Health Secretary Jeremy Hunt delivers a speech during his visit to the Evelina London Children's Hospital on July 5, 2013. Photograph: Getty Images.
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NHS privatisation isn't working, it’s time for a more mutual solution

Mutuals are best placed to initiate a system of healthcare that delivers personalised, holistic care in a cost-effective manner.

As much as many of us would like to ignore the fact, our National Health Service is at the most critical juncture in its long history. An ever-ageing population, together with the stark rise in prevalence of those suffering from lifestyle diseases, both place our healthcare system on a financially unsustainable footing. Indeed, long-term conditions, such as obesity and diabetes, will alone bankrupt the NHS within a decade, with a £19bn funding gap expected if these conditions are not managed properly.

Yet from government there seems to be a lack of good ideas on how to ensure that NHS remains viable as an institution free at the point of use. Many of the arguments surrounding health reform suggest that the solution to this financial crisis is a laughably simple one – more liberalisation. The trend towards NHS liberalisation, which started with Margaret Thatcher and continued with the Health and Social Care Bill, has been at the heart of health reform over recent decades. This trend is based upon the proposition that is all that is needed to improve NHS services is to open up the system to private sector providers. Then competitive forces will, as if by magic, improve patient quality whilst making the necessary savings.

But although competition in certain cases is to be welcomed, it is alone insufficient to tackle the health systems incoming problems. The complex conditions of the future will require a different type of healthcare, delivered by a different healthcare system. The NHS of the past, which was designed to combat acute diseases like polio and tuberculosis, is simply not configured to treat the chronic diseases associated with ageing and flawed lifestyle choices. These conditions require more integrated forms of service delivery that provide holistic, whole-person care.

It has long been known that integrated care is the holy grail of NHS reform. Yet the coalition government has failed to make this a top priority, and the cancellation of the £3.8bn Better Care Fund is clear evidence of this. In fact, instead of choosing the harder path towards better healthcare integration, the government has opted for and prioritised yet more liberalisation in the form of the Any Qualified Provider programme.

This initiative is intended to open up services and improve patient choice. Under this scheme, private providers are allowed to deliver basic NHS services. At a first glance, by the government’s standards the programme seems to have been a success, with 105 firms singed up to the scheme. But instead of opening up the service to smaller providers, as was first intended, the process has been criticised for prioritising the larger providers. A study of AQP found that 24 of the 105 firms were large companies with at least 250 members of full-time staff.

AQP is not the answer to integrated care, as it merely atomises and fragments care by multiplying the number of bodies delivering healthcare. In this way, it simply destabilises existing services and damages care pathways. It cannot, therefore, deliver the whole-person care we need. Because of this, we at ResPublica ask that the government seriously consider scrapping the Any Qualified Provider scheme. Competition and choice are to be welcomed, but they should not come at the price of collaboration and holistic care. We would instead argue for a different approach.

In our latest report, Power to the People: The mutual future of our National Health Service, we argue that mutuals are best placed to initiate a system of healthcare that delivers personalised, holistic care in a cost-effective manner. Mutual organisations are, by their very nature, democratic and benevolent institutions. As such, they are perfectly placed to integrate the needs of patients with the capabilities of clinicians in an inclusive fashion.

Such a proposal is not an odd suggestion. Mutuals already have a firm foothold in the NHS. Foundation Trusts, which operate on a mutual model, are now the standard composition for hospitals, and mutual NHS spin-outs are raising standards across the sector. One type of mutual organisation that has often been ignored, but could perhaps perform such a vital role, is the friendly society.

Before the advent of the NHS, most healthcare was provided through friendly societies. Just before the onset of the Great War, there were 26,877 friendly societies operating in England and six million members. The democratic and inclusive characteristics of these organisations would make them ideal candidates for performing an integrator role that would connect disparate elements of the NHS to deliver the holistic care our older people need.

As the report makes clear, the financial benefits of this model could be vast. By integrating care, we estimate that the NHS could save £4.5bn by 2020. Embracing mutualism would not only integrate care and deliver better outcomes, it would have significant financial benefits as well. Clearly, if we are to have the integrated care that so many of us need, then policy makers will have to ditch their fixation with ever increasing liberalisation and assess the benefits more mutualism could bring to the NHS.

Adam Wildman is research manager at ResPublica 

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Should feminists talk about “pregnant people”?

Two writers present the arguments for and against.

NO

“I’m not sure what the public health issue is that would require a focus only on those who become pregnant, as opposed to any of those involved in pregnancy, either becoming pregnant or causing someone else to become pregnant,” Dr Elizabeth Saewyc, a Canadian professor in nursing and adolescent medicine at the University of British Columbia, recently told journalist Jesse Singal when he asked her for clarification on a study she conducted into trans youth and pregnancy.

Her statement is, on the face of it, extraordinary: unlike those who “cause someone else to become pregnant” (males), those who “become pregnant” (females) actually, well, become pregnant, with everything that entails from the risk of varicose veins and pre-eclampsia, to having an abortion or being denied abortion, to miscarriage or giving birth and living with the economic strain and social discrimination that come with motherhood.

As absurd as Saewyc sounded, her position is the logical endpoint of “gender neutral” language about pregnancy. Pressure on reproductive rights groups – especially those in the US – to drop references to “women” and instead address themselves to “people” have been growing over the last few years, and the American body Planned Parenthood now regularly mentions “pregnant people” in its communications. In theory, this is supposed to help transmen and non-binary-identified females who need reproductive health services. In practice, it creates a political void into which the female body, and the way pregnancy specifically affects women, simply disappears.

The obscuring of the female body beneath obscenity and taboo has always been one of the ways patriarchal society controls women. In 2012, Michigan Democratic representative Lisa Brown was prevented from speaking in a debate about abortion after she used the word “vagina”, which Republicans decided “violated the decorum of the house”. Now, that oppressive decorum is maintained in the name of trans inclusion: in 2014, the pro-choice organisation A is For was attacked for “genital policing” and being “exclusionary and harmful” over a fundraiser named Night of a Thousand Vaginas.

Funnily enough, trans inclusion doesn’t require the elimination of the word vagina entirely – only when it’s used in reference to women. A leaflet on safe sex for trans people published by the Human Rights Campaign decrees that “vagina” refers to “the genitals of trans women who have had bottom surgery”; in contrast, unaltered female genitals are designated the “front hole”. And it’s doubtful that any of this careful negation of the female body helps to protect transmen, given the regular occurrence of stories about transmen getting “unexpectedly” pregnant through having penis-in-vagina sex. Such pregnancies are entirely unsurprising to anyone who knows that gender identity is not a contraceptive.

It does, however, protect from scrutiny the entire network of coercion that is cast over the female body: the denial of abortion rights in the Republic of Ireland, for example, affects the same class of people who were subjected to the medical violence of symphysiotomy — a brutal alternative to cesarean, which involves slicing through the cartilage and ligaments of a pelvic joint to widen it and allow a baby to be delivered — the same class of people who were brutalised by Magdalen Laundries (institutions established to house “fallen women” which operated from the late 18th to the 20th centuries), the same class of people who are subject to rape and sexual harassment. That class of people is women. If we give up the right to name ourselves in the service of “inclusion”, we permit the erosion of all our hard-won boundaries.

Sarah Ditum is a journalist who focuses on feminism.

YES

No matter who you are and how straightforwardly things go, pregnancy is never an easy process. It might be a joyous one in many ways, but it’s never comfortable having to lie on your back in a brightly lit room with your legs hitched in stirrups and strangers staring at parts of your anatomy some of them hesitate to name. Then there are the blood tests, the scans, the constant scrutiny of diet and behaviour – it may be good practice for coping with a child, but the invasion of privacy that takes place at this time can have a dehumanising effect. And that’s without having your gender denied in the process.

If you’ve never experienced that denial, it might be difficult to relate to — but many women have, at one time or another, received letters addressing them as “Mr” or turned up at meetings only to discover they were expected to be men. It’s a minor irritation until it happens to you every day. Until people refuse to believe you are who you say you are; until it happens in situations where you’re already vulnerable, and you’re made to feel as if your failure to conform to expectations means you don’t really deserve the same help and respect as everyone else.

There is very little support available for non-binary people and trans men who are happily pregnant, trying to become pregnant or trying to cope with unplanned pregnancies. With everything geared around women, accessing services can be a struggle, and encountering prejudice is not uncommon. We may not even have the option of keeping our heads down and trying to “pass” as female for the duration. Sometimes our bodies are visibly different.

It’s easy for those opposed to trans inclusion to quote selectively from materials making language recommendations that are, or appear to be, extreme – but what they miss is that most trans people going through pregnancy are not asking for anything drastic. We simply want reassurance that the people who are supposed to be helping us recognise that we exist. When that’s achievable simply by using a neutral word like people, does it really hurt to do so? I was always advised that manners cost nothing.

Referring to “people” being pregnant does not mean that we can’t also talk about women’s experiences. It doesn’t require the negation of femaleness – it simply means accepting that women’s rights need not be won at the expense of other people’s. We are stronger when we stand together, whether pushing for better sex education or challenging sexual violence (to which trans men are particularly vulnerable).

When men criticise feminism and complain that it’s eroding their rights, this is usually countered with the argument that it’s better for everyone – that it’s about breaking down barriers and giving people more options. Feminism that is focused on a narrow approach to reproductive biology excludes many women who will never share the experience of pregnancy, and not necessarily through choice. When women set themselves against trans men and non-binary people, it produces a perfect divide and conquer scenario that shores up cis male privilege. There’s no need for any of that. We can respect one another, allow for difference and support the growth of a bigger feminist movement that is truly liberating.

Jennie Kermode is the chair of the charity Trans Media Watch.