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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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Inside the minds of the Isis murderers

As pressure on the terror group who claimed responsiblity for the Manchester attack intensifies, the threat to Britain will only become more acute.

The police and security services had consistently warned that a significant terrorist attack in Britain was inevitable. Yet no warning could have prepared us for the horror of the suicide attack on the Manchester Arena on Monday night. Twenty-two people were killed and at least 60 were wounded as they were leaving a concert by Ariana Grande in what was the most deadly attack in Britain since the London bombings of 7 July 2005, in which 56 people died.

Like the London bombers, the Manchester suicide attacker, Salman Ramadan Abedi, was British. He was 22, lived in Manchester and studied business management at Salford University before dropping out. He worshipped at Didsbury Mosque. The son of Libyans, Abedi is said to have returned recently from a visit to the North African country, where Islamic State has a foothold.

Ariana Grande is a former children’s TV star who made her name on channels such as Nickelodeon. Her fan base is overwhelmingly young and female, and many of those killed or wounded were children, including Saffie Rose Roussos, an eight-year-old girl from Leyland, Lancashire.

Islamic State inevitably claimed responsibility for the massacre, dismissing the victims as “crusaders”, “polytheists” and “worshippers of the cross”. This is not the first time Islamist terrorists have targeted children.

A Chechen jihadist group calling itself ­Riyad-us Saliheen (meaning “Gardens of the Righteous”) took more than 1,100 hostages, including 777 children, in a school siege in Beslan, Russia, in September 2004. In the event, more than 330 were massacred, including 186 children. Gunmen from the Pakistani Taliban also stormed a school in 2014, killing 148.

For terrorist actors, these are neither whimsical nor irrational acts. Contemporary jihadist movements have curated a broad and expansive intellectual ecosystem that rationalises and directs their actions. What they want is to create an asymmetry of fear by employing indiscriminate barbarism to intimidate and subdue their opponents into submission.

We have grown accustomed to a wave of terrorist attacks being carried out in the name of the self-styled Islamic State ever since the group’s official spokesman Abu Muhammad al-Adnani began prioritising them in 2014. (He was killed in an American air strike on Aleppo province in Syria in August last year.)

The US-led coalition against Islamic State has weakened the terror group in its former strongholds of Mosul in Iraq and Raqqa in Syria. In response, IS has been forced to concentrate more on what it calls “external operations” – by which it means inspiring its sympathisers and operatives to carry out attacks on Western countries. Indeed, al-Adnani encouraged the group’s supporters not to migrate towards IS-held territory but rather to focus their efforts on attacks in their home countries.

“The tiniest action you do in the heart of their [Western] land is dearer to us than the biggest action by us,” he said in an audio statement released last year. “There are no innocents in the heart of the lands of the crusaders.”

Islamic State refers to its strategy as “just terror”. Its framing places culpability for attacks on Western states on these nations themselves by claiming that IS actions are a response to aggression or assault. That much has been outlined in the group’s literature. “When will the crusaders end their hostilities towards Islam and the Muslims? . . . When will they recognise that the solution to their pathetic turmoil is right before their blinded eyes?” the militants ask in the IS magazine Dabiq. “Until then, the just terror will continue to strike them to the core of their deadened hearts.”

IS offered a rationale of this sort as justification for its bombing of a Russian commercial aircraft – Metrojet Flight 9268, travelling from Sharm el-Sheikh in Egypt to St Petersburg. That attack in October 2015 killed 224. Similar reasoning was offered for the attacks in Paris the following month in which 137 people were killed, in a series of co-ordinated, commando-style gun and bomb outrages across the city.

“Revenge was exacted upon those who felt safe,” IS declared in Dabiq. “Let the world know that we are living today in a new era. Whoever was heedless must now be alert. Whoever was sleeping must now awaken . . . The [caliphate] will take revenge for any aggression against its religion and people, sooner rather than later. Let the ­arrogant know that the skies and the lands are Allah’s.”

***

Through my academic research at King’s College London, I have ­interviewed scores of Westerners who became foreign fighters in Syria and Iraq to quiz them about their motives. Last year, one man from High Wycombe who had joined IS told me that it wanted to attack British targets in response to the vote in the House of Commons to extend British air strikes against IS targets to include sites in Syria (the British had only been targeting the group in Iraq until that point). “Do they [the British government] expect us to sit back and do nothing? ­Idiots,” he said.

In this respect, IS frames its attacks as acts of “revenge” and predicates its response on the Islamic principle of qisas, which is comparable to lex talionis or the doctrine of “an eye for an eye”. Qisas was always intended to be a tool of private redress for an individual or his/her family to seek justice in matters relating to bodily harm. Typically, it relates to cases of murder and manslaughter, or acts involving physical mutilation (say, leading to loss of limbs). The principle creates a framework for retributive justice.

The contemporary Salafi-jihadi movement has adopted a particularly innovative approach to the concept of qisas in two ways. First, groups such as IS have taken the idea and construed it in a way that justifies indiscriminate terrorism, such as the attack in Manchester. They argue that qisas has a political dimension and that it can be applied to international affairs in a way that holds civilians responsible for the perceived crimes of their governments.

Second, qisas is normally applied only in cases where the aggressor is known. IS, by contrast, holds every citizen-stranger of an enemy state responsible for the actions of his or her government. Thus, when it released its statement claiming responsibility for the Manchester attack, it said that it had struck against a “gathering of the crusaders . . . in response to their transgressions against the lands of the Muslims”.

It is this militaristic construction of qisas that allows IS to rationalise the bombing of a venue where large numbers of young girls had gathered to watch a pop concert, dismissing them as “crusaders”.

This is not new. In 1997, Osama Bin Laden told CBS News that “all Americans are our enemies, not just the ones who fight us directly, but also the ones who pay their ­taxes”. His rationale was that all Americans, by virtue of citizenship alone, are vicariously liable for the actions of their government.

Just a few years later, Bin Laden used the same idea to justify the 11 September 2001 attacks and also invoked it in reference to the Israeli-Palestinian conflict. “The blood pouring out of Palestine must be equally revenged,” he wrote. “You must know that the Palestinians do not cry alone; their women are not widowed alone; their sons are not orphaned alone.”

IS used the concept most dramatically in January 2015, when it burned alive a Royal Jordanian Air Force pilot, Muath al-Kasasbeh, whose plane had crashed in its territory. A video of the killing was circulated on the internet and social media. The group claimed his bombing raids had killed civilians and that it wanted to punish him with “equal retaliation”, in keeping with qisas.

What is well known about al-Kasasbeh’s murder is that he was burned alive inside a cage – but that is not the whole story. To understand how IS tethered this to the principle of qisas, it is the end of the gruesome video that is invested with most significance. After al-Kasasbeh has died, a truck emerges and dumps rubble over the cage. It was claimed this was debris from a site he had bombed, thus completing the “equal retaliation” of returning like for like. The idea was that IS had retaliated using the two principal forms in which a missile attack kills – by fire or debris.

***

The Manchester attack came on the fourth anniversary of the brutal murder of Fusilier Lee Rigby in Woolwich, south London. Rigby was killed by Michael Adebolajo and Michael Adebowale in the middle of the afternoon on a street outside a military barracks. That attack was in keeping with a pattern we have become increasingly accustomed to in Europe: an unsophisticated plot that employs ordinary, everyday items – a car, say, or a knife.

The consequences of such attacks have been seen across Europe, most notably in Nice on 14 July 2016, when 86 people were killed during Bastille Day celebrations after a jihadist drove a truck into crowds on the promenade. Similar attacks followed in Berlin, Westminster and Stockholm.

The security services find that these murderous attacks are extremely hard to disrupt because they typically involve lone actors who can mobilise quickly and with discretion. The Manchester attack was different. Explosives were used, which means the plot was inherently more sophisticated, requiring careful planning and preparation.

We know that two of the 7/7 bombers had previously trained in Pakistan’s lawless tribal regions, where they honed their skills. In other plots, such as the connected attacks in London and Glasgow Airport of 2007, the explosive devices failed mainly because the bomb-makers had found it difficult to travel abroad and develop their skills in safe environments. Whatever Abedi’s connections, the long war in Syria and Iraq has once again created a permissive environment for terrorist training and attack planning.

The devastating impact of this has already been felt across Europe. Since the Syrian uprising began in 2011, more than 800 Britons are believed to have travelled there to fight. From Europe as a whole, the figure is over 5,000, of which a significant number are believed to have joined IS. Of the British contingent, the security services estimate that about half have returned or become disengaged from the conflict. Of those who remained, a hundred are believed to be active, the rest having been killed.

It is improbable that Abedi acted alone in Manchester or that this plot had no international component. Indeed, he was already known to the authorities (and had returned recently from Libya). As pressure on IS intensifies across Syria and Iraq, the threat to Britain will only become more acute as the group’s sympathisers prepare for what they consider to be a fightback.

This speaks to the scale of the threat facing Britain, and Europe more generally. Our police and security services have been stretched and continuously tested in recent years. Just recently, in March, the Metropolitan Police assistant commissioner Mark Rowley told Radio 4’s Today programme that 13 plots had been thwarted since Lee Rigby’s murder in 2013. Put another way, the police have disrupted terrorist plots every four months for the past four years.

Naturally, Islamic State is not the only threat. On 13 May, one of Osama Bin Laden’s sons, Hamza, released a video, titled “Advice for martyrdom-seekers in the West”, on behalf of al-Qaeda. Hamza, 27, who was his father’s favoured successor to lead the group, called on its supporters to concentrate on attacks in the West rather than migrating to conflict zones in the Middle East and beyond. Scenes of previous ­terrorist attacks in Britain played throughout the video.

The central leadership of al-Qaeda is increasingly looking for opportunities to reassert itself after being eclipsed by Islamic State and losing control of its affiliates in Syria. It needs attacks and a cause in the West with which to revive itself. Hamza therefore cited the January 2015 Charlie Hebdo attack in Paris as a critical example, calling for the assassination of anyone deemed to have “insulted” Islam.

The Charlie Hebdo attack was especially important for al-Qaeda because it enabled the group to transcend the fratricidal conflicts that frequently define relations between the various jihadist groups. In Syria, for instance, al-Qaeda’s affiliates (when it had better control over them) and Islamic State have been in open war with each other.

Yet, the Charlie Hebdo attack brought warm praise from the group’s Islamist rivals because none of them wanted to appear ­unsupportive of an atrocity that had, as the terrorists proclaimed, “avenged” the Prophet Muhammad’s honour.

The British man from High Wycombe who joined IS told me the group had welcomed the attack for precisely those reasons. It was something that, in his view, had confirmed the “nobility” of the attackers, even if they had not been members of IS.

Is it too late for the West to save itself, I asked him. What if the West simply accepted all of Islamic State’s demands: would that provide respite?

The answer was as emphatic as it was stark: “We primarily fight wars due to ppl [sic] being disbelievers. Their drones against us are a secondary issue.”

He went on: “Their kufr [disbelief] against Allah is sufficient of a reason for us to invade and kill them. Only if they stop their kufr will they no longer be a target.”

In other words, we are all guilty, and we are all legitimate targets.

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 25 May 2017 issue of the New Statesman, Why Islamic State targets Britain

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