Friday, 25 January 2013

Others Must Fail

That Millwall have brought forward their FA Cup tie against Aston Villa from Saturday to tonight, to avoid a clash with tomorrow's planned march and demo against the closure of the A&E unit at Lewisham hospital, is no surprise. The club have long made a virtue of their community links, while protests against hospital consolidations have long since supplanted protests against pit and steel mill closures in the repertoire of public solidarity. But there is a lesson here, in the zero-sum nature of a football match, that illuminates the current issues around not just hospitals but public services generally.

The physical organisation of the NHS has always reflected the ideology of the time and thus had a wider political resonance. The 1948 design was a triumph of the central planning that had proven effective during the war, but it remained an essentially liberal scheme in its focus on patching up current workers and improving the quality of future workers (i.e. children). In other words, the NHS was seen as an investment in labour, hence the relatively low priority afforded to geriatric and chronic care. This led to inevitable tension as the public pressed for services to be extended to areas of health lacking an obvious return on investment, hence the compromises over charges for dentures, spectacles and prescriptions (while a failure to take your medicine might aggravate an illness and result in lost work days, a prescription is by definition issued to the walking wounded). The centrality of the general hospital partly reflected the contemporary industrial paradigm of the massive industrial "works", surrounded by the "light engineering" of cottage hospitals, and partly the inadequacy of GPs and primary health care facilities (with a few exceptions, such as the Peckham experiment).

The district general hospital model reached its peak in the early 1960s, coincident with the waning of the associated industrial paradigm. Thereafter, it came under increasing pressure due to the closure of mental health institutions, the increase in treatment costs (due to advances in medical technology), and the growth in demand for geriatric care as the population started to age. Successive governments have committed to a reformed structure that combines better primary care (larger GP practices and neighbourhood clinics) and greater specialisation, which means more concentration of A&E, maternity and acute services, and fewer district general hospitals. This has largely been supported by doctors and consultants, for whom specialist units entail greater professional status and better working conditions. The isolation of service elements into specialist units also facilitates privatisation, in terms of economies of scale, de facto monopolisation, and a simpler interface to commissioning and referral bodies, but it would be wrong to think that this has been the main driver. General hospitals made sense in a society centred on an industrial proletariat. A more fragmented and subtle model is inevitable in a more fragmented and subtle economy.

Economics are at the heart of the health industry, but public discourse tends towards an interpretation seen through the emotional prism of "care". Thus closing a local hospital ward or A&E unit is seen as evidence that administrators care more about costs than patients, while personal horror stories focus on uncaring nurses and the resulting squalor or preventable accidents. An example of this reluctance to discuss health beyond the vocabulary of care is the current state of antibiotics. Research and development have been underfunded for years now, largely because Big Pharma realises it can make more money out of palliative products, such as cancer drugs (maintenance is more profitable than cure as it guarantees a future revenue stream). When the inevitable antibiotic crisis arrives, the price of a solution will go up and resources will then be shifted to take advantage, but too late for many. It is easy to point to this as proof that central planning can do a better job than a free market, however another way to look at it is as the conscious engineering of a failure that in turn creates opportunities for new profit.

Failure is central to capitalism. The more the destruction, the more the creativity. However, this does not lead to an overall raising of standards, but to their stretching. The very good co-exists with the very bad. In other words, greater inequality. A good example of this is the recent fuss over horse meat in burgers. The real point is not adulteration, i.e. swindling by unscrupulous manufacturers, but that economic necessity obliges many to eat crap (but cheap) food. Naturally, some will attempt to shift the blame onto the poor themselves, to cite personal agency and choice, but this simply ignores the question: why is there a market for food so cheap it obviously cannot be healthy?

There is a parallel example of this in education, where the government seems determined to categorise more schools as failing. Some will interpret this as a tactic to justify imposing academy status and Whitehall control, but I think this is strategic and about the insistence that a marketised service must exhibit one of the chief features of a true market, namely a variety in quality between the options, even if this is often artificial (the investment of modern schools in branding and ethos is telling). Where price has yet to intervene, parents require visible signals to enable meaningful choice, hence the primacy of league tables and the Ofsted inspection regime. Nick Clegg on LBC this week admitted that he may send his son to a private school rather than one of the state schools in Putney. The ideological sleight-of-hand here is to treat state and private as part of a single market, a common set of options, despite the absence of a level playing field between providers and the inaccessibility of choice for most parents (i.e. the unaffordability of private education and the fact that "good" state schools bias towards middle class entry). The point is that "failing" state schools are the necessary justification for choosing the private sector. "I just want the best for my child", says Westminster School alumnus Clegg. Without the excuse of failure, the choice of a private school looks more like naked self-interest.

As with schools, so with hospitals. The persistent theme of public services since the 1980s has been one of relative failure. Failure is the corollary of choice. This contrasts with the theme from the 1950s through the 1970s, which was the perils of uniformity, symbolised by Hattie Jacques's hectoring matron as a sort of hospital sergeant-major. This is why the Health Secretary, Jeremy Hunt, is happy to paint a bleak picture of poor care across many NHS hospitals, to the point of talking about a "normalisation of cruelty". Such language is absurd, but it suits his purpose which is to advance privatisation: the failures of the NHS have obliged me to take action. As Gore Vidal said: "It is not enough to succeed. Others must fail". That is the romance of cup football: there must be a winner, and there must be a loser.

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