Lansley’s NHS reforms will undermine fairness

Another organisational shake-up does not surprise doctors, but this is a much bolder move towards pr

Andrew Lansley has launched a white paper that has been heralded as the biggest shake-up of the NHS in a generation.

The key proposals are:

  • Abolishing ten strategic health authorities by 2012 and scrapping the 152 primary care trusts by 2013. This would mean that up to 30,000 managers face being cut or redeployed.
  • Replacing these management structures with about 500 GP "consortiums" (not optional), meaning that family doctors will have control of £80bn of public money.
  • Allowing hospitals to leave public ownership to become "not-for-profit" companies.

The first thing to note is that the NHS has been in a state of almost continuous reform for nearly three decades. There has been some form of organisational change almost every year since the early 1990s. Many of these changes resemble each other; 2002's primary care trusts were difficult to distinguish from 1982's district health authorities. The same goes for NHS trusts and foundation hospitals.

The cumulative effect -- apart from the fact that most new structures don't have time to show positive effects before they are changed again -- is cynicism in the medical profession, as evident in this doctor's blog:

As the ministers and commentators observe the effects of their "bold vision" and "strategic planning", I am happy to tell them how much difference this will make to most Jobbing Doctors -- very little. You see, we have seen this all before.

Under the internal market established by Margaret Thatcher, and not-much-changed by Tony Blair, GPs surgeries already operate much like private businesses that commission services from hospitals. Equally, under private finance initiatives, private companies have been involved in building numerous new hospitals.

But what the new plans do amount to is a much bolder and more open step towards privatisation of the National Health Service. As with so many of the coalition's reforms, the move towards less bureaucracy is not matched by guarantees of accountability, which are needed to maintain a consistent standard countrywide.

Oddly enough, Melanie Phillips makes a good point about this:

It also surely runs the risk of fragmenting the service, since GPs will try to look after their own clinical patch rather than the general good. And this gets to the crux of the problem. A national service needs to offer unified provision throughout the country in order to be seen to be equitable.

Yesterday, Lansley spoke of the need for competition and choice, echoing Thatcher's market ideology, ignoring that last time this was implemented, we were left with a hugely unfair postcode lottery. Lest we forget, the much-reviled target culture did produce results, with waiting list figures, among others, drastically improved (LabourList has some numbers here).

The NHS was founded on the principle of fairness. Let's not undermine that by restructuring the system in such a way that it has no mechanisms to help that fairness flourish.

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Samira Shackle is a freelance journalist, who tweets @samirashackle. She was formerly a staff writer for the New Statesman.

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Why Game of Thrones is the perfect show for the modern age

There is something horribly relatable about George R R Martin’s world of Westeros, whose characters have now become part of public myth.

By now, it feels as if George R R Martin – the author of Game of Thrones, narrative sadist and ruiner of all things beautiful and good – has been appointed scriptwriter for the news. I am not the first to observe this. Martin is famous for killing off everyone’s favourite characters and sending his stories careering into pits of bleak uncertainty just when you thought everything might turn out all right. Since Prince became the latest beloved star to die this year, it has become abundantly clear that life is imitating Game of Thrones, and there’s nothing to do but watch the next bit through your fingers and try to avoid spoilers.

The staggeringly popular HBO show based on Martin’s books is in its sixth season, and it is wild, glorious trash. I mean that as a compliment. I love this horrible, problematic show more than I can possibly justify, so I’ve stopped trying. It is hardly a social-justice warrior’s dream, given that it seems to be racing against itself to sexually degrade as many female characters as possible in the space of a 45-minute episode.

The argument for the endless misogynist violence is that it has to be shown, not to titillate viewers, absolutely not, but because that sort of thing just happened back in the murky medieval past. This would be a decent excuse if sexual violence were indeed a thing of the past; or, come to that, if Game of Thrones was actually set in the past, instead of in a fictional fantasy world where there are shape-shifters, zombies and dragons.

There is one aspect, however, in which Game of Thrones has a claim to being the most realistic show on television. Despite the wizards, the wights and the way every character manages to maintain perfect hair even when they’re being pointlessly tortured to death, there is something horribly relatable about Martin’s world of Westeros, whose characters have now become part of public myth. What sets it apart is not the monsters, the nudity or the festering gallons of gratuitous gore, but the overwhelming sense that the plot got run off the rails three books ago and is being steered towards a terrible precipice by a bunch of bickering, power-mad maniacs. This, coincidentally, happens to be the plot of the entire 21st century so far.

Viewers might tune in for what the actor Ian McShane called the “tits and dragons”, but they stay for the unremitting horror. Martin gleefully tramples over all the tropes of conventional sword-and-sorcery fiction. There are no noble quests or heroes’ journeys. Instead, horrible things happen to good people for no reason. Heroism goes extremely unrewarded. The few times injustice does get punished, it happens by accident. Fair maidens are not saved, protagonists are slaughtered at random, and war is always a stupid idea, even though the ­surviving cast members are still trying to solve all their problems by waging it.

Most fans of the show have idly wondered which warring noble house they’d want to be born into. Are you brave and upstanding like the Starks, an entitled aristocrat like the Lannisters, or a mad pirate bastard like the Greyjoys? Personally, I like to think that I’d be at home in Dorne, where knife-fighting and aggressive bisexuality are forms of greeting, but the truth is that I’d have been dead for at least two seasons by now and so would you. And not excitingly dead, either. Not beheaded-by-the-king dead, or burned-as-a-blood-sacrifice-to-the-god-of-fire-by-your-own-father dead. Statistically speaking, we’d be peasants. We probably wouldn’t even get names. We’d just be eating mud and waiting for the war to be over. You know it’s true.

The moral lessons so far are murky but sensible. Dragons are awesome. Men are invariably dreadful. Following religious zealots into battle is a poor life decision. Honour is a made-up concept that will probably get you killed. Most importantly, there are very few truly evil people in the world: instead, there are just stupid people, and scared people, and petty, vindictive people, and sometimes those people get put in charge of armies and nations, and that’s when the rest of us are really buggered. That’s what Game of Thrones is about.

I’m not even confident of a happy ending. I’ve made peace with knowing that my favourite characters are unlikely to make it out of the series alive, and even if they do, it won’t matter, because a giant army of ice zombies is coming to eat the world.

And that’s what makes it brilliant. There are plenty of horrible, sexy things on television, and in these anxious times every novelist worth his advance seems to be turning his hand to grim dystopian fiction. The problem with most dystopias, though, is that they’re too predictable. They serve up worlds where, however awful things get, someone is at least in charge. They are comforting for that reason, in the same way as conspiracy theories are comforting. It is less distressing to believe, for instance, that a secret race of lizard people is managing the destiny of the human race than to believe that nobody is managing it at all.

Stories help us rehearse trauma. They help us prepare for it. You sit down to watch terrible things happening to made-up people and you imagine how you’d cope if that were you, or someone you loved, and even if the answer is “not at all” you find yourself feeling a bit better. Right now, the really frightening prospect is that the world is actually being run by vicious idiots with only half a plan between them who are too busy fighting each other to pay attention to the weather, which is about to kill us all.

That, along with the epic theme music, is why I still love Game of Thrones. It feels like aversion therapy for the brutal randomness of modern politics, with a side order of CGI monsters and a lot of shagging. There you go. I hope that’s given you all the excuse you need to tune in for season six. I did my best. If you need me, I’ll be behind the sofa. 

Laurie Penny is a contributing editor to the New Statesman. She is the author of five books, most recently Unspeakable Things.

This article first appeared in the 28 April 2016 issue of the New Statesman, The new fascism