The Guardian has a series of articles looking at UK’s water industry. Looks like it’s a cash cow for foreign investors with prices to consumers inflated to service debt and excessive payments to shareholders. Well worth a look (and tofu-eating is not mandatory ;) …
England is one of the few countries in the world where water is fully owned by private companies. These companies answer to investors based thousands of miles away from their customers.
“What we have here is just a crazy system,” said Kate Bayliss, from the department of economics at SOAS University of London and author of several papers on England’s privatised water. “We are managing our water in the interests of offshore investors.”
These offshore investors include private and state-owned international funds, banks, multinationals and billionaires headquartered outside the UK, and they control at least 72% of English water, new Guardian research has found.
Here’s how England’s profitable water system has been sold off around the world:
Foreign investment firms, private equity, pension funds and businesses lodged in tax havens own more than 70% of the water industry in England, according to research by the Guardian.
The complex web of ownership is revealed as the public and some politicians increasingly call for the industry to be held to account for sewage dumping, leaks and water shortages. Six water companies are under investigation for potentially illegal activities as pressure grows on the industry to put more money into replacing and restoring crumbling infrastructure to protect both the environment and public health.
More than three decades after the sector was sold off with a promise to the public they would become individual small shareholders or “H2Owners”, control of the water industry has become dominated by overseas investment vehicles, the super-rich, companies in tax havens and pension fund investors. The ownership structure is such that transparency and accountability are limited, according to Dr Kate Bayliss, a research associate with the department of economics at Soas University of London.
In the 30 years since England’s water was privatised by Margaret Thatcher, water companies have set up a system in which billions of pounds leave the network in an average year.
It’s money that could have gone towards building a more resilient water system, say academics. Among them, Dieter Helm, an Oxford professor of economic policy specialising in utilities, went as far as saying in 2021 that England’s water system was “a scandal of financial engineering”.
If Jeremy Hunt succeeds in replacing Boris Johnson as British prime minister, it will be another instance of the ‘nice Tory’ coming after the panto villain.
Hunt’s pitch to the Tory faithful is that he’s the ‘serious’ one: the earnest ex-head boy with a grasp of detail and the ability to get things done. And that impression appears to hold water, with even the liberal media repeating these ideas.
Earlier this week, The Guardian’s Ben Quinn waxed lyrical about Hunt trying to play the role of “elder statesman from the backbenches, offering gentle and usually friendly criticism over the government’s Covid mistakes”. Of his latest leadership hopes, Quinn was positive: “Firmly on the centrist side of the party, he could be viewed as a calming presence after the tumult of the Johnson years, if the membership are desperate for some stability.”
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The fact that Hunt was health secretary – the longest-serving in history – barely makes it into the narrative at all. If it does, it’s restricted to his battles with junior doctors and funding – both of which Hunt likes to portray as victories.
Maybe it’s not surprising that so much of the media takes at face value Hunt’s self-presentation as a nice guy with a “consensual approach” (slogan: “Unite to win”). For most of his tenure as health secretary – except, perhaps, during the junior doctor dispute – they fairly uncritically adopted Hunt’s persona of the ‘champion of patient safety’.
I spent much of Hunt’s period as health secretary running openDemocracy’s OurNHS section, investigating what he was really up to. I soon discovered that when you looked past his press releases, you found a very different story – one of missed targets, lengthening waits, crumbling hospitals, missed opportunities, false solutions, funding boosts that vanished under scrutiny, and blaming everyone but himself. This is that story, which was first published on openDemocracy on 13 July 2019.
Hunt’s hospital legacy
Hunt took over responsibility for the NHS in 2012. By the time he left the post six years later, patient experience and staff morale had both taken a dramatic turn for the worse across many key indicators. Winter crises deepened, with official figures showing 2017, 2018 and 2019 were successively “worst on record”. The British Medical Association (BMA) reported that by 2018, “the “winter crisis” has truly been replaced by a year-round crisis”.
Nationally and locally, a range of treatments were restricted. Hernia, hip and knee operation patients weren’t treated until they were in severe pain. Cataract operations and hearing aids were restricted to one eye or ear (who needs two anyway?). Vasectomies, erectile dysfunction treatment and diabetes monitoring were scrapped or severely restricted in growing numbers of areas. In response, NHS hospitals increasingly turned to offering ‘self-pay’ options to private patients.
Hunt oversaw years of historically low funding increases (around 1%, compared with an average of 6% in the years between 1997 and 2010, and compared with the 4.3% recommended by the Office of Budget Responsibility and the likes of the Kings Fund, Health Foundation and Nuffield Trust, as the minimum to keep up with health inflation and increasing demand). Perhaps most damagingly, he oversaw a significant cut to the amount that hospitals were paid per procedure (payments which make up three quarters of their income).
Hunt’s response was to send out “failure is not an option” missives to hapless local NHS executives, instructing them (on pain of having their entire board suspended) to clear their financial shortfalls, while making sure they did so “without compromising patient care”. So that’s all right then! Even when “extra” money was found, as it was to some extent after the 2015 election, it came with so many strings attached that frontline patient care received little benefit, and was often in the form of loans that mean, remarkably, hospitals are now more ‘indebted’ to the government, than they are to the PFI deals that are still squeezing them. Hunt’s parting gift, the NHS ‘Brexit Dividend’ birthday present, is also full of strings and inadequacies, as we’ll see below.
Hunt’s reaction to this was to introduce what I dubbed a “Hospital Closure Clause” into an unrelated piece of legislation, which stripped away many of the requirements to consult local people on future closures. Further closures, land sell-offs and down-grades to services and opening hours have followed. And justifications that the land sold off by hospitals would be used to provide homes for nurses have proved utterly hollow when it turned out that only 17% of the houses built – fewer than 1000 homes – would be ‘affordable’. The trend is likely to continue, given that Hunt’s much trumpeted ‘NHS birthday present’ (of which more later) did not cover capital funding for buildings and equipment.
In 2019, the NHS had a £6bn backlog of essential maintenance and repairs, as under Hunt £4.3bn was raided from capital budgets to pay daily bills. And hospitals were told (by the Naylor review) that the way to make up this shortfall was to sell off more land and buildings, and enter into more private finance arrangements.
This policy failure, during a funding squeeze, is perhaps not surprising – the reality is that care at home requires more, not less, funding than care in hospitals, as reviews by the University of Manchester, the British Medical Journal, the National Audit Office and even the Department of Health itself have shown. Hunt repeatedly ignored the many experts warning him that this was the case. In the end, though, billions of pounds of ‘transformation’ money supposedly set aside to deliver the policy change, instead had to be quietly re-purposed into keeping cash-strapped hospitals just about afloat.
Meanwhile, in vital but neglected areas such as general practice, maternity and mental healthcare, Hunt routinely over-promised and under delivered.
In October 2017, Hunt told MPs: “We’ve got 30,000 more people working in mental health today than we had when [Labour] left office” – a claim that was revealed to be false. Not long before leaving office, he won headlines for promising that mothers would get a ‘dedicated midwife’ throughout pregnancy and birth, although later reports suggested that this wasn’t, in fact, the case, and that women were just being promised ‘one of a team’. In other words, no change.
Not long before his departure, Hunt told Parliament that NHS privatisation “is not happening” and was “fake news”. But his actions suggest he was as ideologically wedded to continued competition and privatisation (in various guises) as his notoriously destructive predecessor, Andrew Lansley. An enormous amount of clinical and management energy was wasted in having to work to keep services from being chipped off by the private sector – even though such privatisation is a hugely costly process with no proven benefits.
While various privatisations collapsed, failure seemed to be rewarded. In 2013, a privatised treatment facility in Stevenage run by the company Clinicenta was bought back by the NHS following the deaths of three patients during routine surgery, with local officials raising concerns about “serious failings” and “evidently substandard” care. But just as Clinicenta was collapsing, its parent company – Carillion – was rewarded with further NHS contracts including major PFI schemes at Royal Liverpool Hospital and Midland Metropolitan Hospital.
After Carillion itself collapsed, The Guardian revealed documents that showed that, “civil servants working for Jeremy Hunt successfully lobbied the Cabinet Office to stop failing Carillion hospital projects from being overseen by an independent watchdog”.
The tech bonanza is another novel form of privatisation. Hunt’s successor Matt Hancock has been criticised for an overly credulous attitude to technology, but Hunt laid all the groundwork. The NHS signed substantial contracts with the likes of health app firm Babylon under his oversight, as well as running into a massive controversy over the care.data project in which Hunt and his tech Tsar, Tim Kelsey, were unable to adequately reassure a concerned public that personal data would not be sold to private firms. In what he described as his “most important speech as health secretary”, Hunt boasted that; “The future is here… 40,000 health apps now on iTunes… this is Patient Power 2.0.” The announcement was somewhat overlooked as it was also the speech in which he launched his astonishing attack on doctors (more below). But perhaps Hunt envisaged a future with fewer doctors – not long afterwards, he faced fierce criticism by doctors for issuing “potentially fatal” advice to parents to use “Doctor Google” to diagnose their children’s rashes.
David Cameron sold the controversial 2012 Health and Social Care Act by claiming that it put doctors in charge of decision-making. In reality it put privatisers in that position, along with commercial providers taking over and sub-contracting to the NHS. In 2016, openDemocracy reported on a version of these arrangements called “Accountable Care Organisations”, an idea based on US hybrid insurer-hospital organisations such as Kaiser Permanente. This gives private providers involvement in decision-making about what treatments patients do or don’t receive, and financial incentives to minimise treatment (as Michael Moore’s film ‘Sicko’ exposes). Hunt visited the US firm at least three times.
However, Hunt did little to promote the real solution – reintegrating social care under the NHS’s public, free provision. Instead, he suggested that the ageing population was a massive “commercial opportunity” – and ‘integration’ began to look to campaigners like merely code for ‘helping the private care sector get its hands on more NHS cash’.
The underlying issues were left unresolved, the promised social care green paper was delayed no less than five times (and counting), experiments to ‘integrate’ ran into frequent problems, and the social care sector continued being just another convenient scapegoat for delays in discharging people from hospital. Hunt is still pursuing market solutions, suggesting during the leadership campaign that while social care cuts had gone too far, the answer is to ‘incentivise’ individuals to save for their own social care.
Perhaps none of this is surprising. Back in 2005, Hunt co-authored a book called ‘Direct Democracy’, which stated; “Our ambition should be to break down the barriers between private and public provision, in effect denationalising the provision of healthcare in Britain” and that the NHS was “no longer relevant in the 21st century”, although he has since distanced himself from the book’s vision.
Hunt adopted three key strategies to ensure that the NHS wasn’t his career graveyard, as it had been for many Tory predecessors: hiding, hiding, hiding the figures, and (most of all) hiding behind someone else. His biggest talent is also, in fact, Boris Johnson’s: ducking accountability. The strategies are somewhat different, of course. Johnson’s bluster makes you suspect you’ve been had (but it appears that Britain, or at least the Tory part of it, includes a lot of masochists who rather enjoy that). Hunt’s smoothness means you don’t even notice. And the success of these tactics tells us much about technocratic attitudes to democracy, accountability, leadership and so-called public service ‘reform’.
Hunt’s complaints about Johnson refusing to debate him rang hollow to those of us who have followed him closely. Hunt is famous for dodging debates, whether with junior doctors, angry hospital users, in parliament or on the ‘Today’ programme, on which Hunt was a regular no-show during NHS crises. Where he did appear, he often restricted his appearances to issues over which he had no actual control, such as promoting a sugar tax. In fact, he became so notorious for shirking debate that hospital campaigners launched a “Hunt the Hunt” campaign, and junior doctors camped out on his departmental doorstep.
Blaming the patients
Hunt had no end of people that he (and his media cheerleaders) could blame for the problems besetting the NHS.
First off, patients. Be they old people, for being too old (“a challenge more serious than global warming”, Hunt said, even though this narrative doesn’t actually reflect the reality that health needs are highest in your last years of life, whenever that comes). It is true that health needs are rising among the poorest – and health inequalities increasing sharply – but blaming austerity policies and inequality for rising health demand wouldn’t have endeared Hunt to anyone in the Tory party. Instead, he relied on the ‘ageing population’ line routinely, when pressed on failures to meet NHS targets – such as an interview with the BBC’s Laura Kuenssberg, where he said, “the targets you talked about are because of the pressures of an ageing population”.
To add insult to injury, under Hunt’s tenure, the dehumanising labelling of old people as “bed blockers” returned, even as he did nothing serious to solve the issues of social care. Then there were children – and parents – blamed for being too fat, even as public health funding to address such issues was slashed. And smokers, who, along with overweight people, started to be banned from routine surgery under Hunt’s watch. Such patient-blaming decimated the NHS’s core values of universalism and comprehensive care, to the horror of doctors and nurses.
I asked Hunt about this at an Institute for Government event not long before he left office. He told me blandly that, “this shouldn’t be happening”. But there was no sign of him taking any action to stop what he routinely blamed on ‘local decisions’ (as we’ll see again with rationing of care).
Always top of the scapegoat list, of course, are migrants. From 2013 onwards, Hunt’s department worked closely with the Home Office on a string of initiatives to impose the ‘hostile environment’ (a policy which the former head of the NHS described as a “national scandal”). That led to cases like Albert Thompson, the Windrush victim who was denied cancer care. Hunt went pretty unscathed when these scandals finally broke through into the public consciousness, and these restrictions are still largely in place – along with the upfront charging systems now set up in hospitals, which many have observed could now easily be rolled out to others.
Blaming the staff
Blaming the staff is, of course, another favoured tactic of politicians, and one that Hunt embraced wholeheartedly (though he would no doubt like to think of it as ‘delegation’).
In terms of senior staff, in 2013, Hunt hired his Oxford contemporary, Simon Stevens, as chief executive of the NHS. Stevens quickly adopted the role of media frontman whenever the going got tough.
In hiding behind Stevens, Hunt benefitted from the post-2012 legal framing of the NHS as a standalone organisation (or rather, a tangle of competing, squabbling standalone organisations), given its money and left to get on with it. When problems arose, it was down to ‘the NHS’s own plan’, and ‘local decisions’. No longer did the secretary of state have a duty to provide or secure healthcare for us all.
But on the whole, Hunt outsourced strategic policy thinking (and ‘heavy lifting’ to shift public attitudes on charging, privatisation and hospital closures) to costly and wasteful management consultants including the Big Four accountancy firms (despite promising to rein in this spending), not to mention a collection of sirs, lords and commissions, regulators, right-wing think tanks, and in-house consultants dubbed “ninja privatisers” who were responsible for numerous expensive failures. (To be fair to Hunt, quite a bit of this policy outsourcing strategy was developed by his health secretary predecessors, both Tory and Labour).
As a result of the 2012 Act, Hunt had just one last bit of legal and parliamentary accountability for the NHS – the “mandate”, which required him to put the NHS’s annual objectives before parliament. But in 2015, when the scope of the mandate was being revised for the next five years, his department issued a public consultation that Hunt somehow failed to actually tell anyone about (it wasn’t even published on their departmental consultation page) – a ruse that caused something of a backlash after OurNHS got wind of it, particularly given the hints about widespread withdrawal of treatment.
Frontline staff became Hunt’s favourite whipping boy
While senior staff and outsourced policymakers were convenient stooges, frontline staff became Hunt’s favourite whipping boy. He kicked off his tenure by telling parliament that “cruelty became normal in our NHS and no one noticed”, implying that the criticisms of the terrible Mid-Staffs scandal were normal for the million plus NHS workers.
But all this was just a foretaste of what was to come for doctors, nurses and other health workers.
In 2015, Hunt and Cameron promised a “seven-day NHS”, but Hunt was condemned in May 2016 by parliament’s Public Accounts Committee, which deemed the plan “completely uncosted” and said that Hunt’s department had made “no coherent attempt” to address the staffing impact of this pledge.
Hunt veered close to accusing anyone standing in his way of being responsible for “avoidable deaths”
Perhaps what aggravated and demoralised doctors and nurses more than anything else, was Hunt’s audacious use of tactical shroud-waving. Previous Tory health ministers frequently accused their opponents of using deaths to make political points. But Hunt repurposed this trick against his opponents, veering close to accusing anyone standing in his way of being responsible for “avoidable deaths”.
Announcing his intention to impose a new contract on doctors, Hunt claimed that “around 6,000 people lose their lives every year because we do not have a proper seven-day service in hospitals… No one could possibly say that this was a system built around the needs of patients – and yet when I pointed this out to the BMA they told me to ‘get real.’ I simply say to the doctors’ union that I can give them 6,000 reasons why they, not I, need to ‘get real’.”
Margaret McCartney, a GP, author and broadcaster, told me: “It’s dangerous to keep on misrepresenting data even when experts have told you that you are making a mistake… Hunt’s claim about weekend deaths, used to justify changes to the junior doctor contracts, has been debunked (patients admitted at the weekend tend to be sicker).”
The shroud-waving was a tactic he had already deployed effectively against his first parliamentary opponent, Andy Burnham, and indeed against interviewers. Questions about failures to meet targets on waiting times, when not being excused by the “ageing population”, were often met with impassioned statements about patients failed by the NHS in Mid Staffs, Morecombe Bay, Gosport and elsewhere – a strategy he also deployed consistently in media interviews (such as his interview with the BBC’s Laura Kuenssberg, when he was challenged on LBC by an angry doctor in the same week).
He had deployed the tactic too, against Lewisham campaigners, when his administrator’s report suggested closing the hospital and related changes would “save around 100 lives a year”.
Indeed Hunt has made the “patients’ champion” persona his own. He told the New Statesman that he had made patient safety his “life’s mission” and that when he left frontline politics; “I want to write a book on patient safety. I would like to do for patient safety what Al Gore has done for climate change…”
In reality, having wielded the Francis report into the Mid Staffs scandal as a weapon from the get-go, he junked most of its key recommendations.
Having promised in 2013 to bring in minimum standards of safety for ratios of nurses to patients, two years later he and Simon Stevens quietly tore these promises up as too “mechanistic”, to the concern of the report’s author, Robert Francis. Hunt’s repeated promise to put the patient at the centre of everything that the NHS did, including in its constitution (another Francis report recommendation) was similarly junked a year after its headline-garnering work was done. Promises to protect whistleblowers resulted in just another toothless system. Moves towards openness were undermined by increased reliance on the market and private sector provision, with nothing done to address the destructive ethos of competition between and even within hospitals that Francis had identified as a key part of the problem at Mid Staffs.
Phil Hammond, the doctor and broadcaster who has written extensively on patient safety, told me: “Hunt developed a selective interest in some aspects of patient safety… so although he will be able to cherry-pick to make it look as if some aspects of safety got better…. Hunt repeatedly refused to introduce mandatory safe staffing levels… There are of course some brilliant NHS staff who are very dedicated to safety, who have improved the situation in their particular hospital or GP practice, but I don’t really see how Hunt can take credit for that. Finally, despite his strong words about no more cover-ups in the NHS and better support for NHS whistleblowers, many of them say the situation hasn’t improved and they are still not being listened to and are being persecuted.”
So much for Hunt’s “patients’ champion” persona.
And of course, much else that happened to the NHS under his watch wasn’t very good for patients, either – in terms of safety, but also access to healthcare, privatisation and rationing. And this is where the last of his strategies came in very useful.
Playing with the figures
Part of Hunt’s pitch is that he is “on top of the detail”. In reality, he has worked to make it harder or impossible for the rest of us to check-up on the detail. Once A&E waiting targets were routinely being missed, he simply stopped publishing weekly data on the failures and dropped hints that the target would soon be dropped. Similarly, in response to regularly missing the target on maximum 18-week waiting times for planned operations, that target was quietly dropped. In response to alarming headlines regarding the rising number of hospitals declaring ‘black alert’ (unable to guarantee life-saving emergency care, and having to divert patients elsewhere), the ‘solution’ was to ban hospitals from using the term ‘black alert’.
Under Hunt, the Department of Health routinely refused to answer parliamentary questions and Freedom of Information requests about which private companies the NHS’s money was going to on the basis that they didn’t centrally collate it. And it was also reluctant to release raw, uncollated spending data, being the last department to do so and only giving in after a petition to release it. Inconveniently timed information on the financial crisis engulfing hospitals was tucked away from view too.
Also worrying, it turns out (in the long term plan) that Hunt’s deal was conditional on the NHS achieving significant savings through the use of technology (something that many experts were dubious about), reducing face-to-face appointments by one third, and also on there being no additional pressures from the social care sector (that was on the verge on collapsing). And this 3.4% doesn’t apply to capital expenditure, staff training and pay, or public health budgets – all of which would remain up in the air until the next spending review. Theresa May promised the “Brexit dividend” would fund the increases. That didn’t quite pan out though, did it? As a Nuffield Trust health expert put it, “The NHS would be wise to hang onto the receipt for this particular birthday present.”
There are many more facts I could throw at you to help you see Hunt’s legacy. Public satisfaction with the NHS fell during Hunt’s time in office, for example. Both maternal deaths at childbirth and infant mortality started to worsen again towards the end of Hunt’s tenure, after decades of improvement. And one last statistic is perhaps the most damning. In an interview with the New Statesman, he quoted Stephen Pinker as saying that “life expectancy has gone up!”. While this is true globally, the story in Britain is different. Since 2015, projections for life expectancy in the UK have fallen by more than a year.
It tells you much about British politics that a man with Hunt’s record was promoted to foreign secretary, and after losing one leadership bid, again now stands a small chance of becoming prime minister. It tells us a huge amount about the state of the British press that Hunt is treated as a serious candidate.
And it’s worth remembering, that whoever succeeds Johnson will face the same advantages that Hunt has always had: an establishment that doesn’t care too much what happens to ordinary people’s services, so long as no one makes a fuss, and a pliant media, always ready to believe the spin of some old public schoolboy.
Tony Gosling and Martin Summers discuss politics on the Not the BCFM politics show. It’s four hours long, I’m only a third of the way through but seems particularly impressive this week. Martin Summers has PPE (Politics, Philosophy and Economics, the degree that UK Prime Ministers often have) at Oxford. This podcast is often carp about the climate crisis.
A rough guide to factions in UK politics. Comments are welcome.
This is my own work looking at the influences behind various UK politicians. You are welcome to disagree with any point. It should be recognised and accepted that some politicians will not have any philosophical or ideological basis at all – many people simply unquestionably accept the politics and world-view of their parents. Some of them may also be mad or simply whores to power or financial gain.
Socialists are a diverse bunch often fighting injustice e.g. anti-racism, and campaign for human rights, universal healthcare, democracy, equality, workers’ rights, etc. There are more radical Socialists outside of parliamentary politics fragmented according to adherence to the different historical origins and aspects of Socialist Ideology. The Labour party catchphrase “For the many, not the few” catches the Socialist ethos perfectly. [17/1/22 This article is now dated and was written while Jeremy Corbyn was leader of the UK Labour Party. “For the many, not the few” was a slogan of Jeremy Corbyn’s Labour Party and the title of the 2017 Labour Party manifesto. This ethos has been abandoned by the current UK Labour Party under leader Keir Starmer which should be regarded as a return to Blairism i.e. Tories pretending to be Socialists and no mainstream political representation of Socialism in UK.]
Parliamentary Socialists are not that concerned with historical Socialist ideology. They will recognise and object to the vast inequalities in wealth and control of the media but that’s about it.
Neo-Liberals are Capitalists who believe that “the market will provide”. These are the ones who are keen on deregulation so that businesses are unhindered by “red tape” – actually laws and regulations that protect standards and ordinary people – and the privatisation of everything. Brexit is all to do with deregulation so Brexiteers are mostly Neo-Liberals.
Neo-Conservatives are Neo-Liberals with the added aspect that they are Zionists – supporters of the state of Israel. Theresa May and many of the Conservative party are Neo-Cons.
Rabid Zionists are extreme supporters of the state of Israel. These are the ones that make accusations of anti-Semitism within the Labour party. The Al Jazzera series ‘the Lobby’ shows that Israel is directing accusations of anti-Semitism and the Israeli embassy may deserve its own entry in this guide.
Appeasers to Zionism. Since Zionists are attempting to apply a veto on UK politicians there are those that appease them to gain advantage. Strangely, these are often found to be trombonists.
The DUP (Democratic Unionist Party). Theresa May’s minority government is supported by the DUP. In any abusive relationship, the party that needs the relationship least is in the position of power.
6/3/19 Apologies that I neglected the nationalists. I did intend to but was on a roll.
Being a doctor – or any public sector worker – shouldn’t be such a battle. That’s why we must support junior doctors in their planned strikes.
For the last 9 years I have been the medical director of an NHS service providing confidential help to doctors and dentists with mental health problems, seeing a rising number of doctors week on week.
But our patients have changed.
In our early days the ‘typical’ patient was an older male (GP or psychiatrist) with alcohol problems.
Now nearly half of all new patients are under 30 years old. They come to us with depression, anxiety and symptoms akin to posttraumatic stress disorder. Many have worked in the NHS only a few years. They started out bushy tailed and bright eyed, but end up ‘burnt-out’ (a polite euphemism for depression) after only a few years working. Our youngest patients are only a few months qualified and many are in their Foundation years.
Patient after patient talks of feeling betrayed and bewildered by their loss of enthusiasm about a profession that they had strived to enter (often since their early teens). How their desire to care for patients is sapped by every working day. The language they use to describe their work is that of the battlefield. Being on the ‘front-line’, of ‘surviving’ another shift, being ‘at war’ with management. They talk of feeling abandoned by the NHS. Of working intolerable shifts that appear to have been designed by robots with no concept that humans will need to work them. Of having no sustenance – literally and metaphorically – as they try their best to deliver care to patients.
They talk of working in an unforgiving environment – where every error will lead to punishment and where every move is watched and recorded. They describe the fun having gone out of their profession. They say that they cannot see a future any more in medicine.
Our junior doctors are striking for more than pay and conditions – important though these are. Their planned strike is consciously or unconsciously action to shine a light on what is going on within the NHS – to shine a light on the conflict between idealism and industrialization.
Increasing privatisation has changed the relationship doctors have with their patients. Constant reorganisation has fragmented services, and shattered long-standing teams. At a series of NHS listening events I held in 2014, the overwhelming term used by all NHS staff to describe their working environment was ‘Fear’.
The pay of junior doctors has never been good – not when calculated across the hours worked, the responsibilities they have and when compared to their non-medical peers.
But this was part of the compact we all had – we gave our all for our patients and the organisation we worked in gave their all to us – cared for us, nurtured us, trained us. We also knew that the intolerable hours would end as we climbed the medical career ladder. Now all of this has been fractured.
The new junior doctor contract will erode not just pay but also the current safety net against exploitative hours of work. Saturdays will be counted the same as week-days (tell their children that when they are off school and wanting to see Mum or Dad). Women and others who take career breaks will be discriminated against. Junior doctors have been forced to look into the abyss and chose between pain today (strike action) or pain tomorrow (agreeing to an unfair and unsafe contract). They are being treated as children rather than the committed adults they are – their please ignored, instead accused by Jeremy Hunt of being ‘extreme’, ‘militants’, and even unpatriotic.
The junior doctors are not alone in their discontent. The nurses who are marching this Saturday, the teachers and social workers, in fact most public sector workers have seen insecurity, exploitation, fear, and subtle discrimination as the backdrop to their working lives.
The junior doctors are fighting for fairness for all of these workers. They are leading the charge for a restoration of the values that should drive our public services. For a change by those who employ them – ultimately our Government – who have a moral duty to protect those who care for some of the most vulnerable in society.
Without this change, goodwill will disappear forever and with it the glue that binds our public services together. The government must now stop their bullying tactics and accept that something is profoundly wrong the NHS today and act before it is too late.
This article is published under a Creative Commons Attribution-NonCommercial 4.0 International licence.
The junior doctor contract governs the pay and conditions of work from doctors’ foundation year to registrar level. All doctors who are not consultants or fully qualified GPs are considered ‘junior’ doctors. This contract was scheduled for renegotiation, but the British Medical Association (BMA) – the largest representative body of doctors – walked away because the offer on the table was not fair to doctors and not safe for patients.
The government’s initial response was brazen, and threatened to impose the new terms without consultation – a position it has had to water down since the BMA decided to ballot its members for strike action. Here’s why the BMA has done so the first time in 40 years:
An NHS in crisis: overworked and undervalued.
Britain’s doctors have had enough. In a stretched and underfunded health system which doesn’t train enough doctors and nurses to meet its own needs – or invest in the infrastructure needed for new hospitals and facilities unless aprivate contractor is taking a nice slice of the pie – the solution seems to have been ‘work harder and take up the slack’. According to the Royal College of Physicians, the NHS “remains reliant on doctors working longer than their contracted hours…the amount of ‘goodwill work’ is increasing year-on-year.”
Trusts struggling to pay their tithes to the private owners of NHS hospital buildings have responded by reducing staff salaries, meaning fewer doctors and nurses are covering more patients and expected to do so for free. The situation has reached crisis point and doctors are experiencing enormous burnout, with more doctors applying to live abroad every year. Into this context came the new contract.
It’s not about the money.
The ‘offer’ of the new contract has been condemned first and foremost as fundamentally unsafe. Just as with the recent tube strike, the new contract threatens to force doctors to work longer and later with fewer safeguards.
The BMA approached negotiations acknowledging financial limitations but determined to improve safety: it wanted no doctor to work more than 72 hours in a week; no more than four nights in a week on-call; a rest day either side of nights before starting back on day shifts; and facilities to sleep-in for those who otherwise make a dangerous long drive home.
The government was unwilling to accept these terms, and furthermore wanted to reduce breaks to just one 30 minute break in a ten hour on-call shift. As a recent viral video asked, could you save a life if you’d been up all night?
But it is, also, about the money.
The new contract would mean a 15-40% pay-cut depending on your specialism, with GPs and emergency care doctors being some of the hardest hit. Let that sink in.
With wages starting beneath the national median anddecreasing yearly like all public sector pay, and out of pocket expenditure for licensing, exams and indemnities, junior doctors earn significantly less than the tabloids would have you believe. Their reports often use a cunning sleight of hand: taking the figures for the pay of those doctors doing the most private work – GPs who run a private practice and some consultants who run private clinics – and presenting the data as proof of ‘greedy’ public sector workers.
There are two ways doctors’ starting wages increase: extra pay for unsociable hours, and pay advancement as you progress through the ranks of seniority and responsibility. Both of these are under threat in the new contract.
The government has suggested that working from 7am until 10pm Monday to Saturday are sociable hours – and therefore should not be paid extra – which is funny considering MPs just reduced their own working hours and increased their own pay. As for pay progression with seniority, no actual offer was made.
The changes hit women hardest.
The contract changes penalise those who take time out to start a family and those who work part-time –overwhelmingly affecting women in both cases. Additionally there are concerns that changes to breaks will make work more dangerous for pregnant women. As noted above GPs will be amongst those taking the largest wage cut, one of the few specialisms with more women than men.
Hunt and the government have shown a complete disdain for even the barest semblance of actual negotiation. When the BMA walked away from negotiations a year ago, it wasn’t as a strategy to get better terms, it was because the negotiations were a farce. It has taken the threat of industrial action for a pathetic attempt at reconciliation to come from the Department of Health, full of vague, unconvincing rhetoric. It is too little, too late. No fruitful discussions can continue with Hunt as health secretary. We have no reason to believe in his word or his competence.
We deserve more. Doctors do not take strike action lightly. Whilst we will always maintain emergency and essential services, the BMA will be balloting its members to strike against the contract in the next month. We hope to see you on the picket lines.
About the author: Nick is a junior doctor. He tweets at @ZastaNick.This article is published under a Creative Commons Attribution-NonCommercial 4.0 International licence.
England’s Junior doctors held a 24-hour strike from 8am yesterday. It was the first of a planned series of strikes. Jeremy Corbyn’s Labour Party and the Green Party should be commended for their support of the strike. (The strike only applies to England).
While it’s very tempting to address the strike, today’s featured article instead addresses a fundamental problem with the NHS which is largely ignored by corporate media – that of the huge bureaucratic overhead of imposing a fake, imaginary ‘market’ so that the private sector can extort it’s ‘tax’. The conclusions to be drawn from this article should be clear.
But there is one pot of money that sits curiously unexamined, glistening and untouched.
It’s the cost of the NHS ‘market’ itself. Administering the hugely expensive artificial ‘marketplace’ created by successive governments to allow both NHS and private ‘providers’ to compete with each other to offer services to NHS and other ‘purchasers’.
No-one knows the exact cost of this bureaucratic ‘marketplace’. A recent estimate by rebel Lib Dems put the figure as high as £30billion a year. Dr Jacky Davis and other doctors and campaigners including the National Health Action Party have put it at £10billion a year. The Centre of Health & the Public Interest put it at a ‘conservative’ £4.5billion a year.
Even the most conservative of these estimates is a yearly amount which would, if re-directed away from useless market activities, fund both the £2billion annual NHS shortfalland free critical social care to everyone, which the Kings Fund’s Barker Commission recently said would cost ‘substantially less’ than £3billion a year.
Despite fierce urging from expert MPs to look at what the ‘market’ costs the NHS more closely, the government, mainstream media, think tanks and policy makers have dismissed, ignored and even suppressed this information, with unevidenced assertions that ‘modern healthcare systems’ need vastly expensive bureaucracy, market or no market.
Successive governments wedded to ‘market reform’ have refused to produce useful figures that would definitively establish the cost of the NHS market. It has been left to academics, MPs and activists to try and fill the void, through historical and international comparisons, as well as tentative attempts to cost different activities that are forced on the NHS by the ‘market’.
The Select Committee noted that the NHS would have some administration expenses even if it didn’t run itself as a ‘market’. But they noted evidence from the NHS Chief Historian, Professor Charles Webster that in the pre-market late-80s, the NHS spent only 5% of its budget on administration.
The difference in administration costs pre- and post-market – 9% of the NHS budget – is over £10billion a year of the current £120bn budget. That’s more than the entire cost of every GP in the land.
The government tried to suppress the 14% figure, which was in a York University report it commissioned then refused to publish for 5 years. The York study found that ‘market’ mechanisms like “the purchaser-provider split, private finance, national tariffs…mean…transactions costs of providing care have increased, and may continue to increase.”
The Select Committee report suggested that “the purchaser / provider split may need to be abolished”. They added that they were “appalled” that the Department of Health “was unable to give us accurate figures for staffing levels and costs dedicated to commissioning and billing.”
MPs concluded “the suspicion must remain that the Department of Health does not want the full story to be revealed.”
£10billion a year may be a conservative estimate
In fact the increase in administration costs due to the ‘market’ is likely to be even higher than £10bn.
Professor Colin Leys, author of ‘The Plot Against the NHS’, told OurNHS that these figures relate to 2003, before the second big wave of market ‘reforms’ including “the Independent Sector Treatment programme, the huge expansion of the Commercial Directorate of the Department of Health, the marketing division set up to help trusts learn to advertise and sell their services, the Competition and Cooperation panel, Monitor’s vast expansion…”
The key driver of high NHS inflation is rising drug and medical device costs, new, expensive clinical possibilities, and rising demand as the population ages, runs the accepted wisdom. So why have administration costs kept pace with – or even outstripped – these unavoidable inflationary drivers? Shouldn’t we expect to see administration costs forming a falling proportion of NHS costs?
Professor Webster told OurNHS that instead, “serial reorganisations and escalating marketisation are imposing enormous cost and waste on the NHS, with administrative costs spiralling out of control since 1980.”
Professor Leys adds, “It of course depends on how much you think admin costs would have risen anyway to deal with more complex interactions of modern health care, but to my mind attributing 20% of all NHS costs to admin costs [ie about £25billion], and half of that to the costs of operating as a market, is very reasonable.”
Professor Paton takes a more conservative view, halving the £10billion figure to conclude that “the recurrent annual costs of the market can be estimated (conservatively) at £4.5 billion”.
He concludes in his report earlier this year that the NHS market itself is “an unaffordable ideological luxury”, with few if any discernible benefits.
The market and ‘transaction costs’
Away from the academic estimates, though, a quick glimpse at the empty hospital carpark after the managers and admin staff have left for the day, brings home the reality of how much must be being spent on paperwork and IT white elephants to administer the market.
The market introduces ‘transaction costs’ – advertising, negotiating, contracting, invoicing, billing, auditing, monitoring contracts, collecting information, resolving disputes both in courts and out, all employing and training a ballooning bureaucracy – even leaving aside any profits extracted by the private sector.
At the grassroots, Hackney GP Jonathan Tomlinson told OurNHS that applying the ‘market’ adds huge costs at every stage, “because they diffuse through every interaction, from a decision to prescribe or perform a scan, make a referral, set up a service or close a hospital.”
Then there’s what Paton calls the “circular re-organisation”, with endless “re-invention of expensive agencies under different names supposedly abolished, alongside the costly complexity of the new, often overlapping, agencies …”
How many managers does it take to change a health system?
Then there’s the 211 Clinical commissioning Groups, advised by soon-to-be privatised Commissioning Support Units and NHS England (the biggest quango in history). All of them shove a lot of cash at the management consultants, too (under central quango instructions).
Then there’s the ballooning bureaucracy created to regulate and further marketise this decentralised jumble – the NHS Trust Development Authority, Monitor, the Care Quality Commission, NHS Professionals, NHS Property Services, Healthcare UK… Some of these bodies are soon to be privatised themselves – but, just like the rest of the ‘shadow state’ of management consultants and thinktanks, they’ll still be receiving huge chunks of public money.
Of course the NHS needs managers – but this many? Duplicated across so many fragmented, competing, deficit-ridden organisations?
There have been recent tentative attempts to cost some of the individual elements of the market. Just the legal fees to comply with one Clause of the Health & Social Care Act cost local Clinical Commissioning Groups £77million a year, Labour uncovered earlier this year.
And hospital cash is sucked up in fending off the private sector, too. Earlier this year, the competition to run just one hospital – George Eliot – cost at least one and a half million pounds of public money, my Freedom of Information requests revealed. Over half, £771,000, went straight into the pockets of the big 4 management consultancy firms. Such sums are not atypical – nor is the fact this process changed absolutely nothing, in the end.
Another million pounds has just been blown on tendering ‘older people’s services’ in the East of England – again for the private sector to try (and fail) to demonstrate they could do a better job. But the private sector has got deep pockets – and will keep trying.
There are tens of thousands more of these expensive tenders underway or in the pipeline in every part of the NHS. Dr Tomlinson says “we had to cough up £40k to tender for a local practice that we were already successfully running – and at least that to tender for the Out of Hours contract.”
International comparisons are also helpful. A recent Commonwealth Fund reports suggest that the – til recently – less marketised UK system has been the most cost efficient in the developed world. A still more recent report found that Scotland now spends substantially less on hospital administration, than does England’s increasingly marketised system.
The Liberal Democrat conference this week heard a minority report from the NHS working group which suggested that scrapping the NHS market could save as much as 25% of the annual NHS budget. But their proposals to scrap the market were denied a vote by the party leadership.
The report noted that “countries where there is market competition in healthcare spend between 20% and 40% of their healthcare expenditure on administration”. It highlighted evidence from international experts that the increased use of markets in healthcare sharply increased administrative costs in New Zealand. Canada, Australia and Germany – soaring in the latter case by 63.3% between 1992 and 2003 and now standing at 20% of their health systems costs.
In the most marketised system of all, the USA, one healthcare dollar in every three is spent on adminstration of a system that delivers far poorer outcomes than the NHS. The Lib Dem report points out that healthcare billing alone cost up to 13%, noting “billing costs in healthcare providers are ten times the average of all businesses in the US. There is an inherent complexity to the business of delivering healthcare.”
These arguments are frequently dismissed by opponents. Former Editor of NHS managers bible the Health Services Journal, Richard Vize dismissed Labour’s tentative efforts to cost the market as “The old line that culling bureaucrats and lawyers is all that’s needed to fund new services…does not stand up to scrutiny.”
But where is that scrutiny?
The government told the Health Select Committee that the NHS still had “consistently low management and administration costs, ranging from 3-8%.”. But MPs on the Select Committee found “considerable lack of clarity and consistency in … these data.”
Professor Webster (former NHS Chief Historian and Fellow of All Souls) says the “the managerial lobby” have mounted “a clever distraction…a defensive response…artfully disguis(ing) the scale of the increase by accounting procedures, such as concentrating on Managers and Senior Managers, to the exclusion of other relevant staff categories, reducing ‘administrative’ costs back to 5 or even 3 per cent.” But even this, he adds, cannot disguise that “the percentage of admin and clerical staff in the NHS has doubled (from 12%) since 1980”.
The government now boasts of ‘cutting red tape’, saying “There are now over 20,500 fewer managers, senior managers and admin staff, and nearly 14,500 more professionally qualified clinicians than there were in 2010.”
But as Dr Tomlinson says, any reduction in admin staff doesn’t mean a reduction in admin costs,necessarily, as now “medical professionals are doing a lot of the work such as choose and book, coding, and so on, that could be said to be market costs.”
OurNHS asked Kings Fund Chief Economist John Appleby if the recent influential Barker Commission on the future of health and social care funding had looked at the cost of the NHS market.
Appleby replied “no it didn’t. wld need to look at net change..might not be net ‘saving’ as you assume.”
“One problem is no study yet to test cost-effectiveness of market in NHS”, Appleby added.
His own Kings Fund 2011 study on the market ‘reforms’ to date merely said the cost was ‘expensive’ but ‘unknowable’.
Who is served by the lack of intellectual curiosity by these unaccountable ‘think tanks’ to whom the Department of Health has largely outsourced policy-making? Although their accounts are not very helpful, insiders tell me that the Kings Fund make a substantial proportion of their income from advising this sprawling bureaucracy how to deal with the permanent revolution of the marketplace.
Privatisation doesn’t work
If competition and markets improved health, perhaps the extra costs would be worth it.
We’ve had twenty years of being told the NHS should be run like a supermarket, most recently from M&S man Sir Stuart Rose.
And – as an inquiry convened by Debbie Abrahams MP found earlier this year, there’s scant evidence the market improves quality or health equity (and plenty of evidence it worsens both),whilst costing considerably more.
Just about the only academic study that claimed some ‘cost-effective’ benefits for NHS competition has been criticised for its “heroic” assumptions and failing to factor in the “whole system costs” of competition.
But then, we’ve known since the pioneering work of Nobel Laureate Kenneth Arrow in 1963 that markets in health care simply don’t work. Being a ‘customer’ of healthcare is not like being a customer of, say, oranges – it takes expertise that you and I simply don’t have, and the consequences of the wrong ‘choice’, or a provider closing down, are far more serious.
Bevan and Beveridge’s vision was for not for pseudo-‘choice’ but for local, skilled professionals making decisions on the basis of a ‘strong public sector ethos characterised by commitment and altruism’. They recognised only a publicly owned system could avoid ‘opportunistic behaviour by those who would seek to profit from illness’, with incentives to over-treat and over-investigate, stimulate patient demand through advertising.
Few health economists can agree whether NHS ‘productivity’ has improved, declined, or isn’t an appropriate measure. But evidence from the ground shows patient satisfaction and NHS staff morale are now declining rapidly.
For the cost of the market isn’t just financial. Patients are inconvenienced and even endangered as they are shunted between competing hospitals, GPs, community services and ambulances, all trying to dump costs on each other. The Francis report into the failures of care at Mid Staffordshire found that drive to market-friendly ‘Foundation Trust’ status had created a “supposed ethos of competition and commercial negotiation” which promoted secrecy and undermined co-operation between medical professionals.
Hinchingbrooke, the first NHS hospital to be fully handed over to the private sector – is still a financial basket case, despite having cut corners – and staffing – to the extent that everyone from the Royal College of Nursing to the Care Quality Commission are united in their condemnation of poor standards ofcare and demoralised staff.
Imagine what improvements to our healthcare could have been made, had NHS financial and leadership resources not been squandered on creating a market. As Paton comments, the ‘opportunity costs’ are huge.
So how do we rid ourselves of the creaking edifice of the NHS market?
The market system is now so entrenched it has been compared by demoralised staff to Stalinism.
The proposed Bill has already attracted support from Lord David Owen, Green MP Caroline Lucas and the Green Party leadership, Labour Parliamentary candidates, the National Health Action Party and the author of the recent minority Lib Dem report on the NHS, Charles West.
Getting rid of the market would be uncomfortable for the cadre of NHS managers, management consultants and think tanks whose main skill is permanent reorganisation. But it wouldn’t happen all at once. They’d have one last big job on their hands before retraining as something more useful to society, leaving a slimmed down management and a beefed up medical workforce to get on with the job of running an NHS in the interests of patients, not profits.
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About the author
Caroline Molloy is Editor of OurNHS and a freelance writer. In 2011/12 she was part of a successful campaign which reversed one of the largest planned NHS privatisations in the country, involving 9 Gloucestershire hospitals. Since then she has been campaigning alongside local and national groups to defend the NHS.
This article is published under a Creative Commons Attribution-NonCommercial 3.0 licence.
“Whatever you may think of the value of IQ tests it is surely relevant to a conversation about equality that as many as 16% of our species have an IQ below 85 while about 2% …” he said as he departed from the text of his speech to ask whether anyone in his City audience had a low IQ. To muted laughter he asked: “Over 16% anyone? Put up your hands.” He then resumed his speech to talk about the 2% who have an IQ above 130.
Johnson then told the Centre for Policy Studies think tank, which helped lay the basis for Thatcherism in the 1970s: “The harder you shake the pack the easier it will be for some cornflakes to get to the top.”
“… greed [is] a valuable spur to economic activity.”
Royal Mail shares: Goldman Sachs sets price target of 610p
Goldman Sachs has risked a further escalation of the Royal Mailprivatisation row by putting a price target on the shares of 610p despite telling the government that the business should be floated at 330p last month.
Analysts at Goldman said the postal group’s valuation should benefit from an increase in parcel deliveries, despite falling letter volumes.
The investment bank’s 12-month price target of 610p represents an 85% premium on the flotation price, and gave further ammunition to those critics of the privatisation who argue the government sold off Royal Mail too cheaply.
The business secretary, Vince Cable, defended the government’s valuation of Royal Mail on Wednesday after solid results from the newly privatised group sent its shares even higher.
Royal Mail was privatised last month when the government sold 60% of its stake to investors in an initial public offering (IPO).
Royal Mail shares were up 5% by mid-morning on Wednesday to 559.5p – 70% higher than the flotation price of 330p. Its market value has increased by £2.3bn since the flotation, which valued Royal Mail at £3.3bn.
Operating profit for the six months ended 29 September was £283m, up from £144m a year earlier.
Locked in a cell just outside Heathrow, out of sight from the holidaymakers and business visitors, he can no longer get up off his mattress. He has not eaten in over 90 days. He can no longer stand or see. He struggles to talk.
On Friday, at 8:00 am, he will be forcibly put on board a flight and sent to Lagos, where he says he will be targeted by Islamic terror group Boko Haram. He was due to be deported tonight, but the Home Office has ordered new removal directions. Needless to say, he will be even weaker on Friday.
In a decision which has no legal, medical or moral consistency given the ‘end of life’ plan, a Home Office doctor has branded Muazu ‘fit to fly’. Yesterday morning, independent doctors visited him as he lay on the mattress in the detention centre and decided the precise opposite. There is a strong chance this man will die when he is deported.
Investment banks to be asked in Commons why sale of asset favoured foreign investors and if float price was set too low
The investment banks tasked with allocating shares in last month’s controversial Royal Mail float face a grilling by MPs over allegations they discriminated against UK pension funds and favoured foreign investors.
Goldman Sachs and UBS led an offer that has been widely criticised for short-changing taxpayers by selling a major government asset on the cheap, after Royal Mail shares immediately soared on the stock exchange and continue to trade at a premium of around 70%.
Those concerns have been exacerbated by the presence of sovereign wealth funds – including Kuwait, Singapore and Abu Dhabi – on the Royal Mail’s share register.
One senior City source, who has worked on major UK privatisations, said: “The Royal Mail was probably a bit cheap, but it is one thing to sell it at a cut-price to UK pension funds … There was a disproportionate amount of shares that went to sovereign wealth funds.”
Senior representatives from Goldmans and UBS will appear in parliament next Wednesday to answer questions from MPs on the business, innovation and skills select committee, alongside peers from JP Morgan, Citibank, Deutsche Bank and stockbroker Panmure Gordon.
The MPs’ concerns over the flotation are echoed by City figures. A top UK fund manager said: “A lot of people were very upset at their allocation, even on day zero before the shares started trading at a premium.
“It may be that the advisers did not take account of the political implications and do as good a job as they could have done.”
A source close to the committee confirmed: “This is something the committee is aware of. It may well come up in the session.”
In the months running up to the privatisation, it is understood that Royal Mail, the government and its advisers were working with a small group of financial institutions in order to get an early idea of how the shares should be priced.
That inner core of investors, which is thought to have largely excluded top UK pension fund managers, ended up with the most sizeable allocations.