The role of the NHS and the health of the nation

“Medicine is a social science and politics is nothing more than medicine on a large scale” Virchow, R.

It is profoundly paradoxical that, in a period when the importance of public policy as a determinant of health is routinely acknowledged, there remains a continuing absence of mainstream debate about the ways in which the politics, power and ideology, which underpin it influence people’s health. Alex Scott-Samuel Towards a Politics of Health

Socialism for the banks and capitalism for the poor has been the modus vivendi for the 2000s. Costas Douzinas and Slavoj Žižek The Idea of Communism Verso books 2010

The NHS reforms are aligned with the rest of Tory policy, which is to dismember the public realm and roll back the state. The Big Society’s architect Philip Blond said last year, “There is a distinction between the state as facilitator and the state as provider, and I think the state as provider really is now a bankrupt model”

The Health and Social Care Bill, currently ‘on pause’ for a ‘listening exercise’ proposes the following for the NHS:

• The secretary of state for health (Andrew Lansley) no longer has a duty to provide or secure the provision of health services. As one experienced doctor explains: “it will mean that there is no elected politician charged with a duty to provide a national health service. No one we can hold to account when the health service is sold off, chopped up and shredded in the Tory money making mills. No one we can hold to account when our local hospital is sold off, chopped and shredded.”
• Any willing/qualified provider can provide NHS services and NHS hospitals all have to become foundation trusts, meaning, effectively, private independent entities. They will then be subject to competition law and allowed to go bust so that essential services will close, not because they are no longer essential, but because they are unprofitable.
• In order to raise money hospitals will be able to provide as much private care as they like in order to raise money. This will result in entire wards being handed over to paying patients, opening up a 2 tier system within the same hospital.
• Commissioning consortia (otherwise known as GP commissioning consortia) will be given control of the majority of the NHS budget. This is the bit where the government say they are giving ‘control’ to the GPs. This is overwhelmingly unpopular amongst GPs. Most are agreeing to take on this role only in order to prevent private companies doing it. As the head of the British Medical Association GP committee said, ‘just because people climbed into lifeboats it doesn’t mean they approved of the Titanic sinking’. Some GPs have already handed responsibility to UnitedHealth, a subsidiary of one of the largest US health insurers whose parent company has a significant history of fraud. The consortia will control where GPs refer their patients and what services are available to patients. There will be considerable scope for conflicts of interests as commissioning organisations will frequently also be healthcare providers. Given that the NHS will be force to make £20bn ‘efficiency savings’ –based on a highly questionable assessment by accountants McKinsey their main purpose will be to ration care.

The reforms have been condemned by almost everyone qualified to understand them. Having watched very carefully the reporting for the last few months, I have seen no serious support for them from anyone. The British Medical Association were overwhelmingly opposed at their Special Representative Meeting in March and almost 99% of the Royal College of Nurses supported a motion of no confidence in Andrew Lansley at their conference today.

As ill-conceived and dangerous as these reforms are, the NHS plays but a part in the health of the nation.

According to Alex Scott Samuel, Senior Clinical Lecturer in the Division of Public Health at the University of Liverpool, and  co-founder of the Politics of Health Group, the determinants of health can be understood in terms of upstream, midstream and downstream causes. Interventions are more effective at determining health outcomes the further up they are made. The NHS fits into the midstream.

Upstream: fundamental or root causes

• Inequalities in power, income and wealth, social status, knowledge, beneficial social connections. These things give people access to the resources they need to have a healthy and fulfilling life. Inequalities create a social gradient with consequences in health so that disease prevalence and mortality are higher in people from lower social classes.

Midstream: Social determinants

• Nutrition, shelter, education, transport. These include state funded housing, education and public transport as well more or less market dominated sources. For an example of the control of food by markets see the essential Stuffed and Starved by Raj Patel
• Public services including the welfare state and the NHS.

Downstream: Proximal causes

• Lifestyle factors such as diet, exercise, smoking and drinking.

The aim of this government is to shift the burden of responsibility as far downstream as possible. But while the responsibility for change is being shifted downstream there is no transfer of power. Responsibility without power or resources with which to act leads to helplessness and is disempowering.

The consequence or making people helpless and disempowered is increasing sickness, in particular mental illness including anxiety and depression. Many of my patients suffer from mental illnesses and they are exceptionally stressed in the present economic and social climate. Many of them who have never been able to work are having their benefits stopped after failing the new cursory Work Capability Assessment (WCA). They are coming to see me every week, distressed and anxious, sometimes psychotic or suicidal, asking for help with their appeals. The WCA has been criticised by GP Margaret McCartney in the BMJ and many others for failing to take sufficient time to do a full physical assessment or assess psychological disability.

Widening inequalities in wealth, increased costs for university education, a capitulation to fast food manufacturers on public health and savage cuts to social services and local councils all contribute to upstream and midstream causes of ill health.

As a consequence of increasingly sedentary lifestyles and the proliferation of very cheap, highly calorific convenience foods we are facing an epidemic of obesity and associated type 2 diabetes. An upstream response would be to address the power of the food industry, but instead the consequences are being treated by the NHS. For example, people admitted to hospital for conditions related to obesity rose by 30% last year.

In Denmark they are leading the world by taxing unhealthy food, while we are treating the consequences of obesity with surgery or treatments for diabetes. Treating medical consequences rather than dealing with the impact of deprivation is just one example. Creating smoke free environments is more effective at reducing the numbers of people smoking than informing (or nudging) smokers or prescribing nicotine substitutes or other pharmaceutical aids.

In December the government reneged on its responsibility to deal with upstream determinants when it told the National Institute for Clinical Excellence (NICE) to stop work on 6 projects and put on hold a further 13 including its guidance on preventing road injuries in children and young people; spatial planning for health (changing the physical environment to improve health) and policies for smoke free homes and cars. (BMJ)

Research from Aberdeen university showed that the top 30% of drinkers consumed 80% of alcohol in the UK. In other words, significant profits came from excessive consumption, and yet the government have refused to take the advice of their own advisory panel to increase the minimum unit price of alcohol to 50p, instead opting for 21pence, against the evidence of virtually the whole scientific and public health community. (see this article, Estimated effect of alcohol pricing from The Lancet)

At a time of unprecedented cuts the NHS will be under unprecedented pressure as it becomes the place of last resort for people who have nowhere else to turn. Cuts to social care, reported in several papers, mean that elderly patients have to stay in hospital wards designed for critically ill patients at a far greater cost than community care adding to the burden on the NHS and preventing the entry of other sick patients.

Efficiency gains will be nowhere near sufficient to meet the additional demand. The increase in workload will be combined with additional costs due to the exponential use of high tech equipment, new drugs, perverse market incentives, and the administration and transaction costs of operating markets. Rather than funding being increased in anticipation, resources are being cut further than ever before.

At the heart of the NHS reforms is the intention to convert patients into consumers and to shift the responsibility for health as far downstream as possible. The neoliberal project is to explain illness in terms of moral failure and the consequences of this are self loathing and social prejudice, directed overwhelmingly at the poor and vulnerable.

For more on this see: Who is the NHS for? Not me!

To fight the Health and Social Care Bill

• Join Keep Our NHS Public: http://www.keepournhspublic.com/signup.php
• Sign the 38 degrees petition: http://www.38degrees.org.uk/page/s/Protect_our_NHS_Petition
• Lobby your MP and your GP
• Watch the video below: