The politics of health in England: "a National Health Service would be a good idea"

1. The politics of health in England: "a National Health Service would be a good idea" Alex Scott-Samuel Honorary Professor, School of Medicine, Pharmacy and Health, Durham University

2. Acknowledgement When asked what he thought of Western civilisation Mahatma Gandhi is said to have said “I think it would be a good idea”

3. Positionality 1

4. Positionality 2

5. The politics of health in England A National Health Service would be a good idea

6. Towards a political science of health

14. A political science of health: initial areas for research • political inequalities in health (care) • health (care) and party politics • health (care) and public policy • health (care) and the (formal / informal) exercise of power • political aspects of social epidemiology including political determinants of health • policy based evidence making

15. Policy based evidence making The commissioning, selection or invention of evidence to support and justify a predefined policy position

16. Policy based evidence making - examples • the Private Finance Initiative • the Choice = Equity ploy • the 2002 Treasury Cross Cutting Spending Review on Health Inequalities (CCSR) • the Health and Social Care Act 2012

17. CCSR - policy based evidence making 1 ‘political and bureaucratic considerations loomed larger than research evidence’

18. CCSR - policy based evidence making 2 The CCSR failed to address: • macroeconomic policy • globalisation and trade • arms dealing • patriarchy and gender inequity • defence policy and war • foreign policy • international development

19. Policy based evidence making 3 ‘we are only looking for evidence among a prescribed list of diseases and target groups. If it started with the question "where is health best improved and what evidence for (any) action is available?" it would be recommending quite different actions’

20. Policy level and PBEM / EBPM ratio

21. The H&SCA and policy based evidence making

22. Dr Jonathon TomlinsonHackney GP abetternhs blog tinyurl.com/n39mfss

23. ‘Integrated care’ “I'm sitting in the diabetic clinic in the Royal after a conversation with my (private) insulin pump company Animas this morning in which they refused to send me any kit for my pump (I did explain this is life or death) because they hadn't received a piece of paper from the NHS. Seems I'm already living the privatised/US style healthcare nightmare described by Allyson Pollock!”

24. The Health and Social Care Act is one of the biggest confidence tricks ever carried out by a government. We've been defrauded of our beloved universal, comprehensive, integrated, equitable, public sector, national health service.

25. The impacts of the Health & Social Care Act 2012 loss of Secretary of State’s duty of provision loss of universal service loss of comprehensive service loss of free service loss of integrated service

26. NHS now just a logo for a privatised healthcare contracting operation

27. Current NHS policy outcomes Privatisation (Letwin / Lansley / Hunt) + Cuts (McKinsey / Osborne) + Rationing (postcode lottery)

28. Privatisation, cuts and rationing 50% increase in A&E referrals since NHS Direct privatised – being blamed on GPs Harmoni responsible for baby’s death in Hackney – local GPs’ OOH bid rejected Nurses, not culture, blamed at Stafford Postcode lottery will increasingly cause people to go private – with increasing use of health insurance - and to have to pay top-up fees

30. Neoliberalism, insurance and trade Neoliberalism - Wendell Potter – Deadly Spin Insurance – Accountable Care Organisations Trade - Transatlantic Trade and Investment Partnership – TTIP

33. Origins of the Health & Social Care Act 2012

36. pcwww.liv.ac.uk/~alexss/toryattackonnhs.pdf

37. Informed neoliberal opinion“In future, the NHS will be a state insurance provider not a state deliverer. In future ‘any willing provider’ from the private sector will be able to sell goods and services to the system. The NHS will be shown no mercy and the best time to take advantage of this will be in the next couple of years. GPs will have to aggregate purchasing power and there will be a big opportunity for those companies that can facilitate this process. The monolithic arm of state control will be relaxed which will provide a huge opportunity for efficient private sector suppliers.” Mark Britnell, Head of Health, KPMG; former NHS Director of Commissioning, 2010

38. What is to be done?

42. Suggested principlesfor a National Health Service in England

43. Structural and functional integration 1 Physical and mental health and social care should be provided by a single, public sector service. This should be managed and delivered locally, but funding and most policy should be determined centrally so as to avoid inequalities and postcode lotteries.

44. Structural and functional integration 2 There should be coordination and rapid sharing of information between all services in the demonstrable interest of patient care.

45. Management and planning There should be performance management of equity-, quality-, integration- and user satisfaction-oriented objectives, indicators and targets. Health and social care workers and users often know best how services need to change: staff at all levels should be represented in management. Community health councils should be reintroduced

47. Funding 1 Health and social care should be entirely funded from the public purse with no co-payments, user charges or insurance. Eliminating the transaction costs of the current NHS market will make a major contribution – as would the abolition of all six figure NHS salaries.

48. Funding 2 A substantial contribution could also come from the defence budget: citizens will hopefully prefer a strengthened welfare state to an unnecessary armed forces budget. Once we stop attacking other countries they will stop attacking us.

49. Prevention and intervention Preventive services should always be prioritised. Intervention will always receive adequate priority because of clinical Individualism and because of the profit motive.

50. Health inequalities Since capitalism cannot exist without inequality, acceptable inequalities should be debated and defined. To reduce long term health inequalities it will be necessary to engage directly with their root causes, such as inequalities in power, social status / social connections, knowledge, income and wealth.