How to reclaim our NHS
For the health campaigners, unions, medical professional bodies and others who opposed the Health and Social Care Bill, at varying volume and often in staccato style, the moment when it passed into law was demoralising. Their long-drawn-out battle against the Bill had been in vain. But through their efforts they had managed to establish in the public mind the sense that the Government’s health policy was controversial and unpopular. The question facing this very loose alliance now is how to build on this foundation as the Act is implemented, for an ongoing defence of the NHS.
At the ‘Reclaiming Our NHS’ conference in London on 23 June, campaigners will try to forge an answer. In advance of the event several important organisations, including the TUC and the big unions, the National Pensioners Convention, and pressure groups like the NHS Consultants’ Association and the NHS Support Federation, have put their names to a joint statement that warns of “the breakup of NHS services and the undeniable process of NHS privatisation,” and commits them to “reclaim a publicly provided, funded and accountable NHS that continues to deliver comprehensive care to all in our society.”
But how to do this? One issue is whether a single organisation uniting the disparate groups is needed to continue the pressure. “I think we should have some big umbrella organisation,” says Jacky Davis, a consultant radiologist, a founder member of Keep Our NHS Public and one of the feistiest members of the BMA Council (the Association’s central body). “It’s not effective for everyone to be doing their own small thing. We need to be perceived politically as a big organisation. If we put all the little punches together we’d have a killer punch.”
But this is unlikely to happen. Aside from thorny tactical differences and the inclination of organisations to guard their own identity, many believe that the ‘swarm approach’ to campaigning can be “a nimble and durable model,” in the words of David Babbs, Executive Director of online campaigners 38 degrees. “I know some people feel that not having an umbrella organisation was a significant problem in the campaign against the Bill, but that's not my view and it's certainly not top of my list of reasons why I think we lost,” he says.
Guy Collis, Unison policy officer, agrees: “One of the strengths of the campaign against the Bill was that things sprung up all over the place so it looked like a load of stuff was happening everywhere, as in fact it was. No one planned it like that but it looked quite effective.” But there is agreement that some form of coordination is essential. “There’s a need to work together on some aspects, for example on monitoring what’s happening as a result of the Act – we can pool resources on that,” says Collis. “At the moment False Economy, the RCN, the NHS Support Federation and Labour are all doing things.”
Campaigners expect the effects of the Act to be myriad, from the withdrawal of some services to the encroachment of profit-making companies into vital areas of care. There are already examples of opportunistic providers taking advantage of the new climate to impose charges on NHS patients, as happened recently for podiatry in Greenwich. And the deep cuts happening as part of the so-called efficiency savings will be extended by the dynamic of the Act. As Paul Evans of the NHS Support Federation says, “This is all going to happen piecemeal around the country, under the radar. We can only resist it effectively if we know what’s going on, and where. The Government aren’t going to tell us.”
One idea is to set up a university unit dedicated to the task of monitoring. Another option is to collect the information on the new anti-cuts web resource False Economy (funded largely by the TUC but not strictly a union initiative). “We are certainly interested in being that place,” says False Economy’s Clifford Singer. “We do have the infrastructure and we have the most comprehensive list of cuts available at the moment so it makes sense for us to do it. We have the same problem that everyone has of resources, but if the TUC or anyone else wanted to fund a specific project it could be done.”
Proper collection and presentation of information is important partly because the theatre of campaigning is moving away from the national stage. During the legislative process all eyes were on Westminster, but now most campaigners believe the NHS will be won or lost at the local level. Long-standing campaigns, such as Keep Our NHS Public with its network of local groups, have vital experience of these kinds of struggles. For others who came to NHS campaigning because of the Bill, such as 38 degrees, it is “new territory,” as David Babbs admits. “The most important resource you need for local campaigning is a network of inspired local campaigners,” he says. “38 Degrees has one million members all across the UK and many of them have indicated a strong commitment to continuing the NHS campaign, including at the local level. The key is to provide the right information and resources, together with the right networking and support to enable them to get cracking.”
Paul Evans, of pressure group the NHS Support Federation, believes that the success of local community campaigning will depend on how well a broad range of players are able to knit together in each area. “There are many who want to do something to keep the NHS alive,” he says. “Some have national networks, others have research expertise or information, some have funding, others are poor but have highly motivated members who will organise meetings and take to the streets. The art is in creating a framework for them to work together in communities all over the country.”
This hope of broadening the campaign is fuelled by the experience of the last two years, when new groups like 38 degrees and UK Uncut joined forces with the traditional core of health campaigners. According to Lucy of UK Uncut, their distinctive style of direct action has proved surprisingly popular, even with health professionals. “We’ve had a lot of conversations with senior medical practitioners who are very supportive of direct action,” she says. “These are what you might think of as unlikely people for civil disobedience.”
The influence of UK Uncut, “a network of people and not a campaign organisation as such,” could be seen in the ‘Block the Bridge,’ protest on Westminster bridge, and the attempt to form a road block outside the House of Lords by activists chaining themselves together while Peers were debating the Bill. They plan to stay involved in healthcare campaigning. “What we’re interested in is forming links with people who haven’t taken direct action before, particularly health workers,” says Lucy. “Direct action (strikes, occupation and so on) has a long and proud history of ordinary people taking action in their local communities when they have been ignored, oppressed, or pushed out of the political process.” She says the biggest impediment to more people joining actions and occupations is not lack of willing, but simply that people “don’t know how to go about it, so skill sharing is very important.”
If the process of opposing the Bill undoubtedly entailed branching out in new directions, it did not result in the kind of universal involvement across civil society that some had hoped for. In the view of Paul Evans, “Saving the NHS is still not mainstream. Some of our most powerful potential allies, like some of the national charities, whose users will really suffer under a fragmented and privatised system, really must step forward much more boldly.”
But a conversation with Neil Churchill of charity Asthma UK reveals just how far campaigners have to go before their analysis is shared by such organisations. According to Churchill “the Act is of secondary importance. The most important game in town is the productivity challenge. If the NHS fails that challenge it will mean longer waiting times and deteriorating quality. That will lead to the withdrawal of services and charges.”
Churchill’s downplaying of the Act is significant because his views are representative of the Richmond Group of ten patient charities, including Age UK, the British Heart Foundation, and McMillan Cancer Support. He says he would rather there had not been a big reorganisation, but it was a “fait accompli,” and “it is the shift to managing long-term conditions that is the central issue for the NHS.”
Even on the fundamental matter of competition the message of campaign groups and unions has barely registered: “The Act is not about open competition,” Churchill says, “it’s about managed competition, allowing the people who purchase care to introduce competition where it will be beneficial. You could say how did Labour drive down waiting times? They introduced some competition and the NHS raised its game in response and drove the private sector out of business there.” This claim that private treatment centres (ISTCs) reduced waiting times is contradicted by a wealth of evidence, yet the myth persists.
In contrast, some campaigners believe the Act could unleash a dynamic that, in the context of less funding, results in a big bun fight between the different advocacy groups and charities, as they all try to ensure the patients they work for get the care they need. This scenario is further complicated by the fact that many charities are also now healthcare providers, competing for contracts for work that used to be the preserve of the NHS. Marion Birch of Medact, a charity that works for access to healthcare around the world, fears this dynamic. “I’m afraid it is a possible consequence of the Act, because the Act further splits up and fragments decisions that should be taken nationally. Groups need to recognise this danger and talk about it but in the end if they have to represent their particular patients it will be difficult.”
Potentially, Birch says, charities could “help to really make the case for what is happening and how it is adversely affecting the people they advocate for.” But Churchill thinks there will be no need: “We don’t believe there will be competition between groups over funding. There’s enough money in the system to reorganise care so it’s about being more cost effective and delivering better quality. It’s not about rationing care.”
Events may belie Churchill’s optimism, however. “I think the effects of the Act will speak for themselves,” says Marion Birch, but “the causal chains can be complicated and the real cause of what is happening may need to be explained publicly. Doing this through the media is likely to be challenging.”
The people best placed to explain and thwart the most dangerous aspects of the Act are NHS clinicians, the majority of whom opposed the legislation. One example of a practical measure they could take is for GPs to push their Clinical Commissioning Groups (the new bodies supposedly run by GPs that will buy care for patients) to adopt a ‘Fair Commissioning Charter’, committing them to resist the imposition of ‘any qualified provider’ (the mechanism that encourages the entry of the private sector), to refrain from contracts that involve commercial confidentiality, to take all decisions openly in public, and to engage with patients.
This idea, which originated from campaigners like Health Emergency’s John Lister, has been endorsed by the GPs Committee of the BMA. Such steps are important – doctors who want to take a stand may feel exposed without collective backing (and, in this regard, pressure from patients through patient involvement groups is significant too). But passing a resolution is one thing; “without doing something about it and communicating it, it’s useless,” says Jacky Davis, who sits on the BMA Council. She is scathing about the performance of the clinicians’ professional bodies. “I blame the medical establishment for the Bill going through. I’m so angry about it. There’s no doubt in my mind that if the medical establishment had acted together the Bill could never have passed.”
“First they said they’d get rid of the worst aspects of the Bill. That was never going to happen,” Davis continues. “Now they need to tell people how to mitigate the effects of it, and that needs leadership. I count the Royal Colleges out, they’re not going to do anything, despite the fact the Act affects everything in their remit. The only body that can lead doctors is the BMA which has said and done very little since the Act was passed. It’s going to have to come from grass roots pressure.”
Some doctors are taking a direct approach. The newly formed National Health Action Party plans to stand candidates at the next election, following the example of Health Concern in Kidderminster, which caused political shockwaves in 2001 when it propelled Dr Richard Taylor to Parliament in protest at the closure of the town’s A&E department. Clive Peedell, a consultant oncologist who in January ran six marathons in six days in opposition to the Bill – an extraordinary story that nevertheless gained minimal media coverage – is one of the originators of the new party. “The aim is to win seats if we can, but mainly to make the NHS the second issue at the next election behind the economy,” he says. “We will carefully target the constituencies where we stand. Most will be members of the Coalition but a few New Labour MPs who pushed the market in healthcare will also be targeted, which will be a powerful message to say this about taking on the ideology of the market, and is not party political.”
The strategy will be most effective where particular grievances mean it can galvanise local campaigns behind it. But Peedell believes it can be part of a broader wave: “This will be a really exciting political development. The NHS is an amazing brand that people support, and we can connect with that through social media to harness that energy and reach out to a wider spectrum of people than normal politics can.”
“Part of the strategy,” Peedell explains, “is to make Labour rethink its health policy.” Despite the experience of 1997, when Labour promised in its manifesto a publicly provided health service before going on to introduce many of the market measures that now underpin Andrew Lansley’s policies, campaigners hope that a Labour victory next time could at least undo the damage done by the Act. But they have their doubts. “[Labour’s shadow health secretary] Andy Burnham has said they’re going to repeal the Act,” says Jacky Davis. “But Miliband has said he’s going to deal with the three worst aspects of it. So come on guys, what do you mean?”
According to Guy Collis of Labour-supporting union Unison, “repeal is probably unlikely because there are things Labour will want to keep. So it will be about reinstating a public NHS.” Interestingly, he expects that “The Government will do everything they can to keep up the appearance that nothing has changed. Cameron will want to show the NHS doesn’t look much different in 2015 to now.”
While campaigners’ ultimate demand would be a wholesale reconstitution of the health service to get rid of the purchaser-provider split, which is the foundation of the market policies, Collis believes “if any party enters the next election promising another top down reorganisation it will be suicidal. But the big thing in Labour’s favour is the Act was so unpopular the public will be on their side if they take a bold stand. I’ll be surprised if they end the purchaser-provider split but we might be able to get them to make gestures in that direction.”
Clive Peedell, one of those who openly says he wants another reorganisation, nevertheless agrees that it cannot be done all at once: “I think it would have to be a longer term vision to restore the NHS. There is a clear first step to reinstate the Secretary of State’s duties, powers and responsibilities. That would be easy in terms of repealing part of the Act and it would have a big impact. Then other things would be done over time.”
Until then, as David Babbs of 38 degrees puts it, “The new legal framework threatens the NHS, so we need to campaign for that legal framework to be changed. But it's hard to see that happening this side of a general election, so we need to work hard in the next three years to make sure we still have an NHS worth saving.”