Exploring the Radical NHS

As part of the Radicals Assemble: After Hours season at the People’s History Museum in Manchester, members of our team and speakers from Keep our NHS Public Greater Manchester gathered together to voice their thoughts, showcase their research and enter into lively discussion with the public, working under the banner of ‘A National Religion: Activism, Public Opinion and the NHS’. From our project itself, Jenny Crane, Jack Saunders and George Gosling formed part of the panel of speakers, covering topics such as the relationship between the local and the national, and considering how these might affect campaigning challenges and opportunities. The role of activism in the workplace was also discussed, questioning how this might be distinctive within the NHS, as well as the complex role of the use of graffiti in defending the NHS, and how this does – or perhaps does not – align with graffiti’s radical potential.

From Pia Feig and Sue Richardson, representatives from Keep Our NHS Public Greater Manchester, we gained great insight into both the history of their campaigning group, but also some sense of exactly just what it is that the NHS ‘means’ to many people. Pia and Sue were keen to stress that the NHS is ‘not just a folk story’ but an actual need in life, and that it is part of what it feels to be British for many people, and that this is reflected in the level of public support for strikes by NHS staff. They also highlighted that support for the NHS in fact tends to be episodic, and clearly linked to the specific services or even buildings and hospitals that members of the community regularly use. Again this raised the question as to how local support can be translated into wider collective action, while underlying such motivations was undoubtedly the sense that the NHS exists as a marker of a fair society.

Opening questions up to the audience sparked a lively and greatly informative discussion, where questions were asked that provide much thought for further study. One attendee asked ‘to what extent does the New Labour adoption of neoliberal ideas make it difficult to campaign against change?’ – highlighting an emerging potential conflict of interests between Labour supporters and those in support of the NHS. This was clearly a concern for much of the audience, who wondered whether it is more difficult to campaign against changes when it is Labour making those (neoliberal) alterations to the Service. The wider question for much of the group here is whether there has indeed been a move from the NHS’s socialist origins to a neoliberal model?

Given the context of DevoManc, the tensions between the local and the national would appear to be the over-riding theme of the discussion. Reconciling local motivations with national rallying cries is undoubtedly a thorny issue, but something that was called for by most. An example of these difficulties was given in the case of hospitals having their own ‘little ecosystems’, and indeed local hospitals and GPs were said to be integral in building identification with the NHS, which, some in the audience argued, appears to be an almost irrational attachment. At the same time, however, audience members from as far afield as the United States and Germany called for the need to explore the NHS in relation to other international health service provisions, while highlight a praise for the NHS that does not necessarily translate across to other countries. Finally the NHS was proposed to be the last institution embedded in socialist ideology, that (and perhaps somewhat paradoxically) gains support irrespective of politics.

Find out more about our activities at the People’s History Museum

Jeremy Corbyn, Owen Smith and NHS Privatisation

Seven decades after the Labour government of Clement Attlee and his Health Minister Aneurin Bevan founded the National Health Service, the party is having a leadership election. While the popularity of the NHS is enduring amongst the British public, in the Labour fold commitment to it is an article of faith. So at this moment, when the party is polarised and ideological purity is prized above all else by many of the membership, it has unsurprisingly become an important issue in the campaign.

Accusations that Jeremy Corbyn’s challenger, Owen Smith, pushed for privatisation of the NHS have been doing the rounds. They go back to his time as Head of Policy and Government Relations for the major pharmaceutical company Pfizer and then corporate affairs at the biotech company Amgen, before he became an MP in 2010. Inevitably there is scepticism amongst many on the left of connections to big pharma at a time when Amgen was dealing with a US investigation into cancer patient deaths and Pfizer was locked in international disputes with governments of the Philippines and South Africa, who were fighting to gain access to cheaper drugs for treating hypertension and AIDS respectively. The Guardian has pointed to the fact Smith took the industry line on use of non-patent drugs in his early days as an MP.

In response, Smith has denied he was a “lobbyist” and suggested it’s in fact a “massive advantage” to know how the private sector works. Meanwhile, supporters point to his role in Labour’s opposition for Pfizer’s take over of British-owned AstraZeneca. In 2014 this was highlighted by the Telegraph, which called him Ed Miliband’s “Pfizer insider” and concluding ” it is not hard to imagine Pfizer’s disappointment that its significant cash investment in Mr Smith might have yielded a better return than this”. Interviews now typically include a statement endorsing the NHS as publicly-owned and free at the point of use.

Disbelief of these reassurances among those who want to #KeepCorbyn are not just a sign of post-truth politics or of an inability to understand the way the world really works. Explanations often fall on deaf ears, but this is about more than an unwillingness to listen. This is not an argument over the correct answer, but a fundamental disagreement about the question itself.

At the heart of the matter is a 2005 report from the think-tank IPPR commissioned by Pfizer, which focused on the Blair government’s choice agenda. It was actually not an endorsement, warning that patient choice as implemented risked worsening inequities in health. Instead of calling for the policy to be abandoned, however, they proposed changes to make sure choice became a tool for empowering disadvantaged patients to get the most out of the NHS, on the assumption that even without formal mechanisms educated middle-class patients would have this in practice simply by knowing how to work the system. The report ultimately set out a vision and plan for working with patient and community organisations to bring about what was termed “progressive choice” and then rolling it out far more widely across the NHS.

Smith said at the time: “We believe that choice is a good thing and that patients and healthcare professionals should be at the heart of developing the agenda.” He may, of course, have simply been paying lip service to the core message of the report being launched. But had he been deeply convinced and converted to the cause, would that amount to supporting privatisation? The annoying but honest answer is: that depends.

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You see, there is no one agreed definition of “privatisation”. As the work of Birmingham University’s Martin Powell and Robin Miller has made clear, academic as well as political debate over many decades has been hampered by the fact that opposing sides often have quite different definitions in mind. So what might be labelled as “privatisation”? Here are some of the most relevant.

Transfer of assets: Selling off family silver, as Harold Macmillan called it in 1985. This is the part everyone agrees about. The transfers of British Telecom and British Rail to private sector ownership and control, for example, were acts of privatisation. The narrowest possible definition covers only this and it is often implicitly the one called upon by politicians when defending themselves against charges of privatisation, although they’re usually being accused of something else – as seen recently with the furore when the Australian Labor Party accused the Coalition government of secretly planning to privatise Medicare.

Contracting out: The choice agenda can be hard to separate from the increased involvement of private sector providers, something the ‘choose and book’ system aimed to make easier and the accompanying ‘payment by results’ to incentivise. However, the IPPR report was actually ambivalent on the question of private provision within the NHS, which was described as:

“an optional route for enabling choice, rather than a necessity. Private provision, additional to or substituting for public provision, could be encouraged without patient choice; likewise patient choice could be implemented without providing independent sector options. The focus of this report is not on the implications of increasing private provision in healthcare, but on the implications and options for patient choice and equity.”

In fact, the report also suggested that private providers contracted to deliver services to NHS patients should be forced to make comparable information available, on the grounds that public accountability should trump commercial confidentiality. So we now have an added complication. Just as different things might be meant by privatisation, we now have differing government and IPPR notions of choice with very different implications for the role of the private sector in the NHS. For many Corbyn supporters, Smith might well be tainted here less by association to the IPPR report than to New Labour.

Replicating the market: Most experts would call this ‘marketisation’ or ‘commercialisation’ instead. But, while I don’t believe “people in this country have had enough of experts”, I do think we do ourselves few favours by insisting upon academic definitions in arguments going on far away from any ivory towers. The word privatisation will often be commonly used to describe a process whereby those within the public sector are made to compete against each other. While the IPPR report was ambivalent about private providers getting in on the action, it never wavered from the assumption the NHS would be improved if NHS hospitals and other treatment centres had to compete against each other for patients.  In fact the report wanted this – with ‘progressive’ safeguards – extended to primary care.

Consumer culture: Also easily dismissed but often in mind when talking casually about privatisation is the culture shift from being seen as a patient or citizen to a consumer or customer. The excellent work of Alex Mold has examined the rise of the patient consumer over a number of decades. In an age where patients are less deferential to doctors and other figures of authority than they used to be, it is perhaps inevitable that they will become less passive and more demanding. This might even be harnessed to empower patients. The big question, especially for those on the left, is whether this runs the risk of pitting individuals against each other within the NHS, which itself symbolises to many an ideal of pulling together and looking after each other.

Providing private services: Going beyond simply imitating a customer relationship with the patient, it is not unknown for patients to be charged or private work to be done within the NHS. This is not new. Barbara Castle was the Labour minister struggling to finally phase out private wards from NHS hospitals when Margaret Thatcher’s election victory brought the plan to an abrupt end. But ‘self-funded’ work for patients not meeting NHS criteria has significantly expanded since the introduction of Foundation Trusts in 2003, broadening out from fertility services at the same time as more straight-forwardly private services have been increasingly provided as a means of securing a new revenue stream. The balancing act New Labour was attempting here was to make this the new normal while not jeopardising access to NHS services free at the point of use when needed.

Dependence on the private sector: This is not usually understood as part of privatisation but seems to have crept in during this debate, not least in relation to the development and supply of pharmaceuticals. Jeremy Corbyn adopted an extremely broad definition of privatisation which contrasts starkly with the policies of the last Labour government when he said:

“I hope Owen will fully agree with me that our NHS should be free at the point of use, should be run by publicly employed workers working for the NHS not for private contractors and that medical research shouldn’t be farmed out to big pharmaceuticals like Pfizer and others but should be funded through the Medical Research Council as a way of developing those drugs”.

John McDonnell’s attempt to clarify the final point, suggesting this would in practice mean some change to “manage it more effectively” was clear only as a signal not to take it seriously. The Medical Research Council spends around one-tenth what the private profit-making sector does on research and development in the UK, less than charities or the Department of Health itself. So it would be a radical new direction, to say the least, to use the MRC to bring all medical research in-house.

While this is not coherent policy, it does tap into concerns over the dependence of the NHS on the private sector: everything from privately contracted cleaning staff to the ongoing £3,729-per-minute bill for privately financed hospitals under PFI deals. And this carries over to the price the NHS pays for drugs. Throughout the NHS, as the Health Service Journal noted a few years ago, there is “an unspoken crisis in trust” which they summed up as: “We don’t trust ‘Big Pharma’ and they don’t trust the NHS. They don’t trust our competence and we don’t trust their character.” It would be wrong to dismiss this mentality as the paranoia of the far left, but it would equally be bizarre not to expect it to shape the Labour left’s approach to the NHS. Indeed, Nye Bevan himself wrote that: “The field in which the claims of individual commercialism come into most immediate conflict with reputable notions of social values is that of health.”

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The complexities of the politics and policy debates around NHS privatisation are neither the beginning nor the end of the divisions and animosity in the Labour party. And it’s far beyond the remit of this blog to even attempt to make sense of the relationships between echo chamber thinking and a failure to see things from the other side, or ideological purism and caricature in an increasingly polarised polity (all criticisms that could be levelled to supporters of both sides). By the same token, clear thinking and acknowledging different rationales will not in themselves heal the wounds inflicted.

But on Saturday 24 September, either Jeremy Corbyn or Owen Smith will be announced as having won the leadership election. There is no scenario in which bringing the party together and putting in place a credible policy platform will be anything less than a monumental task facing one of them. If the Labour party is to end the year with a policy on the NHS that is both serious and broadly supported by the membership, it will need to address these issues. This will involve fierce disagreement, not only on the details of policy but on the very premise on which policy should be made.

The NHS will be a rallying cry for the Labour party for as long as it exists. But without digging down beneath the rousing platitudes, different meanings for the same words used make it inevitable that suspicion and caricature will be the defining features of the debate. The factious argument over whether those in the centre or on the right of the party support NHS privatisation or not will continue until those at the top of the party spell out what exactly they are in favour of and why, recognising that the answer is neither simple nor self-evident.

This might sound like technocratic wonkishness, but it’s actually a fundamentally moral question that runs right to the heart of the purpose of the party that founded the NHS.

Our First NHS Roadshow!

One of our key public events is the ‘NHS Roadshow’.  This is loosely based on the Antiques Roadshow, and we ask members of the public to bring along their personal items relating to the NHS – baby tags, glasses, campaign badges, prescription forms, old Lloyd George insurance cards. . .  We also hope to use these events as an opportunity to meet with as many people as possible, to hear their stories, and to incorporate them in to our research.  We have a Roadshow planned next month at the People’s History Museum in Manchester, and also are planning Roadshows for next year at Rugby Hospital and at St Fagan’s Museum, in Wales.

Last week, we had our first official Roadshow, in the wonderful Thackray Medical Museum in Leeds.  Attending were three members of our team  – Jenny and Natalie, from the Engagement team, and Jack, one of our Research Fellows.  Many things went very well indeed.  Despite it being a delightfully sunny day outside, our stall was visited by approximately 40 to 50 people.  We shared detailed and fascinating conversations with many of these, hearing about people’s experiences of the NHS over time.  We heard from former patients, who felt that their lives had been saved by the diagnostic or surgical prowess of the NHS; and former staff who remembered, fondly, their times working at specific hospitals.  These are the kinds of stories which we see emerging at the moment through campaign groups, hoping to use the power of individual stories to protect the NHS from change or cuts.  This stories are often disseminated through social media, for example on the @NHSMillion twitter account.

Perhaps because we met with people face-to-face, we were also able to access more complex and nuanced perceptions of the NHS, and its perceived limitations, as well as its benefits.  We heard for example from patients who were angry about the ‘postcode lottery’, whereby their siblings living in different districts were able to access more extensive NHS services.  These recollections challenged the idea of a singular, ‘National’, health service, as did patients who had lobbied hard to ensure that they were referred to certain hospitals, and not to others, because of their reputations, or stories given by friends and families.  One former member of staff, just retired, laughed bitterly when asked, ‘Would you like to contribute to our People’s History of the NHS?’, before offering fascinating and honest recollections about her mixed experiences on the wards.

In what is becoming a recurring theme in our public events, several former patients and members of staff complained about changes made to nurses’ uniforms, from formal to casual (indeed labelled ‘pyjama style’ by one visitor).  Whilst some disliked the loss of ‘Matron’ and the formal nursing appearance, others recognised the need for staff to feel comfortable, tie-ing this to an increase in ‘target culture’ and workload.  We heard from one American citizen who pitied the NHS, feeling that ‘socialised medicine’ was inevitably more inefficient; but also from another who envied the British system of healthcare, speaking of the £800 a month which she spent on her family’s medical insurance.

Some of the conversations which we had helped us to rethink our research priorities and findings so far – thus embedding public feedback in our project from its inception.  Personally, my research is looking at the mobilisation of campaign groups around the NHS over time.  Speaking with people from Leeds has brought new groups to my attention – for example Leeds Hospital Alert – which again reiterated the significance of individual localities in public perceptions of NHS care.  At the same time, many people who I spoke with had not heard of even the largest campaign groups operating today, such as Keep Our NHS Public, and were not especially motivated to learn more about them.  This is not reason to jettison my research (hopefully?), but it is a useful reminder that, when lost in an individual organisation’s archives, it is easy to buy into institutional narratives, and to forget or over-estimate the broader social and cultural perceptions of this group.  Campaign groups may hold very different meanings for their membership than they do for broader publics.

People’s memories and recollections are clearly important for writing a People’s History of the NHS.  This leaves us nonetheless with important questions about how we can best use public events to access these experiences, and about how we should store and analyse people’s narratives to track change across regions and time.  At the moment, we are trialing multiple approaches.  We hoped that people may bring objects to our Roadshows.  This has not yet been the case.  Nonetheless, by having our own objects there – at the Thackray including a false eye, false teeth, and my own NHS baby glasses – we sparked reminiscences from the public.  We must now think carefully about which objects to bring, because their selection inevitably opens up, and thus perhaps closes down, particular narratives.  Should we bring objects which relate to our own research interests, to spark discussion there?  We have both short and long surveys, and can analyse the responses which we receive, and the language used.  We have had activities for children also – the colouring in of Nye Bevan, the writing of acrostic poems with ‘Hospital’ – and must think carefully about how to draw meaning from these glorious scribbles.

The Roadshow also lead me to reflect on questions about how and where to place ourselves in this public work, and also in our research more broadly.  Members of our team inevitably have their own feelings and experiences with the NHS: a highly contested institution.  But by sharing these do we open up debate – encouraging a reciprocal system of sharing with those we speak to – or do we close down discussion, making people feel unsure about sharing different memories or opinions with us?  I felt that people responded well when presented with my NHS glasses from childhood, and that this encouraged further recollections.  At the same time, this is by no means a neutral object.  Indeed, the existence of these glasses signals my long-term relationship with the NHS, that my parents, too, had a commitment to this institution.  That I still own these glasses, and that I would display them at an event, again positions me clearly as a particular type with historian, with particular biases related to this area.  Being reflexive about how we present ourselves at public events, and the responses which this encourages or deters, is highly important; and something which I hope to reflect on further, as our programme develops.

Until then, we hope to see you in Manchester!  Do feel free to get in touch in the comments below or at NHSEngage if you have any comments or suggestions.