The NHS is under serious attack from the Tories and faces rampant privatisation. Colin Leys, co-author of a new book on the NHS, spoke to Yuri Prasad about what the cuts mean—and how this is the logical conclusion of policies pursued by New Labour
Many say that if the government’s health and social care bill were passed in its present form it would mean the end of the NHS as we know it. Does that overstate the threat?
Colin Leys I don’t think it overstates the threat at all. The bill removes the secretary of state’s responsibility to provide a national health service and doesn’t assign it to anyone else. She or he would only be charged with “promoting” it.
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Selected excerpts from ‘The Plot Against the NHS’ by Colin Leys and Stewart Player. Chapter One is available here. I highly recommend this book available from Merlin Press for £10.
A year ago Peter Martin, the chief executive of Tribal Group plc, which describes itself as a “leading provider of commissioning services to the NHS“, presented his view of the future for the health sector in England. He was bullish. Although he described market conditions as “challenging”, he saw an “improved flow of service delivery opportunities” that would significantly support Tribal’s revenue growth. Andrew Lansley’s 2010 white paper would bring “major changes in structure of UK health markets”. Martin’s goal was to focus Tribal’s health business on the profit-making opportunities these reforms would create. He set out five growth priorities: commissioning for GP consortia, clinical support services, patient management services, informatics outsourcing and hospital management services.
This is the future for the NHS that David Cameron and Nick Clegg have planned for us since the launch of the coalition. Despite their claims to the contrary, they have been laying the ground for wholesale privatisation of the NHS, the destruction (without any democratic mandate) of one of Britain’s most cherished and effective postwar institutions, and the transfer of its stewardship and operations to organisations concerned only with maximising revenues and reducing costs. The word “quality” appears nowhere in Tribal’s vision as communicated to investors.
How has the NHS arrived at this moment of crisis? Colin Leys and Stewart Player provide an indispensable guide to understanding the origins of what they call a plot against the NHS. Surely this is an exaggeration? Not so. Cameron, Clegg and Lansley are merely continuing two decades of policies – begun by Tony Blair, endorsed by Gordon Brown, and supported by successive Labour governments – aimed at introducing markets into the health service. Where Labour tried to hide its intentions, the only difference with the Conservative-Liberal alliance is their shameless transparency.
Looking back at Labour health policy now, I have to ask myself how so many of us were unable to see through the mists of what Leys and Player call the “misrepresentation, obfuscation, and deception” perpetrated by Blair, Brown, and a host of health ministers all too willing to genuflect to the market zeitgeist. Too many of us – whether doctors, nurses, or just members of the public – were willing to be bewitched by Labour’s mellow language of reform. The words are all too familiar now: modernisation, choice, empowerment, diversity, plurality, improvement, contestability, and, most beguiling of all, patient-led.
The Department of Health created a commercial directorate to oversee the plan to privatise the NHS. A group of passionate market advocates were hired to transform a public sector institution into a target for private sector takeover. People such as Mark Britnell, who was the Department of Health’s director general for commissioning when Labour was in office and who later joined KPMG – able to sell his experience in government to the world of management consulting – have now been outed as agents for the merciless dismemberment of the NHS. There was a revolving door between civil servants in the department and McKinsey, KPMG and Deloitte. Ex-ministers, such as Patricia Hewitt and Lord Warner, traded their knowledge of NHS privatisation with those who could benefit in the commercial sector.
Doctors’ leaders were little better. The British Medical Association’s John Chisholm and Simon Fradd, who led negotiations with government to revise the GP contract in 2002, won a huge victory by making out-of-hours care for patients optional. Nine out of 10 GPs stopped offering services to patients from 6.30pm to 8am. This withdrawal of NHS care allowed private providers to step in and take over. After Chisholm and Fradd had succeeded in putting out-of-hours care out for private tender, they set up Concordia Health, a private company, that offered to run those very same services, only now at a profit to themselves.
The networks of health institutions that propped up the case for marketisation and privatisation of the NHS were intricate. They include private providers, such as UnitedHealth (whose president of global health, Simon Stevens, was once a key Labour adviser); thinktanks, such as the King’s Fund (whose trustees have included Stevens and Julian Le Grand, his successor in Number 10); and lobbyists, including several NHS outsourcing and private equity businesses.
Having anatomised the diseased political corpus that has begun to infect the NHS with a commercial ethos that will increase costs, cut services and reduce quality, Leys and Stewart try to look to the future. They mount a strong defence, claiming there is no evidence the NHS is in urgent need of fundamental reform. Given the statement by Steve Field, who is leading Cameron and Clegg’s pause to review the Lansley reforms, that the current Bill could “destroy key services” and destabilise the NHS, it seems that the gathering momentum for markets as the solution to whatever ills the NHS might have could be about to stall.
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Selected excerpts from ‘The Plot Against the NHS’ by Colin Leys and Stewart Player. Chapter One is available here. I highly recommend this book available from Merlin Press for £10.
NHS news is dominated by a speech given by David Cameron yesteday. He claims that the NHS must change but that does not justify the privatisation and withdrawal of services that he proposes.
He mentions a crisis of funding. 38 Degrees and UK Uncut are clearly showing how to resolve that issue – by combating tax avoidance by rich tax avoiding Capitalists.
17.05.11: Steve Bell on David Cameron's NHS reforms speech
He engages in “It’s because I love the NHS so much that I want to change it.” emotionality which attracts many comments. I wonder if Craig Oliver was drunk when he came up with that one.
Cameron repeatedly claims that the NHS is safe in his hands BUT the Health and Social Care Bill does away with the government providing a comprehensive health service
and
it has received near total opposition from healthcare professionals. Cameron claims to be willing to listen to doctors and nurses BUT they are calling for the bill to be abandoned.
Many groups and individuals respond to Cameron’s speech.
Conservative election poster 2010
A few recent news articles concerning the UK’s Conservative and Liberal-Democrat coalition government – the ConDem’s – brutal attack on the National Health Service.
David Cameron’s speech today on NHS reform has one familiar element: the extent of his personal attachment to the health service.
“It is because I love the NHS so much that I want to change it,” he says. That is an argument familiar from the election campaign, when Mr Cameron emphasised that the NHS was safe in his hands precisely because he had personal experience of its excellence during the tragic illness of his late son, Ivan. Indeed, it underlay the Tories’ commitment not only to exempt health from spending cuts, but to increase its funding.
Few doubt the NHS needs reform and that spending at present levels is unsustainable given the demands of an ageing population and the expansion in expensive new treatments. But accepting the need for reform is not the same thing as welcoming the Government’s health bill. This is a complicated set of proposals in one piece of legislation, which gives GPs more control over spending and commissioning services and at the same time seeks to take out layers of bureaucracy and increase competition. Many people, including health professionals, who would happily give GPs a greater say in the service, baulk at the extension of commercial competition. And Mr Cameron’s decision to “pause” the reforms – but not, as he says today, to stop them – is a measure of the public disquiet about the Bill and its implications.
Commenting on David Cameron’s speech on the Health and Social Care Bill, at Ealing Hospital, in London, today (16 May), Christina McAnea, Head of Health at UNISON, which represents more than 450,000 health workers, said:
“David Cameron is taking the ‘national’ out of the health service and turning it into a fragmented, money-spinning operation.
“The Prime Minister is using extreme examples to paint an untrue picture. He admits the NHS is providing the best service it has ever done, with reports saying it is the most efficient and equitable health system.
“Cameron’s call to crack down on waste in the NHS is a smokescreen for a move to a wholesale market, which opens the NHS up to privatisation. The real waste is the time spent on the fatally flawed reforms, which will force NHS patients to the back of a very long queue.
“He talks about having more choice and protecting budgets, but health workers are seeing their jobs axed and wards, services and even entire hospitals lost without any arrangements to protect continuity of patient care.
David Cameron’s pledge to ensure ‘substantive’ changes to the NHS ‘reform’ bill should be probed to discover what he actually means, Unite, the largest union in the country, said today (Monday 16 May).
Unite said that the deeply flawed Health and Social Care bill should be scrapped and a rtoyal commission set-up to investigate the future of the NHS.
Unite pointed out the discrepancy between the prime minister’s ‘vision’ and the fact that tens of thousands of NHS jobs had been or were going to be lost in the near future. Wards are already closing, waiting lists growing and services being axed or reduced.
Unite national officer for health, Rachael Maskell, said: ”David Cameron in his speech today was long on rhetoric, but short of specifics. This was a PR exercise in verbal gymnastics due to the political pressures he is under, especially from his Liberal Democrat allies.
”David Cameron wants it both ways with the Health and Social Care bill. He said today there will be no privatisation, no ‘cherry picking’ of services by private companies and no up-front costs for care, but we question how the prime minister’s ‘substantive’ changes are going to be incorporated into the legislation.
”The bill is so flawed that it should be scrapped. The whole bill is designed on the premise of Monitor’s role as an economic regulator and the concept of ‘any willing provider’ i.e. private companies. If the prime minister is serious about these changes, it will mean a new bill.
Responding to David Cameron’s speech on NHS reform today, Mike Hobday, Head of Policy of Macmillan Cancer Support, said:
“We welcome the Prime Minister’s reassurance that the relevant healthcare professionals will be involved in key decision-making about the commissioning of NHS care and the commitment that patients will receive high-quality and coordinated care, rather than the NHS being subject to an unbridled free market. This is a key safeguard to ensure that care for cancer patients does not suffer under the proposed NHS reforms.
“Cancer is a set of highly complex diseases and GPs tell us that they will need specialist help to commission cancer services. This is why it is vital that cancer networks should continue to be used to inform decision making about the commissioning of cancer services, and why the Government must commit to fund them at least until GP consortia are up and running in 2014.
“We hope the ‘listening exercise’ results in a long-term commitment to clinical networks, and are encouraged by the David Cameron’s comments today that this will be the case.”
Commenting on the Prime Minister’s speech on NHS reform in England today (Monday 16 May, 2011), Dr Hamish Meldrum, Chairman of Council at the BMA, said:
“We agree with the Prime Minister that the NHS needs to change. There needs to be greater integration, greater efficiency, and more emphasis on prevention. However, the Health Bill as it is currently written would make these improvements far harder to achieve, leading to a more fragmented health service, with many hospitals at risk of closure. Whilst we welcome his commitment to listening to staff and to taking them with him, most doctors will not feel able to support this Bill unless it is radically amended.”
John Healey MP, Labour’s Shadow Health Secretary, has hit out at David Cameron’s plans for NHS reform, saying they will leave the service fragmented and take it backwards.
Labour has also released a document on the lack of coherence in the Tory-led Government’s plans and showing the level of concern and opposition to them throughout the NHS.
John Healey said:
“This is the Prime Minister’s third launch of his NHS plans. He’s made his ‘I love the NHS’ speech before but today he said nothing to clear up the confusion and chaos around his ideological, top-down reorganisation. He made the case for change in the NHS, but not for his change.
“David Cameron’s plans will fragment the NHS, with a free market free for all undermining the quality, integration and public accountability of NHS services. As even the Tory-led Health Select Committee has said, the legislation as it stands will make better services and better value for money harder not easier to achieve. It will take the NHS backwards.
“David Cameron talks of his love for the NHS, but he has broken his promise to protect the NHS. If he really wants an NHS with no privatisation, no new charges for patient services and no competition for its own sake, he must make fundamental changes to his NHS plans because his Health Bill allows exactly this.”
The difference between David Cameron and Tony Blair is that Blair was better at disguising his intentions. He would never have announced, for example, the sale of public forests. Instead he might have promised “a world-class forest estate” in which “walker-led beacon-foundation woodlands” would be managed through “partnerships with a plurality of recreational providers”. Ten years later we would discover that our forests had mysteriously fallen into the hands of timber companies, and were being felled in the name of customer choice.
Nor would he have done anything as stupid as this government’s attempt to transform the NHS in one bill. Cameron sought to dig himself out of his hole on Monday, but too late. His claim that “there will be no privatisation … no cherry-picking from private providers” reminds us that privatisation and cherry-picking are the likely outcomes of his bill. Blair would have allowed private interests to keep spreading through the health service as slowly and quietly as dry rot. In their book The Plot Against the NHS, Colin Leys and Stewart Player show that Cameron’s health and social care bill consolidates a plan that has been fermenting for many years.
Selected excerpts from ‘The Plot Against the NHS’ by Colin Leys and Stewart Player. Chapter One is available here. I highly recommend this book available from Merlin Press for £10.
p.148~154 References in the original.
Within the BMA a strong challenge emerged to the leadership’s position of ‘critical engagement’ with the government’s plans, and a demand for outright opposition. The development of serious opposition from a large part of the medical profession, and especially from GPs , was significant, because Lansley constantly claimed to have their support.
The false case for the Health and Social Care Bill
The government’s claim that the NHS was in urgent need of further fundamental reform was also becoming more and more obviously false. During the previous ten years, while the NHS was being covertly marketized, the Labour government had raised NHS funding rapidly towards the average level of spending of the other major countries of Western Europe. Spending on the NHS still remained significantly below that of the richer EU nations, and a significant portion of the new funding was absorbed by the cost of market creation. But the extra cash also produced some important improvements. Staff levels were improved, waiting times for elective care were sharply reduced, facilities were renovated or replaced.
This was reflected in the high marks given to the NHS in the Commonwealth Fund report cited in chapter 1. And by 2010 the particular charge constantly made by the marketizers, that England lagged behing European countries in the survival rates for major killer illnesses, was ceasing to be true. Lansley repeatedly declared that a wholesale restructuring of the NHS was ‘a necessity, not an option’, and David Cameron asserted that ‘pretending that there is some “easy option” of sticking with the status quo… is a complete fiction’. But in January 2011, coinciding with the publication of the Health and Social Care Bill, a paper by the King’s Fund economist John Appleby, published in the BMJ, showed tha t the marketizers’ charge was unfounded. It turned out to rest partly on the use of European data that were not comparable with the English data (and in some cases highly unreliable), and partly on selecting static data instead of trends over time. For several of the conditions usually cited English survival rates have in fact been improving so fast over the last 30 years that if the trends continue they will overtake
European rates by 2012.
The real choice
The choice is not between change and no change. It is between handing over a public service to be developed by private enterprise in the interests of shareholders, and ensuring that it develops in the interests of the public – and as the public sees those interests, not as politicians declare them to be. To maintain that there is no capacity for improvement within public provision is empty rhetoric. What evidence is there that public servcies are incapable of change and improvement (provided they are not undermined by financial starvation or market-driven disorganization)?
Around the world there are various examples of excellent public and publicly-provided health services, and all of them need to be studied for ways to improve the NHS in England – and beginning with an examination of those that are developing within the UK itself. The national media largely ignore what occurs across our nearest borders, but what is happening there, and especially in Scotland and Wales, raise crucially important questions about the future now being charted for the NHS in England.
Looking at Scotland
Even before devolution health ministers in Westminster had been too aware of Scottish sentiment to risk pushing the internal market very far there, and the Labour-Liberal Democrat coalition governments that held office in Scotland after devolution, from 1999 to 2007, recognised that voters would not support them if they followed England’s path to a healthcare market. Scotland’s Area Health Boards remained in place, foundation trust status was not introduced, nor was payment by results. The PFI was used for three Scottish hospital-building schemes, and one Independent Sector Treatment Centre was opened at Strathco in Angus. But these measures provoked intense controversy and in 2003, responding to pressure from both doctors and the public, the coalition government ended the purchaser-provider split, restoring direct administration to the NHS in Scotland and decisively closing off the market option. Also in response to public opinion, in 2002 the Scottish Labour-Lib Dem coalition made personal care for the elderly free, instead of means-tested as in England.
The 2007 elections, however, led to the formation of a minority SNP government, and yet further departures from the market-driven policy that was being pursued in England. In 2008 hospital car parking charges – a significant deterrant for families – were abolished, except at PFI hospitals, where legal reasons prevented it; and in 2010 plans were announced to abolish prescription charges from 2011. No further PFI schemes have been undertaken. Glasgow’s biggest acute hospital is being built with public funds, the ISTC at Stracathro was taken into public ownership, and plans to outsource the management of a health centre in Lanarkshire to a private company were dropped. Out-of-hours care is publicly provided.
Perhaps most significant of all for the future, in 2009 elections were introduced for the majority of the members of Scotland’s Health Boards, beginning with two pilot schemes to be evaluated after four years. This means that in addition to professional medical judgement democratic representation, rather than individual ‘patient choice’, could become a significant element in determining the direction of future change.
In face of all this the marketizers inevitably portrey Scotland’s NHS as a failure, with the usual misuse of statistics to support their claim. For example they routinely state that Scotland’s waiting times are worse than England’s, because no element of competition has been introduced into Scotland’s. In fact an analysis of newly-consolidated data concludes that since 2005 waiting times have fallen faster in Scotland than in England. In each year since then Scotland has actually had either the second shortest or (more often) the shortest waiting times of the four nations in the UK. And over the ten years from 1999 to 2008 Scotland’s mortality rates for all causes of death declined almost exactly as fast as England’s. As Dr Matthew Dunnigan, the author of the waiting times analysis, says, the objective comparison of English health statistics with those for the three devolved nations is now a very important task.
Looking at Wales
The story in Wales has many similarities to Scotland’s. For the first eight years following devolution a Labour minority government was in office, only giving way to a Labour-Plaid Cymru coalition in 2007. But as in Scotland, even the initial Labour-led Welsh Assembly Government did not dare follow the English path. The purchaser-provider split remained, but Wales did not adopt foundation trusts or payment by results. Development remained based on collaboration and planning, rather than on a market system with legally enforcable contracts and all the tensions and extra administrative costs involved.
And after 2007, under the Labour-Plaid coalition, the purchaser-provider split was dropped. In 2009 a major reform resulted in the formation of just seven integrated Local Health Boards to plan and operate the NHS in Wales. These are very like the Area Health Boards in Scotland, but also have overall responsibility for all aspects of health, including public health, with a strong emphasis on linking health and social care.
The Local Health Boards in Wales are not elected but they must have members representing local primary care, community care, public health, local government and voluntary organizations, as well as lay members. In one Local Health Board (Powys) the purchaser-provider split was abolished earlier and the Board was integrated with primary care and community health service providers. Other Boards are set to follow suit – exactly the opposite direction of change from that taken in England, where even community health services have been forced into the marketplace.
Wales also declined to use the PFI for hospital-building, led the way (in 2007) in abolishing prescription charges, abolished hospital parking charges, and dealt with the vexed issue of means-tested personal care for the elderly by widening the definition of what is considered nursing care (and therefore free), and by setting a flat-rate contribution to the cost of personal care throughout the whole country.
Considerations for England
We need to ask ourselves why Scotland and Wales opted to keep the NHS as a public service, and even extend the principle of free acess. Longstanding Scottish and Welsh cultural traditions are certainly important, especially a deeply-embedded commitment to social democracy in public life, and in the medical profession, which politicians of all parties have to respect. But another key reason is cost. Next to education health is by far the most important and expensive devolved publis service. Even before the financial crisis politicians of all parties in Scotland and Wales realised that if they followed the English route, and allowed the costs of operating a market to start soaking up ten per cent or more of the health budget, health services would be liable to deteriorate, with dire political consequences for themselves.
They know that the public spending cuts imposed by the government in Westminster will hit Scottish and Welsh health services. But they also know that the effects will be smaller that they would have been had they opted for a market, and that whatever they have to do will have a legitimate foundation in public opinion, which remains at the base of decison-making about the NHS in both countries. And when the crisis has passed they will still have a public health service, not a three-tiered healthcare market and a low-risk playground for healthcare corporations and ‘doctorpreneurs’.
Scotland and Wales don’t exhaust the alternatives for the future in England. Other good models of publically-provided health services exist and deserve study. But the successful evolution of the NHS in the rest of the UK shows that Cameron’s assertion that ‘we can’t afford not to modernise’ – meaning that we have no alternative but to accept the abolition of the NHS as a public service – is pure bluster. It has no foundation in evidence and serves no interest except that of the private health industry. In the parts of the UK that the plot against the NHS couldn’t reach, people see through it. They know that good health care for all means excluding profit-making, and have shown that with sufficient public backing that principle can prevail. We need to insist that in England too the NHS is not for selling.
Selected excerpts from ‘The Plot Against the NHS’ by Colin Leys and Stewart Player. Chapter One is available here. I highly recommend this book available from Merlin Press for £10.
I got my copy yesterday so I have yet to complete it. The book identifies intense lobbying by commercial interests resulting in the privatisation of ancilliary NHS services under Thatcher, covert privatisation of the NHS under Blair’s New Labour administration and Andrew Lansley’s overt privatisation under the current Conservative and Liberal-Democrat coalition government. It draws a picture of the private sector unable to compete with the NHS in terms of cost or quality and the private sector being given excessive, hugely favourable terms. Patricia Hewitt, Alan Milburn and John Reid are identified as covert privateers ‘marketers’ under the Blair administration.
p51
By late 2008 the crisis was at it’s height. Lehmann Brothers was history, Northern Rock had been nationalized along with Lloyds and the Royal Bank of Scotland, and the government’s debt was on course to reach 70 per cent of national income, up from around 40 per cent for most of the decade. In this situation it was obvious that public spending was going to suffer. How would this affect the NHS?
According to the Department of Health, the management consultants McKinsley (where Dr Dash was by now a partner in the company’s London office) were instructed in February 2009 ‘to provide advice on how commissioners might achieve world class NHS productivity to inform the second year of the world class commissioning assurance system and future commissioner development. The advice from McKinsley … was provided in March 2009.’ But the advice McKinsley gave actually tells a different story.
We don’t know what assumptions they were told to make but it looks as if they were told or at least encouraged to assume that NHS spending would remain constant for the next five years, and asked how productivity could be increased to cope with the rise in demand over that time. Their conclusion was that in order to find enough savings to meet the rising cost of providing health care over those years the NHS might have to shed ten per cent of it’s staff. When the press got hold of the report in September 2009 there was a furious reaction from the NHS workforce.
Health ministers then said that the report had been rejected, and even then it had been commissioned without their authority.
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p54
In October 2010 the coalition government announced that it would continue to raise NHS spending in real terms (based on the general consumer price index) over the next four years – the figure actually claimed was an annual rise of 0.1 per cent. As a result most people outside the NHS assumed that the cuts would now stop. But the reality was different. For one thing, the NHS was told to transfer £2.1 billion to local authorities over the next five years as part of a drive to move patients out of hospitals and into more ‘cost-effective’ social or community care. So the NHS budget was actually being cut. And the NHS’s costs (for drugs, equipment, electricity, etc) would go on rising faster than the general cost of living, so that even if its budget stayed more or less constant it would soon be too small to cover all the bills.
On top of this, people’s healthcare needs (or ‘patient demand’, as today’s policy-makers call patients’ needs) would also go on rising as people got older, or more obese, or more depressed – and as more of them became unemployed. The economic crisis was thus also a healthcare crisis, in which drastic measures could be presented as being unavoidable, measures of ‘last-resort’ – even if they implied the end of a high-quality health service equally available to all.
Which was pretty much what the new Secretary of State for Health, Andrew Lansley, decided to do, with proposals for yet another NHS reorganization – a reorganization not only un-mentioned in the election campaign, but one that flatly contradicted David Cameron’s pledge not to undertake any more ‘top-down reorganizations’ in the NHS. Everyone noticed, of course: but the coalition’s argument that the financial crisis meant that all previous bets were off proved effective – even if at first most people couldn’t quite see what Lansley was driving at. All comentators agreed in calling his proposals the most important changes in the NHS since it was set up – but what exactly did the changes mean? And were they really so different from what had been covertly planned for ten years or more under New Labour?
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p68
By the time of the 2010 election a fairly clear picture of what the future NHS market would be like had emerged amoung health policy insiders. Influenced by a decade of exposure to US policy advice, and especially by the link with Kaiser Permanente, they envisaged an NHS that was already much closer to being a kitemark attached to a wide variety of provider organizations and systems than people outside the policy-making circle realized.
They imagined a radically reduced NHS hospital sector, with the surviving NHS foundation trusts focused intently on financial success. They envisaged the bulk of outpatient care being transferred out of hospitals into local, cheaper settings, which would be privately built and owned (as so many NHS hospitals already were, through PFI), or jointly owned with ‘entrepreneurial’ clinicians. They envisaged a growing number of the remaining NHS hospitals being run by private companies. They imagined specialist clinicians becoming increasingly self-employed, rather than working on a salary for a single foundation trust, and selling their services to a mix of public and private organizations.
They expected a growing proportion of patients with chronic illnesses to have fixed budgets for their care, and they accepted that top-ups, for which insurance companies would provide insurance plans, would become a normal form of co-payment, as they already were for some life-prolonging cancer drugs. They expected PCTs to be using private healthcare corporations to help them commission services in a more sophisticated way, or doing it for them, and so driving foundation trusts to become more focused on economy and driving more work to private providers. Fundamentally, they anticipated a replication of many of the structures and values of US managed care.
No one who was familiar with this imagined future could have been surprised by the contents of Lansley’s White Paper of July 2010, or the Health and Social Care Bill of January 2011. The only people likely to be surprised were the public, with whom the marketizers had chosen not to share their vision.
