Policy responses by successive governments
The broad response by first the Conservatives and later Labour governments over the past 30 years has been to reform and modernise public services by introducing a market model into the way in which public services operate. The market, and private enterprise in particular has been held up as the ideal model which all public departments should operate, whether in a modified and adapted form, or one in which public services are simply outsourced to private profit making companies. The assumption is that private companies will always and everywhere be more efficient and cost effective, more customer focused, and offer better value for money – despite the fact that there are numerous examples where this is so obviously not the case, from the G4S Olympics fiasco to more local examples such as SERCO’s fraudulent and substandard GP out of hours service in Cornwall. And more recently the continuing failure of hospital cleaning at RCHT by private out source company MITIE (BBC NEWS 28 July 2015). This section is divided into two parts:
- Part A: the introduction of the market model into the NHS
- Part B: Neo-liberal policies and the health of the nation
We urge you to read Part B in particular in order to get a better understanding of the impact of a political ideology that has dominated both Conservative and Labour policies for over three decades. Part B critiques neo-liberalism in terms of its impact on the health and wellbeing of people. It does so not from the standpoint of an opposing political ideology such as Marxism but from evidenced based medical data that charts the adverse impact on health and wellbeing that neo-liberal policies have had, and continue to have.
Part a: the introduction of the market model into the NHS
(this section is taken from Keep Our NHS Public: an introduction for campaigners. Their document is evidenced based with full references to sources You can read the full document here>>>)
Since 1990, the English NHS has been divided into two parts:
- The ‘providers’ – for example NHS Hospital, Ambulance or Mental Health Trust, a Foundation Trust -or, increasingly, a private company or charity/social enterprise.
- The ‘purchasers’ – the organisations that spend the NHS budget on buying (also called ‘commissioning’) healthcare, from the provider(s). The local ‘purchaser’ used to be the Primary Care Trust but from 1 April 2013, they have been replaced by ‘Clinical Commissioning Groups’ (CCGs) which include a few GPs on their boards. A national body, NHS England, commissions highly specialised services across the whole country.
This divide is called the ‘purchaser/provider split’, which has created a market for health care. At first, this ‘market’ was mostly an internal market, where local NHS bosses (the ‘purchaser’) bought clinical services from other parts of the NHS (the ‘provider’), including Hospital Trusts, Mental Health Trusts, Ambulance Trusts, and Community Services Trusts (district hospitals, district nurses and specialists like physiotherapists). Meanwhile, patchwork privatisation took place.
‘Support services’ have been being steadily privatised since the 1980s
In the 80s many NHS hospitals ‘contracted out’ their support services like cleaning and catering. From the 90s, some of took place as part of expensive Private Finance Initiative (PFI) deals. With PFI, support and maintenance services were bundled with building contracts, the hospital was built and owned by consortia of private companies (with expensively borrowed private debt) and leased back to the NHS. The contracts were often over-priced and inflexible. In the 90s and 2000s, other support services were contracted out, including much diagnostic testing, logistics/supplies, and back office work.
Some (limited) NHS clinical treatment started being privately provided in 2000
Most clinical services remained, until now, provided by NHS hospitals, clinics and employees. However there were some exceptions. In 2000 then health secretary Alan Milburn signed a ‘Concordat’ with the Independent Healthcare Association. This stipulated that the private sector would be considered as an alternative provider. It was presented as a way of rapidly reducing waiting lists.
Over the next 10 years the private sector encroached into clinical provision:
- routine elective operations (like cataracts and hip operations). The ‘choose and book’ scheme allowed patients to choose to be treated at a private hospital / clinic at the NHS’s expense. Some of these clinics were new ‘independent treatment centres’ which were pump-primed with very favourable contracts and lots of money even if they didn’t treat many patients.
- doctors surgeries (through a scheme called ‘APMS’)
- GP out of hours services.
- In elective operations, clinics without intensive care units and with insufficient staff were closed down after patient deaths – but the NHS had to pay tens of millions to escape the contract
- In out of hours, some private providers have been found to be cutting corners, employing insufficient qualified staff, and falsifying inspection data10 .
- Some GP surgeries were closed when the private providers simply moved on, leaving patients without a doctor .
part b: Neo-liberal policies and the health of the nation
The world view that espouses the Market as the supremely efficient model of innovation and wealth creation is called ‘neo-liberalism’ and its dominance in policy formulation across all parties, including the Labour party, deserves particular attention.
How does Neoliberalism impact on Health?
That might seem a strange question, not just because neoliberalism is a poorly understood term, but also because there is no easy and immediate connection between a set of political beliefs and the health of the nation. However, a growing body of research evidence pointing to these connections, is injecting new urgency into the need to understand and challenge what neoliberalism is doing to our health and well being.
The term neoliberalism is infrequently mentioned in the media and therefore not understood by the majority of the public, yet it has been the prevailing political ideology in the west, shaping our norms and values over the last 35 years. It is based around the so-called ‘free markets’ and arose out of the economic crisis of the mid-1970s and was strongly championed by Thatcher and Reagan. According to neoliberalism, the market can resolve almost all social, economic and political problems.The less the state regulates and taxes us the better off we will be. Public services should be privatised, public spending cut and business should be freed from control. Essentially this is maximising market freedom, giving great influence to global corporations, while minimising state intervention. The role of government should be confined to creating and defending markets, protecting private property and defending the realm. All other functions are better discharged by enterprise prompted by the profit motive
The proponents of neoliberalism believe that it provides the greatest possibilities for economic growth and the most equitable distribution of wealth among the population. However, its critics believe that it creates too many financial hardships for its citizens especially the poor. The government should control the economy to mitigate the harmful effects of falls and rises, leading to more equitable distribution of wealth.
However it is a defining set of ideas that helps to rationalize and justify the modern Establishment’s position and behaviour. Evidence so far indicates that neoliberalism has transferred wealth from the majority to the top 1% and especially the very top 0.1% of society. It has contributed to rising inequality and reduced social mobility that is present in society today.[Harvey, D (2005) A Brief History of Neoliberalism. Oxford University Press]
How did neoliberalism take hold?
It was started in 1947 by the Mont Peleron Society, by a world-wide group of academics led by the Austrian born British economist, Friedrich von Hayek and Milton Friedman They wanted a return to the form of liberalism that existed in the late 18th and 19th centuries. They were viewed as extreme at the time and remained on the margins of mainstream politics in the high-income world as the social and social democratic parties swept to power in Britain and in the northern European countries. However, they attracted a lot of interest from influential US banks and corporations, who with their foundations poured vast resources into setting up think tanks, founding business schools and transforming university economics departments into bastions of almost totalitarian neoliberal thinking. In the UK several right wing think tanks further embraced this ideology. These included:
- The Institute of Economic Affairs – founded by Madsen Pirie in mid 1950s
- The Adam Smith Institute – founded by Pirie with Eamonn Butler in 1977
- The Centre for Policy Studies – founded in 1974 by Margaret Thatcher and Keith Joseph with Alfred Sherman, a former communist.
Their purpose was to develop the ideas and language which would mask the real intent of the programme, the restoration of the powers of the elite, and package it as a proposal for the betterment of humankind. A powerful promoter of this programme is the media, mainly owned by multimillionaires, whose interests are furthered its successful adoption. Those ideas anti thetical to the neo-liberal agenda – mainly left leaning or even sensible mainstream economic thinking, are either ignored or ridiculed. This enables socially destructive notions of a small group of extreme right wing thinkers, to assume the form of ‘common sense’ when it is anything but!
A good primer on Neoliberalism that includes how UK political parties have changed over time: http://www.globalissues.org/article/39/a-primer-on-neoliberalism
Politics and Health
Professors Ted Schrecker and Clare Bambra at Durham University in their book How Politics Makes Us Sick: Neoliberal Epidemics look at the effects of neoliberal polices in the UK and US on health over the last three decades. They focus on four areas: Obesity, Stress, Austerity and Inequality
They argue that these represent four ‘neoliberal epidemics’ : neoliberal because they are associated with or exacerbated by the rise of neoliberal politics, epidemics because they are on such an international scale and have been transmitted so quickly across populations that if they were a biological contagion they would be seen as being of epidemic proportions.
Although life expectancy and infant mortality rates have improved between 1960 and 2010, the International rankings of 19 high income countries over the last 30 years, show that both the UK and US have relatively dropped down the league tables In 2010 the US was bottom for both measures despite spending by far the most on healthcare(17.1% GDP in 2013)
In the UK despite a generation of access to healthcare that was free at the point of use for the entire population under the NHS established in 1948, health inequalities between the rich and poor remained stubbornly persistent. A number of reports were produced that identified that the differences were due to what is now called social determinants of health. These are socioeconomically patterned differences in the conditions under which people are born, grow to adulthood, live, work and grow old. In other words, income, employment security and status, local environment, the family and community you are born into, all had a much bigger impact on physical and mental health than previously realised . And this is true not just at the bottom strata of society but at every level: well-to-do middle class income earners also suffer worse health, greater levels of obesity and live shorter lives than those above them.
Several reports have been produced over this time highlighting growing inequality, including the Black and Acheson Reports and most recently in 2010 the Marmot Report – Fair Society, Healthy Lives. Marmot’s six policy objectives are:
- Give every child the best start in life
- Enable all children, young people and adults to maximise their capabilities and have control over their lives
- Create fair employment and good work for all
- Ensure a healthy standard of living for all
- Create and develop healthy and sustainable places and communities
- Strengthen the role and impact of ill-health prevention
He points out that delivering these policy objectives will require action by central and local government, the NHS, the third and private sectors and community groups. National policies will not work without effective local delivery systems focused on health equity in all policies.
Effective local delivery requires effective participatory decision-making at local level. This can only happen by empowering individuals and local communities.
However, the Social Care and Health Act far from simplifying the health system has complicated it by placing Public Health within local authorities at a time of substantial spending cuts in the social services budget and a large funding gap in the NHS budget by 2020, This makes the challenge of integrating local health and social care budgets, which is critical to tackling health inequity, more difficult and more likely to lead to variable outcomes across England.
The Obesity Epidemic
Obesity is a growing health problem in the UK with obesity rates increasing 8-fold over the last 40 years. One in four adults are now obese (having a BMI over 30).
Obesity is associated with increased risk of a number of serious clinical conditions including type 2 diabetes, heart disease, hypertension, cancer(breast, prostate, colon and gynaecological) and fatty liver disease. Diabetes alone now accounts for one in six of admissions and consumes 10% of the NHS budget, almost £10 billion. On current trends, obesity will overtake smoking as the key cause of cancer in about 10 years. Also the current rate rise there will be 5 million diabetics in England and Wales by 2025.
A pronounced inverse socioeconomic gradient exists in the prevalence of obesity, with it being more common amongst the poor and marginalised. The problem can be first seen in early childhood. Politicians are inclined to blame the individual for making the wrong life style choices. Professor Robert Lustig, an internationally renowned paediatric endocrinologist and obesity researcher, says that to blame obesity on the obese is the easy answer, but it is the wrong answer. “The current formulation taken of gluttony and sloth, diet and exercise while accepted by virtually everyone, is based on faulty premises and myths that have taken hold of the world’s consciousness. Obesity is not a behavioural aberration, a character flaw or an error of commission”
He says that the westernised diet, is killing us slowly, due to heavily processed food, high in sugar( especially fructose) and fat, low in fibre and that governments around the world have been co-opted by the food industry. Between 1980 -2008 and increase in BMI were significantly associated with economic globalisation and income equalities between and within countries.[Lancet: Open letter to David Cameron]
Although neoliberalism is not the sole cause, it has a critical influence, magnifying trends. The big problem is that healthy food is more expensive and beyond the budget of poor families. Also in the UK we are seeing increasing food poverty and rising use of foodbanks. Between 2008 -2013 food prices increased by 12% while average wages fell by 7.6% according Professor Ashton, Head of UK’s Faculty of Public Health. Across low-, middle-, and high –income countries there is a strong correlation between consumption of packaged food per person and levels of sugar consumption and obesity. It has been argued that westernised processed diet has been responsible for an epidemic on non–communicable diseases as seen by cases where groups that emigrated and gave up a vigorous Spartan lifestyle to adopt a sedentary high-calorie low-exercise living based on abundant supermarket food. A dramatic example involved the Yemenite Jews who were airlifted to Israel by Operation Magic Carpet in 1949 and 1950 and were thereby plunged abruptly into the 20th century from formerly medieval conditions. Although the Yemenite Jews were virtually free of diabetes upon reaching Israel, 13% became diabetic within two decades! [Jared: The World until Yesterday] The obesity epidemic can be seen as a logical result of a policy environment based on minimal state regulation of the market allowing the provision of a basic necessity to be converted into a highly profitable business, where profit depends on increased consumption of high-margin products that are inexpensive to produce.
Resisting regulation is also part of the picture as ‘corporate disease vectors’ implement sophisticated campaigns to undermine public health interventions.Despite the common reliance on industry self-regulation and public–private partnerships, there is no evidence of their effectiveness or safety. Public regulation and market intervention are the only evidence-based mechanisms to prevent harm caused by the unhealthy commodity industries.[Report: Profits and Pandemics]
Stress, obesity and social insecurity
Chronic stress is a growing problem in society and is a consequence of insecurity, austerity and psychological stress. Two mechanisms by which stress leads to obesity are stress-induced eating and stress-induced fat deposition and are mediated by the adrenal hormone cortisol. This hormone stimulates appetite, particularly giving a craving for sweet and fatty foods. Cortisol also causes those excess calories to be laid down as fat around the abdomen as opposed to gluteal fat. Abdominal fat is particularly hazardous and increases the risk of heart disease and diabetes.