Robbie Coull

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Doctor Magazine, March 2004

The NHS seems to be deteriorating. More money keeps being announced; more doctors, more nurses, shorter waiting times, more targets being reached. But the impression of patients, doctors, and nurses in the front line is that things are not getting better. Their impression is that things are getting worse.

So what is going wrong? How can there be such a difference between what the Government says is happening, and what we perceive to be happening? Funding has been a problem for the NHS since the day it was set up. But the current problems seem deeper than that, and they seem to be unaffected by increased funding.

The NHS was set up by a socialist minister, Aneurin Bevan, in 1948. So, for an explanation of its current problems, I think we need to look at similar changes that occurred in the Soviet Union.

Central to socialist thinking is the idea of equality of resource distribution. Marx believed that if the workers (proletariat) controlled the means of production, they would encourage a more equal society where everyone benefited. Lenin implemented his version of Marxism in Russia after the 1917 revolution when local councils (or ‘soviets’) exercised power. However, after Lenin died, Stalin transformed the Soviet Union into a totalitarian state in which individual dissent was brutally suppressed. In turn this led to stagnation of production, shortages, and famine on a huge scale.

With this in mind, lets look first at the features of the original, socialist, Bevanite NHS:

- Equality of access

- Free at the point of need

- Cradle to grave – universal coverage

- Controlled by a ‘union’ of local units – significant local control and autonomy for GPs, Matrons, Consultant firms etc. with minimal central interference.

- Common ideology - the care of the patient was more important than individual financial reward (after winning over an initially skeptical medical establishment).

- National pay and conditions for workers

- No need for propaganda - held in genuine high regard by the population

- Seen as the ideal health care system – Bevan believed that other countries would copy the example of the NHS, much as Lenin believed that a socialist Russia would spark a world revolution.

However, the NHS has undergone dramatic change since its inception. This has been especially true over the last 25 years of Thatcherite and New Labour power, when increasingly intrusive attempts to control the spiraling costs of the NHS in the face of an ageing population, without losing political ground, has resulted in a modern NHS that looks more and more like a totalitarian Stalinist institution than a socialist Bevanite flagship.

Lets examine some of the features of today’s Stalinised NHS:

- Central control and micromanagement – obsession with statistics and ‘initiatives’ that distract staff from front line duties and dis-empowers local management.

- Burgeoning bureaucracy – more and more pointless paperwork, which instead of improving care, simply drains resources and results in increasing hostility between front line staff and management.

- Shortages and lengthening queues – more and more vacant posts, inability to get even urgent cases dealt with, occult rationing.

- Perverse incentives and obsession with targets – A&E departments keeping seriously ill patients waiting outside in ambulances to avoid breaching their ‘target times’, people being discharged directly from ITU to avoid the hospital having to close to admissions and lose it’s stars.

- Propaganda –announcements of more doctors/nurses/money, of more ‘patient choice’, and of ‘listening to staff’ while the reality at the front line appears to be the opposite.

- Intolerance of dissent – senior management use the language of dialog, but do not appear to be listening. Open dissent is tolerated less and less.

There are of course non-Stalinist elements to the changes in the NHS – for example experimentation with a strictly controlled market economy was something Lenin considered but Stalin did not – but the general trend is there. One of the defining characteristics of totalitarianism is the idea that the State is more important than the People. So it is worrying to note that the new GMS contract moves the NHS even further down that road:

- GMS2 removes the ‘personal list’ that created a direct link between an NHS GP and each of his/her patients

- GMS2 fails to mention ‘patient advocacy’ – previously the cornerstone of general practice - but instead is based largely on GP units hitting population targets.

- Up until now, a GP and a patient would decide on the best treatment for them as an individual. This individualized, co-operative, inclusive, patient advocacy was the cornerstone of General Practice. Under GMS2, GPs will be significantly penalized for not meeting centralized targets, whether they acted in the individual patients’ best interests or not.

What conclusions can we draw from this? Well, none of the predictions are good. The inflexibility and inefficiency inherent in such a system are not compatible with long-term survival. Also, as the totalitarian features progress, the ability of anyone inside the system to effect real change is seriously degraded. So, without a central, dramatic change of direction, increasing frustration and rising inefficiency will make collapse or revolution inevitable.

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