Am I an extremist?

Last night I debated with journalist Ian Birrell on BBC Radio 3 Nightwaves

The question was, ‘Is nostalgia for the idea of an NHS inhibiting necessary, clear-eyed debate?’

NHS workers are united on 2 fronts, The need for care to be based on need and a dislike of constant interference by government BMJ

I believe that there are two over-riding reasons why we are nostalgic, the first being that we are driven by a sense of fairness, that no matter whether you are a judge or journalist, baker or banker the NHS will provide comprehensive free healthcare. This was fought for against the interests of the rich (including rich doctors) right from the beginning. There is a clip on the Nightwaves website  of an interview with Ken Loach about his film The Spirit of ’45 which looks at the roots of the welfare state. The first few seconds of the interview are a recording of GP, Julian Tudor Hart who is old enough to remember life before the NHS:

“I think the expectation was, we’re not going back to the Britain of the 1930s, it wasn’t just never again about war, it was never again about ‘that kind of peace’, where everything was run by rich people for rich people”

Ken Loach says,

There’s no nostalgia, people in the film say clearly what was wrong,  … bureaucracy, there was no industrial democracy, there was no participation between workers and management, the old economic structures persisted, … but the greatest achievement was the NHS … and it’s at the point of destruction now.

Fairness is one nostalgic value that people value deeply. The second is captured by the dancing Matrons in the Olympic opening ceremony. This symbolises nurses and other healthcare professionals being free to take care of patients without the constant interference of government or management. The nostalgic view of the NHS is not so much a harking after a long-lost past, but very much a present day aspiration, in which healthcare professionals are free to act in partnership with their patients, in their best interests. We are in the middle of the biggest top-down re-disorganisation of the NHS in its history and are facing unprecedented drives to cut costs and meet targets with no confidence from patients or the vast majority of healthcare professionals that we will be given any more freedom to get on with providing care.

Ian Birrell’s accusation that I am an extremist is based on his belief that I believe that under no circumstances should the NHS fund private or third sector organisations – and so I would wish to deprive his severely disabled daughter of the care she needs.

I’d like to clarify that this is not my position. If the NHS is unable to provide the care my patients need, I think it should pay for another organisation to provide it. This week I have referred my own NHS patients to a rape crisis centre and a drug treatment service, privately provided, NHS funded.

There is no doubt that the NHS depends on a range of other providers, for example, in Hackney almost 100 different mental health organisations receive NHS funding. I don’t have any problems with this.

It doesn’t therefore follow that I believe a market in competing private providers is in the interests of my patients or the NHS. As Don Berwick – perhaps the most respected expert in healthcare safety in the world points out,

 I find little evidence anywhere that market forces, bluntly used, that is, consumer choice among an array of products with competitors’ fighting it out, leads to the health care system you want and need. In the US, competition has become toxic; it is a major reason for our duplicative, supply-driven, fragmented care system.

On the issue of whether nostalgia is a hindrance to clear eyed debate or necessary reform, I believe, like Berwick that it is not nostalgia, but constant top-down reorganisation that is a barrier to the kind of progress the NHS needs,

“Stop restructuring.” In an echo of Francis, [Berwick] warns that it is destructive of time and confidence and leads to risk averse healthcare. Stability, he says, helps change “become easier and faster, as the good, smart, committed people of the NHS – the one million wonderful people who can carry you into the future – find the confidence to try improvements without fearing the next earthquake.

Quotes from Nye Bevan, In Place of Fear, 1951

“Abuse occurs where an attempt is made to marry the incompatible principles of private acquisitiveness with a public service”

[the NHS] “is an act of collective goodwill and public enterprise and not a commodity privately bought and sold”

“Financial anxiety in a time of sickness is a serious hindrance to recovery, apart from its unnecessary cruelty”

“Preventive medicine: another way of saying health by collective action”

“Instead of rejoicing at the opportunity to practice a civilised principle, Torys have tried to exploit the most disreputable emotions”

“Without rational planning … we are left with a patchwork quilt of local paternalisms”

“A free health service is a triumphant example of the superiority of collective action and public initiative”

“the essence of a satisfactory health service is that poverty is not a disability and wealth is not advantaged”

“… new legislation on the NHS has been announced. It confirms our worst fears … it will mutilate the service” Bevan 1951, response to Churchill’s re-elected Tory government.

Articles by Ian Birrell:

4 responses to “Am I an extremist?

  1. The origin of the NHS lies not in 1948, but in the Dewar report of 1909, not given effect till 1919 because of the war. A key element was that over a fifth of the country, the private sector (GP)s could not extract a viable income from a population so sparse that it was impossible to reach enough patients.

    Not only that, but even many of the better resourced patients had much of their needs m,et from the non-cash economy to which they were able to contribute inputs from their own land or other capital.

    When the hospital in Stornoway was built by private subscription it cost £12,000, and people were astonished that such a large sum could be found in actual cash from a population of probably >50,000 of mainly subsistence farmers and fishermen.

    They were ceranly not shirkers, and they did of course make a contribution to the nation in other ways: as migrant workers, emigrants to the empire and cannon fodder in two wars.

  2. What a brilliant piece Jonathon. I found myself nodding with all the points you make, with your eloquence, thoughtfulness. NO way are you an ‘extremist’ . In no way.

    We have so much re-organisation going on – all the time. Managers obsessed by targets and this (and meetings) takes all their time – as a result so we have no support for everyday service. This feeds a growing disconnect.

    As for meeting need. We are trying to do so much: such as ‘pre-disease’ . . . this is why we need folk like you who can take the bigger picture.

    In my certain opinion Market forces cause harm and further divide an ill-divided world.

  3. “Nostalgia” is an emotive term designed to frame the debate around the NHS as one between well-meaning but ignorant people and hard-headed pragmatists.

    Ian Birrell was a speech writer for David (“we will cut the deficit not the NHS”) Cameron during the 2010 campaign. That should tell you at least something about where he is coming from. I agree with Jonathan’s take that the widespread public support for the NHS is based on its fundamental fairness and decency. The benefits system is not supported because of the perception that it is unfair in its current state.

    Ian’s experience with the NHS’s care of his disabled daughter is a travesty. However, my experience with my child was very different. She had cancer and the NHS saved her life. David Cameron also seems grateful for the care provided to his son.

    Mr Birrell is pushing for privatisation, competition and profit-making. There are actually a number of studies which show that competition in health care on the basis of price actually results in reduced quality of care. This was acknowledged at some point in the long process to get the Health and Social Care bill enacted.

    Clearly, there are problems within the NHS that need to be resolved. The more rational approach would be to look at what works well, and apply it to what has gone wrong. Calling Jonathan an “extremist” is not part of any solution.

  4. I heard the edition of Night Waves.

    Ian Birrell was heard out respectfully in what he had to say, and, several times, spoke at length.

    However, he rudely did not afford the same respect to Jonathon Tomlinson, and, at least twice, had to be stopped from interrupting. If Tomlinson had been an extremist, Birrell would have had nothing to fear in letting him talk, because he would have condemned himself.

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