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The NHS is Britain’s beating heart – don’t let it flatline

After 30 years of meddling with the NHS, are we now at risk of destroying our most precious public s

I have hazy memories of my parents getting their first telephone. It was the late 1960s, and telecommunications was a public service. There was a waiting list but, in time, we got to the head of the queue. An engineer from the General Post Office installed the necessary equipment and we were connected - or at least, connected any time our neighbours weren't using their phone: ours was a "party line". I don't recall any grumbles about the tortuousness of the process, nor about having to share with the people next door. The sense of wonder at what was now possible must have mitigated any frustration. It was marvellous to be able to speak to relatives and friends from the comfort of home, without having to trudge to the phone box.

The National Health Service was viewed in much the same way. My father developed cancer when I was two years old. He was swiftly cured but irrevocably damaged, and he struggled thereafter with chronic ill-health. His illnesses had knock-on effects on various members of our family, myself included. Between us we saw a lot of the NHS. At the centre of it (to my eyes) was our GP, a good-hearted man with half-moon glasses and a somewhat distant manner. When he needed expert assistance, a referral would be made. Waiting times were sometimes long but were accepted with stoicism: the professionals we eventually saw did their best. Looking back, I recognise the profound comfort in those experiences for my parents, who had grown up knowing what medical care could be like - and its financial implications - before the advent of the NHS. No matter how threatening or scary things got, no matter what time of day or night, this health service was there to help and asked nothing in return.

In the mid-1980s, I entered medical school in Nottingham. Like most aspiring doctors, I knew what I was going to be: a public servant, working extremely long and often antisocial hours, the whole arduous endeavour sustained by a powerful sense of doing something important and worthwhile. I would be joining an unquestionable force for good, grouped under the fluttering blue-and-white standard of the NHS.

But even as I embarked on my training, society was changing under the Thatcher government. The emerging citizen-consumer was increasingly exasperated by the inefficiency of state monopolies; no longer could we tolerate waiting months to have something as commonplace as a phone line installed or repaired. Margaret Thatcher's solution was privatisation and exposure to market forces. British Telecom was sold off in 1984, two years after a licence had been granted to its first competitor, Mercury Communications. British Gas and British Petroleum soon followed. It was only a matter of time before government attention turned to the biggest state monopoly of them all.

I was nearing qualification as a doctor when the then secretary of state for health, Kenneth Clarke, published his 1989 white paper, Working for Patients. The huge, sprawling, multicellular organism of the NHS would be cleaved in two, hospitals becoming providers, wooing and responding to the demands of purchasers in a so-called internal market. Competition, survival of the fittest, would deliver a patient-centred NHS, something even the new breed of health service managers, ushered in by the 1983 Griffiths report, was failing to achieve.

The white paper was greeted with consternation in Nottingham. The city had two general hospitals. Each had the full complement of acute care services and they shared the emergency work, alternating days "on take" for admissions. Specialised departments were located at one or the other site. Co-ordinated by the health authority, they supplied virtually all hospital care for the local population between them, with little unnecessary duplication. Now they were to become independent trusts, no longer co-operating, but competing for each other's business.

The central dilemma with the model was: who, in practice, would the purchasers be? In any normal market, they would be the consumers. But in an era when most people's access to medical information was limited to the family copy of Home Doctor, patients could not realistically make informed decisions. The That­cher government's response was to invite GPs to become purchasers, controlling budgets on behalf of their patients. Generous management allowances and the freedom to reinvest savings provided incentives for uptake. Wave after wave of practices signed up, until eventually about 50 per cent of GPs - covering 60 per cent of the population - were fund-holders.

The Labour opposition was incensed by the scheme, arguing that it was creating a two-tier service. By this stage, I was working as a junior hospital doctor in a surgical speciality and the evidence was stark. The admissions office had a card system along the length of one wall, with a slot for each patient on the waiting list. The nearer a card moved to the left, the closer the admission date. Patients from fund-holding practices were flagged with red stickers. When any were in danger of exceeding the eight-week treatment time specified in the fund-holding group contract, they were simply bumped along, displacing those from non-fundholding practices who had already been waiting longer.

Unfair advantage

There were other perversities. A fund-holding practice's budget was set according to its activity in the year before entering the scheme. GPs routinely maximised referrals and prescribing in the run-up to budget-setting to ensure a decent allocation. It was not hard to make savings that could be reinvested. I spent a year working at a fund-holding practice in Oxfordshire in the mid-1990s. A consultant orthopaedic surgeon was contracted to run a clinic at the health centre every fortnight; patients had in-house physiotherapy and counselling. A handsome meeting room had been built and computers upgraded. Other practices opened branch surgeries; elsewhere NHS osteopathy and acu­puncture were made available. Fund-holding GPs and their patients had never had it so convenient or so good. Non-fundholding surgeries, such as the Oxford city practice I went on to join, were being left behind.

The 1997 election result was a great relief. True to its reputation as the party of the NHS, New Labour soon scrapped fund-holding and the internal market. Budgets were returned to health authority control in the form of primary care trusts (PCTs). I remember listening to the closing flourish of Gordon Brown's first Budget speech when he pulled from his metaphorical hat £1.2bn extra funding for the health service. Labour backbenchers sent up a raucous cheer, their reaction to the announcement reflecting my own surge of elation. Here at last was a government prepared to back the NHS with proper resources. The rhetoric of Blair's first term was about ensuring excellent health care for all, regardless of where you lived or who your GP was. New Labour, it seemed, was a party that understood our public service values.

National Service Frameworks (NSFs) began to spew from the Department of Health, dictating to doctors every aspect of the care they must provide for common, important conditions. I took the lead in my practice for the heart disease NSF; we welcomed it as a template against which to assess our standard of care.

All too soon, however, the rigid, controlling instinct of the New Labour regime emerged. The National Institute for Health and Clinical Excellence (NICE) was founded, its remit to abolish postcode lotteries in NHS treatment and further to promulgate a centralised vision of health care. Targets for hospital waiting and for access to GP care were imposed, spawning unintended consequences that inconvenienced or adversely affected more patients than they helped. The NSFs became incorporated into the 2004 GP contract as the tick-box-obsessed Quality and Outcomes Framework (QOF), straitjacketing doctors' ability to tailor treatment according to patients' individual needs. More and more managers were employed to survey and to audit and to enforce compliance with these various initiatives.

My GP colleagues and I have become press-ganged into the role of pill-pushers, the tyranny of QOF subjecting patients to bewildering and sometimes injurious choices of drug, irrespective of circumstances. The only way to practise holistically is to "exception-code" patients, removing them from QOF. But exception-code too many, and the managerial thought-police are quickly on to you - you're incompetent, you're a maverick, or even worse you are setting out to defraud. The distrust and disempowerment of dedicated professionals have been a kind of poison, choking off the immense goodwill that was the lifeblood of the NHS.

To compound matters, at some point during Tony Blair's second term, the decision was taken to revisit the Thatcher experiment. The language had to be distinct, so commissioners rather than purchasers would call the shots. And there could be no return to a two-tier service; all GPs were expected to become involved in the new, practice-based commissioning. Audaciously, Blair went where Thatcher had never dared to tread. The provider market was no longer to be internal: it was opened up to the private sector, treatment reimbursed at fixed-tariff rates. To kick-start the process, New Labour guaranteed returns to a number of independent-sector treatment centres (ISTCs), whose staff are often brought in from overseas, with qualifications, training and experience that are unfamiliar to local practitioners.

ISTCs have proved popular with many patients, who appreciate the plush facilities and short waiting lists that overgenerous block contracts have endowed. But, for the local NHS, there is uncertainty over clinical quality. One of my patients was given an inappropriate orthopaedic operation two years ago. The pieces are still being picked up by an experienced consultant at the local district general hospital. Nor is this an isolated case. Several other patients had to have camera examinations of their bowels repeated as part of a review of 1,800 procedures carried out at our local ISTC, following allegations of failure to diagnose cancer.

Even where quality of care is good, patients who have investigations that detect significant pathology then have to be referred on to consultants at the district general hospital, fragmenting their care and generating additional stress and anxiety, because ISTCs are not contracted or able to manage the conditions they diagnose. ISTCs have destabilised the existing NHS hospitals they rely on for safety-netting, cherry-picking patients at lowest risk and leaving the old providers to deal with complex, high-risk patients whose care is, as a consequence, more expensive. Training the next generation of doctors has been rendered problematic by the skewing of case-mix (patient categories) in medical teaching centres.

Franchised out

Allegedly to disrupt vested interests, New Labour also opened up general practice to the private sector. PCTs were compelled to award an increasing proportion of primary care contracts to commercial organisations. Under Lord Darzi's NHS Next Stage Review, every PCT was forced to commission a new "8-till-8" health centre - funded at levels a conventional practice could only fantasise about - the thinly disguised agenda being to expose existing surgeries to the white heat of (unfair) competition. The fluttering blue-and-white flag of the NHS to which I had once rallied has become a mere franchise, something to be waved by any organisation granted entry into the health-care arena, no matter its motivation.

In spite of the resources New Labour squandered to open up the provider market, practice-based commissioning proved an abject failure. By the time the policy was launched, PCTs had become mature, self-sustaining bureaucracies. With a few notable exceptions - where enlightened PCTs granted GPs substantial freedom of commissioning, and where some impressive innovations and efficiencies were achieved as a result - practice-based commissioning barely drew breath, smothered by managers unwilling to relinquish control.

The relief I felt last May when Labour was finally evicted was every bit as strong as that I'd experienced in 1997. Andrew Lansley appeared to be offering us the opportunity to reinvent the NHS as a modern public service - GP commissioning consortiums collaborating with consultants and other stakeholders to deliver joined-up, efficient, patient-centred care pathways. We had seen our efforts bear fruit in the few places where practice-based commissioning was allowed to flourish and there was an appetite to restore the public-service ethos that New Labour had so wilfully destroyed.

At what price?

Yet, in the months since the white paper was announced, clinician enthusiasm has been ever declining. Recent polls find only a minority of GPs continuing to back Lansley's plans and there has been an extraordinary convergence of concern among virtually every body representing the NHS, from unions such as the BMA, Unite and Unison, to the royal colleges of every medical and nursing discipline, to the NHS Confederation and various independent think tanks such as the King's Fund. There is anxiety about the pace and scale of the reforms, and disquiet about shifting responsibility for rationing on to doctors whose time-honoured role is to do their best for each patient. The show-stopper, though, is the picture that has recently emerged of Lansley's version of the provider market.

This is to remain external, with "any willing provider" (AWP) allowed to pitch for business under the NHS franchise. We have had more than enough experience with New Labour to appreciate the downsides, but the profession could probably live with AWP, relying on the commissioning process to factor in holistic care, were it not for Lansley's completely unexpected determination - smuggled into a brief mention when the Health and Social Care Bill was published on 19 January - to permit providers to compete not just on quality (as now), but also on price. The NHS regulator, Monitor, will be tasked with compelling this price competition. Far from collaborating with providers to design holistic, patient-responsive care programmes, GP consortiums will be bound by competition law and could face legal challenges, should they seek to work organically with selected organisations.

This surprise emphasis on price competition might at first seem reasonable, given the pressures on public spending. But the evidence strongly suggests that price competition lowers quality of care. One need only consider the NHS's single, disastrous experiment with it. Under the terms of the 2004 GP contract, PCTs were handed responsibility for commissioning out-of-hours care for patients, with no national tariff to adhere to. In order to win contracts, many commercial organisations bid low - either as a loss-leader to eliminate local, GP-led competition before increasing contract costs, or in the sincere belief that they could provide adequate care at bargain-basement prices.

In my own area we are all thankful that the PCT has continued to commission out-of-hours services from a not-for-profit company run and staffed by local GPs, which recently achieved second place nationally in a survey of quality. Elsewhere in the country, cut-price out-of-hours providers - by definition often dealing with patients with acute or life-threatening conditions - frequently depend on non-medical staff working to inflexible protocols, or on agency doctors who have little knowledge of local services, and whose language and communication skills can be markedly deficient.

At best, these apparently cheaper services consume more resources as inappropriate admissions multiply. At worst, patients needlessly suffer and die. All these services looked good on paper when the tenders came in. It takes a long time, and a lot of harm to patients, before deficiencies of quality become apparent; and it can be legally difficult to break a contract even when the provider seems to be failing.

Crossed wires

My family moved house recently. BT royally loused up the redirections we had commissioned on our old phone numbers. Innumerable operatives in call centres around the globe were unable to rectify matters, some simply hanging up when the going proved too difficult. In the end, even the high-level complaints manager we were allocated admitted it was beyond her power to put things right.

Disgruntled and nonplussed by BT's failure to make amends, we investigated switching providers, only to find that our contracts render any move prohibitively expensive. We are stuck, at least for the next year. Never mind, it really doesn't matter - it's only phones. But what if it did matter? What if this was a matter of life and death, or of life-enhancing care? What price would we then put on a health service that was there for us - not for profit - no matter how threatening or scary things were, no matter the time of day or night, and which asked nothing of us in return?

Phil Whitaker is a novelist and GP working in the south-west of England

This article first appeared in the 28 February 2011 issue of the New Statesman, Toppling the tyrants

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Brothers in blood: how Putin has helped Assad tear Syria apart

The Syrian catastrophe has created the worst humanitarian crisis since the end of the Second World War. And the world watches helplessly as Putin and Assad commit war crimes.

Sometimes we know the names. We know Omran Daqneesh, the five-year-old boy who, covered in mud and dust, was pictured on the back seat of an ambulance in the aftermath of an air attack. We know his name because pictures and a video of him were released on social media and travelled around the world. The outrage that followed was widespread and sincere, the image of the dazed little boy seeming to symbolise the greater plight of the beleaguered residents of Aleppo. But then the moment passed. Few will know that a few days later doctors announced that Omran’s elder brother Ali, who was injured in the same air strike, had died from his injuries. He was ten.

Sometimes we know the names of the babies pulled from the rubble of collapsed buildings – occasionally alive, but often dead; or the names of the children weeping over lost parents; or the women grieving over lost husbands and children; or the elderly simply waiting (and sometimes wanting) to die.

We know Bana Alabed, the seven-year-old girl trapped inside Aleppo whose Twitter account has gone viral in recent weeks. “Hi I’m Bana I’m 7 years old girl in Aleppo [sic],” reads the on-page description. “I & my mom want to tell about the bombing here. Thank you.”

A series of pictures depicts Alabed and her mother, Fatemah, struggling to live as normal a life as possible, one showing the little girl sitting at an MDF desk with a book. Behind her, in the corner, is a doll. “Good afternoon from #Aleppo,” says the caption in English. “I’m reading to forget the war.”

The conflict, however, is never far away. Alabed, whose mother taught her English, has repeatedly tweeted her own fears about dying, followed by stoic messages of defiance whenever the immediate threat of an impending air strike passes. On the morning of 3 October, her words were simply: “Hello world we are still alive.” On 17 October, Fatemah tweeted: “The airstrikes ended in the morning, all the last night was raining bombs.”

But in most cases we never know the names of the victims of air assaults led by Presidents Bashar al-Assad and Vladimir Putin. One of the most haunting images to emerge in recent weeks was that of a mother and child, killed while sleeping in the same bed. The scene had an eerily preserved-in-amber feel to it: a snapshot of snatched lives, frozen in the act of dying. Pictures of ruined buildings and distraught civilians have become routine now, holding our attention briefly – if at all.

As many as 500,000 people are believed to have been killed since the beginning of the Syrian uprising in early 2011. According to a report released in February this year by the Syrian Centre for Policy Research, a further 1.9 million have been wounded. Taken together, those figures alone account for 11.5 per cent of Syria’s pre-revolutionary population. Combine that with the number of Syrians who have been displaced – more than ten million (almost 50 per cent of the population) – and the sheer scale of the disaster becomes apparent.

The conflict has become the worst humanitarian crisis since the Second World War. Today it centres on Aleppo, in north-west Syria, one of the oldest continuously inhabited cities in the world, and a cradle of human civilisation. Various conquerors from the Mongols to the French have fought battles there but none, so it would seem, has been quite as ruthless or committed to the city’s annihilation as Bashar al-Assad.

Aleppo remains the most significant urban centre to have been captured by the anti-Assad rebels, most of whom will (by now) be strongly influenced by an Islamist world-view. Indeed, the most prominent fighting groups on the rebel side are overwhelmingly Islamist in their troop composition and beliefs, a sad marker of Western failures to support secular forces that led the anti-regime resistance in the incipient phases of the uprising.

Yet Aleppo remains too important to fail. Although rebel forces succeeded in capturing only half of the city – the western side remained firmly in the control of the regime – the symbolism of anti-Assad forces holding ground in Syria’s second city (which also served as the country’s economic hub) has buoyed the rebel movement.

Assad is more brazen and bullish than at any other point since eastern Aleppo fell into rebel hands in July 2012. That optimism is born of a strategy that has already worked in other parts of the country where the regime’s troops have slowly encircled rebel-held areas and then sealed them off. Nothing can leave, and nothing can enter. Once the ground forces seal off an area, an aerial campaign of barrel bombs and missile attacks from both Syrian and Russian fighter jets inevitably follows.

To get a sense of just how terrible the aerial campaign has been, consider that the United States accused the Russian air force of potential war crimes when a UN aid convoy was bombed just west of Aleppo last month. It was carrying food and medicines when it was hit. Since then, the UK and France have said that Russia’s bombardment of Aleppo amounts to a war crime.

Putin’s support has come as a boon to Assad ever since Russia formally entered the conflict in September 2015. Despite his administration already using Iranian forces and aligned groups such as the Lebanese Shia militia Hezbollah, rebels had continued to make significant gains throughout the early months of 2015. The most important of these was the capture of Idlib city, 40 miles from Aleppo, which presented Assad with two problems. The first was that it dented the official narrative of revanchist military successes by his forces. The ­second was that it handed the rebels power in a province adjoining Latakia Governorate in the west, where Syria’s Alawites are largely concentrated (Russia has an airbase in an area south-east of the city of Latakia). The Alawites are a heterodox Shia sect to which the Assad family belongs, and which forms the core of their support base.

Keen to reverse these gains – and others made elsewhere – Assad enlisted Putin, given Russia’s long-standing interests in, and ties to, Syria. The Kremlin has long regarded Syria as an important ally, and has served as the country’s main arms supplier for the past decade. There are important assets to preserve, too, such as the Russian naval base in the port city of Tartus on the Mediterranean, which was first established during the Soviet era.

For his part, Putin has felt emboldened by events. The world is changing – not just in the Middle East and North Africa, where the
contours of power continue to be recast, but also closer to home in Ukraine, where the pro-Russian president Viktor Yanukovych was overthrown in 2014.

The West is still haunted by the 2003 invasion of Iraq and has been reluctant to be drawn too deeply into the Syrian War. In 2013, the Assad regime used chemical weapons against its own people. This was a violation of President Barack Obama’s so-called red line against the use of chemical weapons, but no retaliatory action came and there was nothing to prevent the Kremlin from using force to shape events in Syria – as it had done in Ukraine.

All of this has marked a new phase of brutality in a conflict already noted for its barbarism. Civilians who avoid death from combined Russo-Syrian air assaults suffer under Assad’s strategy of “starve or submit”, in which supplies are withheld from besieged areas, slowly choking off those ­inside. It has been used to devastating effect against civilians in towns such as Madaya and in Daraya, on the outskirts of Damascus, both of which fell to government control after being sealed off from the outside world for several years. Such a strategy is not designed to deliver quick victories, however. Consider how the residents of Daraya defied Assad’s forces for four years before capitulating in August 2016.

Assad and his allies (Putin, Iran, Hezbollah) have decided to punish and brutalise, deliberately, civilian populations in rebel-held areas. To invert the famous aphorism attributed to Chairman Mao, they hope to dredge the sea in which the revolutionaries swim. And so, it is the 300,000 residents of eastern Aleppo who must suffer now.




It’s easy to lose track of precisely what is happening in the Syrian War as parcels of land swap hands between rebels and the regime. Assad’s forces first began encircling Aleppo at the start of July this year and succeeded in imposing a siege by the middle of that month, after cutting off the last of two rebel-controlled supply routes into the city. The first was the Castello Road, which leads from the town of Handarat into the north-western part of ­rebel-controlled territory. The second route, via the Ramouseh district (which led into the south-western end of the city), had already been sealed off.

The closure lasted for roughly four to five weeks before the rebels re-established access. Aleppo is too important for them, and the siege has forced various groups to work together in breaking it. The effort was led by Jaish al-Fateh (JaF, the “Army of Conquest”), an umbrella group and command structure for several of the most prominent jihadist and Islamist groups operating in northern Syria. JaF also co-ordinated the Idlib military campaigns. One of its key members is Jabhat Fateh al-Sham (JFS, “the Syrian Conquest Front”), which was previously known as Jabhat al-Nusra (JaN or “the Supporters’ Front”) and was recognised as al-Qaeda’s official chapter in Syria.

Several months before the regime began its assault on Aleppo, rebel groups in the north recognised the deteriorating situation there, stemming principally from Russian air strikes. As a result, al-Qaeda urged the various factions to merge and work together to counteract not just Assad, but also Putin. Even the global leader of al-Qaeda, Ayman al-Zawahiri, issued a speech last May titled “Go Forth to Syria”, in which he called on all fighting groups to unite in order to consolidate their control across the north. This opened the way at the end of July for Jabhat al-Nusra to declare that it was formally severing its links with al-Qaeda. It “rebranded” as Jabhat Fateh al-Sham.

There are two reasons for doing this. The first is to erode partisanship among the Islamist groups, forcing them to set aside differences and narrow their ambitions in favour of the greater goal – in this case, the breaking of the siege of Aleppo, while also deepening rebel control across the north. The second aim of rebranding is to win popular support by portraying themselves as fighting in the service of ordinary civilians.

Groups such as JFS and others are succeeding in both of these goals. Responding to the abandoned and assaulted residents of Aleppo, they have repeatedly demonstrated their commitment to alleviating the humanitarian crisis. Much of their messaging echoes this theme. The group’s English-language spokesman is Mostafa Mahamed, an Egyptian who previously lived in Australia. “[JFS] is deeply embedded in society, made up from the average Syrian people,” he explained on Twitter, after the group decoupled from al-Qaeda. “We will gladly lay down our lives before being forced into a situation that does not serve the people we are fighting for . . . jihad today is bigger than us, bigger than our differences.”

It is indisputable that this ethos of “fighting for the people” has endeared the group to civilians living in besieged areas – even when those civilians don’t necessarily agree with the full spectrum of its religious beliefs or political positions. That goodwill was only reinforced when the group helped break the siege of Aleppo (in which approximately 500 rebels were killed) in August, if only for a few days. Assad reasserted control within a week, and entrapped the residents again in the middle of that month. The rebels are now planning how to break the siege decisively, but have not yet launched a major counteroffensive.




A freelance American journalist and film-maker, Bilal Abdul Kareem, who has reported on rebel movements inside Syria more intimately than most, has found himself among those trapped inside eastern Aleppo since the siege was restored seven weeks ago. “We came here expecting a two- or three-day trip,” he told me during an interview over Skype.

Life inside is becoming insufferable for civilians, Abdul Kareem said; every building is potted and scarred by shrapnel damage. Those whose homes remain standing are the lucky ones. “Your day consists of nothing,” he said. “There’s no work, there’s no fuel, no industrial zone, no food to sell. ­People sit around and chit-chat, drink tea, and that’s all they do.”

Food supplies are already running low, with most people limiting themselves to basics of chickpeas and groats – crushed grains such as oats or wheat. Sealed off from the rest of the world, those inside preoccupy themselves with survival and wait for the next wave of attacks.

It is tempting to ask why the inhabitants of Aleppo did not flee when they had the chance. Indeed, the Assad regime routinely accuses the rebels of preventing civilians from leaving besieged areas, though there is no evidence to support this view. On 17 October Russia and the Syrian regime said they would halt their bombardment for eight hours on 20 October to allow rebels and civilians to evacuate the city.

In truth, what choice do the civilians have? Most do not trust Assad and they are therefore unwilling to move into regime-administered areas. The alternative is to become refugees, with all the uncertainties and trials associated with that. For instance, refugees have found themselves subject to sectarian violence in Lebanon, and they have few opportunities to find employment in Lebanon, Turkey or Jordan, the three countries where most of the fleeing Syrians have found shelter.

For them, merely to exist in rebel territory is an act of defiance, which is precisely why Assad’s forces make no effort to distinguish between combatants and civilians in rebel areas. To be present is a crime.

The effects of this have been devastating. A spokesman for the Syrian American Medical Society told Middle East Eye, an online news portal, that in July, Syrian and Russian jets had hit medical facilities in rebel-held territory every 17 hours.

Only a few hospitals and medical staff remain. The physical conditions are primitive and perilous. Doctors work in makeshift facilities – a former flat, a commercial garage – which makes them unable to provide anything beyond basic emergency care. In-patient facilities are non-existent, not just because of high demand from those newly injured in fresh attacks, but also from fear that the facility itself will be targeted. “People are literally shuffled out of the hospital with IV [intravenous drips] in their arms,” Abdul Kareem says.

The West’s indifference to all this – coupled with its occasional pious pronouncements and diplomatic dithering – has squandered any goodwill Washington might once have had among Syria’s beleaguered civilians. When Sergey Lavrov, Russia’s foreign minister, and John Kerry, the US secretary of state, agreed a ceasefire in September it lasted barely two days because they overlooked the fears of those trapped inside eastern Aleppo.

The deal had stated that no party would try to capture any new territory. That might seem reasonable enough but given that the ceasefire came into effect just days after Assad re-established the siege of Aleppo, those on the inside were being asked, in effect, to acquiesce to their own starvation.

Deprived of food and medication, no one trusted Assad to negotiate access in good faith, especially after he thwarted UN efforts to deliver aid. “People saw it as a conspiracy,” Abdul Kareem told me. Moreover, there were no significant groups inside eastern Aleppo that claimed to have accepted the terms of the ceasefire in the first place. Kerry had negotiated on their behalf without approval and without securing any humanitarian concessions.

“What planet are these people on?” Abdul Kareem asked. “[Do] they think people will turn on their protectors, for people who didn’t do them any good? They look to JFS and Ahrar [Ahrar al-Sham is one of the Islamist groups fighting in JAF]. Western intervention is pie in the sky.”

The rise of these reactionary rebels is a direct result of liberal elements not being strongly supported at any stage in the conflict. Left to fend for themselves, many have deserted their cause. Those who have persisted not only risk the constant threat of being killed by Russo-Syrian bombs, but are also at threat from jihadist elements operating in rebel areas. That much was clear when remnants of the secular opposition protested against the leader of JFS, Abu Mohammed al-Golani, in the southern Idlib town of Maarat al-Nouman earlier this year. Many of those who did were arrested by jihadists and intimidated into silence.

Whereas liberals are fragmented and frayed, the Islamist rebels continue to coalesce into an ever more coherent unit. The overwhelming might of Russian airpower has convinced them of the need to form a united front in order to pool their resources and co-ordinate their efforts. That is one of the reasons why a jihadist group called Jund al-Aqsa (“Soldiers of al-Aqsa”) announced early this month that it was disbanding and being absorbed into JFS.

Herein lies the real story of how Aleppo – and, indeed, Syria itself – has been delivered to the jihadists. A conspiracy of all the external parties has forged a menacing millenarian movement that is embedded in civil society and communities across the north. Whether Aleppo falls or not, the jihadists will endure.

Shiraz Maher is a contributing writer for the New Statesman and a member of the war studies department at King’s College London

Shiraz Maher is a contributing writer for the New Statesman and a senior research fellow at King’s College London’s International Centre for the Study of Radicalisation.

This article first appeared in the 20 October 2016 issue of the New Statesman, Brothers in blood