The Tory stealth attack on the NHS

If the Tories have their way, they will break apart the health system, just like our schools. This i

The new coalition government has made a great deal out of ring-fencing the health budget, giving the public the impression that the National Health Service will not suffer the cuts that other departments are facing. It is fast becoming clear, however, that there will be significant cuts in health like everywhere else. Plans put forward by the Conservative Secretary of State for Health, Andrew Lansley, if allowed to proceed, will undermine the structure and principles of the NHS in the largest overhaul of the service since its foundation.

The idea is to hand over the NHS budget to GPs, who will then commission services on behalf of individual patients. There has been little public discussion of the proposals, and the extent of the planned reorganisation - and the commensurate cuts in budget - is only now leaking from private briefings to key managers.

The NHS budget for 2010-2011 is £110bn and there are around 40,000 GPs working in England and Wales. At present, the budget is divided among the ten strategic health authorities (SHAs), which devolve it down to primary care trusts (PCTs). The strategic authorities set strategy and hold local delivery agents to account. The PCTs commission services from hospitals, GPs, opticians and primary services. Trusts have increasingly been forging strong links with local authorities to provide social care to the elderly and people with disabilities or other needs.
Under the plans, this infrastructure will be demolished and the SHAs abolished. The PCTs might survive, but with reduced powers and little or no authority over budgets or services; it is most likely that they will simply be employed by doctors as the administrative mechanism to purchase health services for individual patients. Richard Sykes, chairman of the London SHA, recently resigned in protest.

The last major reorganisation of the NHS took place in 2002 and has therefore had less than a decade to settle. The PCTs are midway through a restructuring process to separate the provider arm from the commissioners; now, no one seems to be sure whether this will proceed. There are undoubtedly bureaucratic tangles, but these are not insurmountable.

Stealth care

The new vision for GP-led commissioning envisages both sole practitioners and group practices handling the entire budget and commissioning services for their patients from hospitals, local authorities, private companies and primary services. There are questions concerning the details, not least whether GPs will want to take on this responsibility. Will single GPs be prepared or be able to commission such a wide range of services, or will they delegate to a consortium of local doctors? Will they subcontract the commissioning process to private companies involved in health care and so bring privatisation to the NHS by stealth?

It is not clear where public consultation fits into the GP-led model. The Health Secretary may argue that, because decisions are made with individual patients, this is inherently a form of consultation. But it would constitute a fragmentation of the pro­cess, as there would be no forum for leading discussion on, for example, investing in new specialist trauma services at particular hospitals, or reconfiguring stroke services. The SHAs have been the lead agencies conducting consultations. If they are abolished, this kind of consultation may also be lost.

It is also unclear how strategic decision-making will be conducted, if at all. Just as the schools system is being broken apart, taking away the strategic responsibilities of local authorities, so it is with health. The "big society" seems to mean the abolition of the collective.

Public health will be another casualty. Lives are saved through the promotion of healthy lifestyles and public education, as well as programmes to help people, say, give up smoking. Focusing such attention on health inequalities is one of the ways that we direct health services at the poor. But it appears that the expenditure on public health initiatives will be slashed from 7 per cent of the allocated budget to just 4 per cent.

PCTs are being told to reduce their management and administrative costs by roughly 50 per cent. The effect of this is to hobble any attempt at strategic management. Many targets have now been abandoned. Although there has been some unease at the rigidity of target culture, it is undeniable that imposing targets and holding people to account for specific time limits in accident and emergency units, for seeing a consultant and for performing operations have saved and improved the lives of millions of people.

Cities will be particularly hard hit by Lansley's shake-up. In London, there are probably several hundred thousand people who are not registered with a GP and they will not be able to get any access to health care. Anyone who is not eligible to register with a GP could be denied medical and health services.

Ask a doctor

Since its foundation, the NHS has been redistributive. It was designed to redistribute to the poor so that health inequalities are reduced. Its success has been patchy, but that objective is embedded at all levels and in every service. If strategic planning is abolished and service purchasing is fragmented, the aim of reducing inequality will be abandoned, too.

Lansley is a man on a mission who has been developing these ideas from his constituency, South Cambridgeshire. No one I have spoken to seems to know if he has been talking to the doctors themselves.

If his plans are fully instituted, GPs' contracts would have to be renegotiated and they would be well advised to consider whether it is to their advantage - and that of their patients - to take over responsibility for managing the NHS. It could be a poisoned chalice. Doctors could be made to take the blame if the plan collapses, leading the way to the wholesale privatisation of the NHS.

Also opaque is the extent to which these proposals form part of an ideological programme under the leadership of the Prime Minister, David Cameron, and the coalition cabinet, or whether ministers are being left to their own devices. There are similarities between the proposed education and health policies, but they do not appear to be co-ordinated as part of a coherent vision for the country. Every postwar government has come in with a clear ideology and a plan; for good or for ill, we knew what we were getting. The Conservatives have not presented this health plan to the public, and it is not even evident that they have made it clear to their coalition partners.

NHS agencies are being told that the new structure should be in place by 1 April 2012. There has been no announcement about any
of these changes - no public consultation and no critical review. Yet here they come.

Frances Crook is a non-executive director of a primary care trust and writes here in a personal capacity.

Journey of the GP

Before the Second World War, health care in the UK was piecemeal at best. The poor had little right to care - the lowest-paid workers could consult a GP, but their families could not - and many relied on charity.

This changed with the creation of the National Health Service in 1948. In a huge shift, each resident of the UK was from this point registered with a GP, who would act as the individual's point of entry into the medical system. In the early days of the NHS, GPs were demoralised, suffering from low pay and status. GP practices as they exist now began in 1955, when money was made available for individual doctors to develop grouppractices.

In 1990, while Margaret Thatcher was still prime minister, the "internal market" was formed; this allowed certain practices to buy services from other parts of the NHS. Successive reforms under Labour have left a similar system in place.

Meanwhile, GPs' status has improved, with recent contract changes allowing them to opt out of working during weekends and in the evenings. The press has criticised their pay as excessive. The figure is extremely variable, but a full-time practice partner now earns about £110,000, while a salaried GP earns approximately £74,000. A 2006 report showed that some GPs were earning £250,000 a year.

Samira Shackle.

Frances Crook is the Chief Executive of the Howard League for Penal Reform.

This article first appeared in the 05 July 2010 issue of the New Statesman, The cult of the generals

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Are smart toys spying on children?

If you thought stepping on a Lego was bad, consider the new ways in which toys can hurt and harm families.

In January 1999, the president of Tiger Electronics, Roger Shiffman, was forced to issue a statement clearing the name of the company’s hottest new toy. “Furby is not a spy,” he announced to the waiting world.

Shiffman was speaking out after America’s National Security Agency (NSA) banned the toy from its premises. The ban was its response to a playground rumour that Furbies could be taught to speak, and therefore could record and repeat human speech. “The NSA did not do their homework,” said Shiffman at the time.

But if America’s security agencies are still in the habit of banning toys that can record, spy, and store private information, then the list of contraband items must be getting exceptionally long. Nearly 18 years after TE were forced to deny Furby’s secret agent credentials, EU and US consumer watchdogs are filing complaints about a number of WiFi and Bluetooth connected interactive toys, also known as smart toys, which have hit the shelves. Equipped with microphones and an internet connection, many have the power to invade both children’s and adults’ private lives.

***

“We wanted a smart toy that could learn and grow with a child,” says JP Benini, the co-founder of the CogniToys “Dino”, an interactive WiFi-enabled plastic dinosaur that can hold conversations with children and answer their questions. Benini and his team won the 2014 Watson Mobile Developer Challenge, allowing them to use the question-answering software IBM Watson to develop the Dino. As such, unlike the “interactive” toys of the Nineties and Noughties, Dino doesn’t simply reiterate a host of pre-recorded stock phrases, but has real, organic conversations. “We grew it from something that was like a Siri for kids to something that was more conversational in nature.”

In order for this to work, Dino has a speaker in one nostril and a microphone in the other, and once a child presses the button on his belly, everything they say is processed by the internet-connected toy. The audio files are turned into statistical data and transcripts, which are then anonymised and encrypted. Most of this data is, in Benini’s words, “tossed out”, but his company, Elemental Path, which owns CogniToys, do store statistical data about a child, which they call “Play Data”. “We keep pieces from the interaction, not the full interaction itself,” he tells me.

“Play Data” are things like a child’s favourite colour or sport, which are used to make a profile of the child. This data is then available for the company to view, use, and pass on to third parties, and for parents to see on a “Parental Panel”. For example, if a child tells Dino their favourite colour is “red”, their mother or father will be able to see this on their app, and Elemental Path will be able to use this information to, Benini says, “make a better toy”.

Currently, the company has no plans to use the data with any external marketers, though it is becoming more and more common for smart toys to store and sell data about how they are played with. “This isn’t meant to be just another monitoring device that's using the information that it gathers to sell it back to its user,” says Benini.

Sometimes, however, Elemental Path does save, store, and use the raw audio files of what a child has said to the toy. “If the Dino is asked a question that it doesn’t know, we take that question and separate it from the actual child that’s asking it and it goes into this giant bucket of unresolved questions and we can analyse that over time,” says Benini. It is worth noting, however, that Amazon reviews of the toy claim it is frequently unable to answer questions, meaning there is potentially an abundance of audio saved, rather than it being an occasional occurrence.

CogniToys have a relatively transparent Privacy Policy on their website, and it is clear that Benini has considered privacy at length. He admits that the company has been back and forth about how much data to store, originally offering parents the opportunity to see full transcripts of what their child had been saying, until many fed back that they found this “creepy”. Dino is not the first smart toy to be criticised in this way.

Hello Barbie is the world’s first interactive Barbie doll, and when it was released by Mattel in 2015, it was met with scorn by parents’ rights groups and privacy campaigners. Like Dino, the doll holds conversations with children and stores data about them which it passes back to the parents, and articles expressing concerns about the toy featured on CNN, the Guardian, and the New York Times. Despite Dino’s similarities, however, Benini’s toy received almost no negative attention, while Hello Barbie won the Campaign for a Commercial-Free Childhood’s prize for worst toy of the year 2015.

“We were lucky with that one,” he says, “Like the whole story of the early bird gets the worm but the second worm doesn’t get eaten. Coming second on all of this allowed us to be prepared to address the privacy concerns in greater depth.”

Nonetheless, Dino is in many ways essentially the same as Hello Barbie. Both toys allow companies and parents to spy on children’s private playtimes, and while the former might seem more troubling, the latter is not without its problems. A feature on the Parental Panel of the Dino also allows parents to see the exact wording of questions children have asked about certain difficult topics, such as sex or bullying. In many ways, this is the modern equivalent of a parent reading their child's diary. 

“Giving parents the opportunity to side-step their basic responsibility of talking to, engaging with, encouraging and reassuring their child is a terrifying glimpse into a society where plastic dinosaurs rule and humans are little more than machines providing the babies for the reptile robots to nurture,” says Renate Samson, the chief executive of privacy campaign group Big Brother Watch. “We are used to technology providing convenience in our lives to the detriment of our privacy, but allowing your child to be taught, consoled and even told to meditate by a WiFi connected talking dinosaur really is a step in the wrong direction.”

***

Toy companies and parents are one thing, however, and to many it might seem trivial for a child’s privacy to be comprised in this way. Yet many smart toys are also vulnerable to hackers, meaning security and privacy are under threat in a much more direct way. Ken Munro, of Pen Test Partners, is an ethical hacker who exposed security flaws in the interactive smart toy “My Friend Cayla” by making her say, among other things, “Calm down or I will kick the shit out of you.”

“We just thought ‘Wow’, the opportunity to get a talking doll to swear was too good,” he says. “It was the kid in me. But there were deeper concerns.”

Munro explains that any device could connect to the doll over Bluetooth, provided it was in range, as the set-up didn’t require a pin or password. He also found issues with the encryption processes used by the company. “You can say anything to a child through the doll because there's no security,” he says. “That means you've got a device that can potentially be used to groom a child and that's really creepy.”

Pen Test Partners tells companies about the flaws they find with their products in a process they call “responsible disclosure”. Most of the time, companies are grateful for the information, and work through ways to fix the problem. Munro feels that Vivid Toy Group, the company behind Cayla, did a “poor job” at fixing the issue. “All they did was put one more step in the process of getting it to swear for us.”

It is one thing for a hacker to speak to a child through a toy and another for them to hear them. Early this year, a hack on baby monitors ignited such concerns. But any toy with speech recognition that is connected to the internet is also vulnerable to being hacked. The data that is stored about how children play with smart toys is also under threat, as Fisher Price found out this year when a security company managed to obtain the names, ages, birthdays, and genders of children who had played with its smart toys. In 2015, VTech also admitted that five million of its customers had their data breached in a hack.

“The idea that your child shares their playtime with a device which could potentially be hacked, leaving your child’s inane or maybe intimate and revealing questions exposed is profoundly worrying,” says Samson. Today, the US Electronic Privacy Information Center (EPIC) said in a statement that smart toys “pose an imminent and immediate threat to the safety and security of children in the United States”. 

Munro says big brands are usually great at tackling these issues, but warns about smaller, cheaper brands who have less to lose than companies like Disney or Fisher Price. “I’m not saying they get it right but if someone does find a problem they’ve got a huge incentive to get it right subsequently,” he says of larger companies. Thankfully, Munro says that he found Dino to be secure. “I would be happy for my kids to play with it,” he says. “We did find a couple of bugs but we had a chat with them and they’re a good bunch. They aren’t perfect but I think they’ve done a hell of a lot of a better job than some other smart toy vendors.”

Benini appears alert to security and the credibility it gives his company. “We took the security very, very seriously,” he says. “We were still building our systems whilst these horror stories were coming about so I already set pipelines and parameters in place. With a lot of devices out there it seems that security takes a backseat to the idea, which is really unfortunate when you’re inviting these devices into your home.”

As well as being wary of smaller brands, Munro advises that parents should look out for Bluetooth toys without a secure pairing process (ie. any device can pair with the toy if near enough), and to think twice about which toys you connect to your WiFi. He also advises to use unique passwords for toys and their corresponding apps.

“You might think ‘It's just a toy, so I can use the same password I put in everything else’ – dog’s name, football club, whatever – but actually if that ever got hacked you’d end up getting all your accounts that use that same password hacked,” he says.

Despite his security advice, Munro describes himself as “on the fence” about internet-connected smart toys as a whole. “Most internet of things devices can be hacked in one way or another,” he says. “I would urge caution.”

***

Is all of this legal? Companies might not be doing enough ethically to protect the privacy of children, but are they acting responsibly within the confines of the law?

Benini explains that Dino complies with the United States Children's Online Privacy Protection Act (COPPA) of which there is no real equivalent in the UK. COPPA says that companies must have parental permission to collect personal information over the internet about children under 13 years of age. “We’ve tried to go above and beyond the original layout of COPPA,” says Benini, when describing CogniToys transparent privacy documents. Parents give their consent for Elemental Path to collect their children’s data when they download the app that pairs with the toy.

Dino bears a striking similarity to Amazon Echo and Google Home, smart speakers that listen out for commands and questions in your home. Everything that is said to Amazon Echo is recorded and sent to the cloud, and an investigation by the Guardian earlier this year discovered that this does not comply with COPPA. We are therefore now in a strange position whereby many internet of things home devices are legally considered a threat to a child’s privacy, whereas toys with the same capabilities are not. This is an issue because many parents may not actually be aware that they are handing over their children’s data when installing a new toy.

As of today, EU consumer rights groups are also launching complaints against certain smart toys, claiming they breach the EU Unfair Contract Terms Directive and the EU Data Protection Directive, as well as potentially the Toy Safety Directive. Though smart toys may be better regulated in Europe, there are no signs that the problem is being tackled in the UK. 

At a time when the UK government are implementing unprecedented measures to survey its citizens on the internet and Jeremy Hunt wants companies to scour teens’ phones for sexts, it seems unlikely that any legislation will be enacted that protects children’s privacy from being violated by toy companies. Indeed, many internet of things companies – including Elemental Path – admit they will hand over your data to government and law enforcement officials when asked.

***

As smart toys develop, the threat they pose to children only becomes greater. The inclusion of sensors and cameras means even more data can be collected about children, and their privacy can and will be compromised in worrying ways.

Companies, hackers, and even parents are denying children their individual right to privacy and private play. “Children need to feel that they can play in their own place,” says Samson. It is worrying to set a precedent where children get used to surveillance early on. All of this is to say nothing of the educational problems of owning a toy that will tell you (rather than teach you) how to spell “space” and figure out “5+8”.

In a 1999 episode of The Simpsons, “Grift of the Magi”, a toy company takes over Springfield Elementary and spies on children in order to create the perfect toy, Funzo. It is designed to destroy all other toys, just in time for Christmas. Many at the time criticised the plot for being absurd. Like the show's prediction of President Trump, however, it seems that we are living in a world where satire slowly becomes reality.

Amelia Tait is a technology and digital culture writer at the New Statesman.