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Putting the NHS out to corporate tender isn't working

The rota developed more gaps than an exceptionally holey piece of Emmental cheese.

A few years ago, our out-of-hours service was put out to competitive tender. The existing co-operative run by local GPs narrowly missed out on the new contract, coming an agonisingly close second to a private provider that I call “the Big Beast of the North”. The Big Beast won the bid with promises of slick organisation and a swanky service redesign. Our clinical commissioning group (CCG) chairman announced a new era of corporate professionalism; the amateurism of the former service would be put to shame.

It didn’t work out like that. In the decade that the GPs ran the co-op, we never had a shift unfilled. Once the Big Beast took over, the rota developed more gaps than an exceptionally holey piece of Emmental cheese. Doctors had to be flown in from other parts of the country to provide a skeleton service. The formerly loyal staff of administrators, drivers and screen-watchers – whose jobs were transferred under employment protection rules – began leaving in droves; several told me they’d had enough of the chaotic, unresponsive new management.

The CCG tried to calm nerves, citing the inevitable turbulence that comes with change. Everything would settle down, we were told. It never has.

Admittedly, the Big Beast has long since given up the expensive business of flying in doctors from elsewhere – we have become habituated to a chronically patchy service in which our local out-of-hours centre is closed as often as it is open. Staff turnover has remained exceptionally high, with new recruits alienated by unanswered emails, mistakes over pay and the faceless management that is supposed to be running the show.

The Care Quality Commission inspected a few months ago; three years into the contract, the service still “requires improvement” in safety, effectiveness and leadership.

The big corporate providers that have sprung up in the wake of the Health and Social Care Act 2012 – which opened the NHS to unfettered private competition – are exceptionally adept at writing bids. They employ large teams specifically to manage the paperwork involved, and they know exactly which phrases will tick the boxes that commissioners use when scoring applications. But our experience illustrates the yawning gap between what is promised and what is delivered once the contracts have been won.

It has been a painful lesson, but the constraints of the Health and Social Care Act render the learning futile. The tendering process prohibits commissioners from taking account of the track record of an incumbent provider. Nor are they permitted to put a value on the strength of existing working relationships, or the goodwill of staff.

When our community trust’s contract was put out to tender earlier this year (it runs district nursing, health visiting, cottage hospitals, and so on), it was like Groundhog Day. The local bid lost out to a big corporation. I was working at our cottage hospital last week; the desk in each consulting room had two PCs on it. The old ones, belonging to the former trust, were now defunct. The shiny new ones beamed the corporate logo screen saver, but no one had a log-in, so we couldn’t use them. The only operational PC was at the reception; I had to jot down patient details on paper, disappear to conduct my consultations, and then return to the reception to type up my notes.

The nurses next door in minor injuries were similarly hamstrung. They had been issued with smart lanyards in the corporate livery, but insufficient software licences had been purchased to allow them to use their new computers. No one was manning the IT desk when they rang for help and, they told me, there had already been problems with their pay.

Doubtless this is the inevitable turbulence that comes with change, and we can look forward to a new era of slick organisation and swanky service redesign. But it has an awful feeling of déjà vu about it. 

This article first appeared in the 13 July 2017 issue of the New Statesman, The Maybot malfunctions

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Want an independent-minded MP? Vote for a career politician

The brutally ambitious are not content to fall in with the crowd. 

“Never having had a ‘real’ job outside of politics”: this is what the majority of respondents told a YouGov poll in 2014 when asked the most undesirable characteristic of the British politician. The result is hardly surprising. Type the words “career politician” into your search engine or raise the topic at a dinner party, and quickly you will be presented with a familiar list of grievances.

One of the fundamental criticisms is that career politicians in parliament are elitists concerned only with furthering their own interests. Their pronounced and self-serving ambition for climbing the ministerial ladder is said to turn them into submissive party-machines, sycophants or yes men and women, leading them to vote loyally with their party in every parliamentary division. But do we actually have evidence for this?

A new in-depth analysis, to be published later this month in the academic journal, Legislative Studies Quarterly, presents a forceful challenge to this conventional wisdom. In fact, I find that career politician MPs in the UK are more likely to rebel against their party than their non-career politician peers. Why?

My study was motivated by the observation that the existing impression of the party loyalty of career politicians is based mostly on anecdotal evidence and speculation. Moreover, a look through the relevant journalistic work, as well as the sparse extant academic literature, reveals that the two main hypotheses on the topic make starkly contradictory claims. By far the most popular — but largely unverified — view is that their exclusively professional reliance on politics renders career politicians more brutally ambitious for frontbench office, which in turn makes them especially subservient to the party leadership.

The opposing, but lesser known expectation is that while career politicians may be particularly eager to reach the frontbenches, “many of them are also much too proud and wilful to be content to serve as mere lobby fodder”, as the late Anthony King, one of the shrewdest analysts of British politics, observed nearly thirty years ago on the basis of more qualitative evidence.

Faced with these opposing but equally plausible prognoses, I assembled biographical data for all the MPs of the three big parties between 2005-15 (more than 850) and analysed all parliamentary votes during this period. I followed the debate’s prevalent view that an exclusive focus on politics (e.g. as a special adviser or an MP’s assistant) or a closely-related field (e.g. full-time trade union official or interest group worker) marks an MP as a careerist. In line with previous estimations, just under 20 per cent of MPs were identified as career politicians. The extensive statistical analysis accounted for additional factors that may influence party loyalty, and largely ruled out systematic differences in ideology between career and non-career politicians, as well as party or term-specific differences as drivers of the effects.

As noted above, I find strong evidence that career politician backbenchers are more likely to rebel. The strength of this effect is considerable. For example, amongst government backbenchers who have never held a ministerial post, a non-career politician is estimated to rebel in only about 20 votes per parliament. By contrast, a career politician dissents more than twice as often — a substantial difference considering the high party unity in Westminster.

This finding reveals a striking paradox between the predominantly negative opinion of career politicians on the one hand, and the electorate's growing demand for more independent-minded MPs on the other. In fact career politicians are the ones who perform best in delivering on this demand. Similarly, the results imply that the oft-cited career-related dependency of career politicians on the party can be overridden (or, at the very least, complemented) by their self-image as active and independent-minded participants in the legislative process. This should attenuate the prevalent concern that a rise in career politicians leads to a weakening of parliament’s role as a scrutinizing body.

Finally, the findings challenge the pervasive argument that a lack of experience in the real world disqualifies an MP from contributing meaningfully to the legislative process. Instead, it appears that a pre-parliamentary focus on politics can, under certain circumstances, boost an MP's normatively desirable willingness to challenge the party and the executive.

Raphael Heuwieser is researching political party loyalty at the University of Oxford.