breathtaking lack of judgement that leads to expensive errors In policies that just don't work and are often reversed at further cost.

The second step is to ensure that rationing is not directed at those who are ill. That should be the very last resort.

Rationing is too big subject for this comment Sam, so maybe My Black Cat will find a way to blog about it if she ever manages to get the Internet connection to The Spell Pantry mended. Or maybe rationing is so complicated that MBC will give up on it!

The importance of distinguishing between wants and needs has long been recognised, but has proved remarkably difficult to implement in practice, except in barn door situations, such as a purely cosmetic face job vs a hip replacement. But what if the facial disfigurement is real, and caused by say fire or genes, or even iatrogenic (caused by medical intervention - say surgery that went wrong)? It starts to grow in justified medical 'need', and soon is in competition with that hip replacement.

Much as the economists try to remove it from the equation, at the end of the day the assessment boils down to a value judgement - about things like life expectancy and quality of life. Is ten years of minor improvement worth one of major improvement? How do we decide - and who should decide? Oregon famously went down the (semi-)democratic route - and came up with some pretty whacky answers - famously, cosmetic breast surgery trumped treating an open thigh fracture.

Many if not most British doctors of Dr No's generation will have been brought up on 'not striving officiously to keep alive', and will stop short of futile and burdensome treatment, including, if necessary, putting it to relatives that it is now better to let 'nature take it course'. But equally, we would strive very hard to keep a dying patient alive for a few extra weeks - and damn the cost - if it meant the patient could attend his, or her, daughter's wedding. But then, even that is based on a value judgement - Dr No judges that attending a daughter's wedding has great value for a parent.

The WD and her Black Cat are right - rationing is a huge topic, and no doubt Dr No and the WD and her cat, once the later has got her whiskers back in order, will sooner or later return to it. In the meantime, Dr No merely observes that he agrees with the WD - there is much waste in the NHS, often at the hands of sometimes willing, sometimes not-so-willing but nonetheless compliant, complicit doctors - and that is as good a place to start as any.

"The WD and her Black Cat are right - rationing is a huge topic"

Of course it is as you both, and black cat, say Dr No ... and;

"How do we decide - and who should decide?"

Doctors of course, hence you've just highlighted why it is vital that 'you' must take over leadership and decision making managerial positions too. Because you can then identify and reduce waste as well as make cost effective 'and rationing' judgements based not only on clinical and financial reasons, but, as you and Witch doc displayed, be able to consider humaniterian and compassionate aspects too - and that's a tall order for those without a medical background.

... has anyone seen Dr G anywhere, eh? ... black cat, polish'm wishers quick ... cos we have a job 4 uuu .... :-)

Dear Sam,

Rationing is a major topic, as well as a word our leaders studiously avoid.

I did have some hope that the Coalition reforms would move commissioning powers to the front line, and that consequently there would be some compassion and flexibility in the financing of treatments. The engagement of front line docs would help.

In practice, at least in Borsetshire, the PCTs have been hollowed out, then reinvented as commissioning groups with the same boundaries and personnel involved. The number of referrals is down substantially, seemingly as a financial control measure. Whether these patients will turn up in time with more advanced disease, or whether they are being well managed, we shall see.

As I have blogged, I am involved in management, commissioning, deanery and college work. The people I meet there are generally good people who are well motivated, but their priorities do get affected by group think, and they do get instructions from on high that they have to implement. Even a colonel has to follow orders as well as give them.

You wrote about that before, wouldn't that change with more docs in leadership positions though?

... and 'independent' group think is not a bad thing ... so long as it is that ...

It must be frustrating. I hope with this clinical leadership drive, things will improve soon because it's such a shame when people like yourself feel they can do much more but don't because they also feel their hands are tied ... take care :-)

:-)

Thanks Sam. Just various bits and bobs that needed attending to behind the scenes - now done.