On the morning of Wednesday 20 October 2010, as I did every weekday, I logged onto a forum when I was supposed to be working as an administrator for Brighton & Hove’s NHS Primary Care Trust (PCT) and scanned the first few topics. “Is everyone lubed up and ready for Gideon’s comprehensive spending review?” began one post, referring to George Osborne’s extra £7bn of welfare and public service cuts, about to be announced after six months of Conservative-led coalition which had so far spoken much of austerity and the need to curb government spending, endlessly parroting its “all in this together” rhetoric, but which had so far only announced one of the swingeing reforms that had been feared.
“No need,” I replied. “They’ve done us.”
On 12 July, one year after chief executive David Nicholson had declared that the NHS needed to make £20bn of efficiency savings in the next four years, new Secretary of State for Health, Andrew Lansley, had issued the white paper that would later become the Health and Social Care Bill. Entitled Equity and Excellence: Liberating the NHS – echoing George W Bush’s linguistic contortions to justify the invasion of Iraq – it outlined the most radical top-down reorganisation since the NHS was founded in 1948, in direct contravention of David Cameron’s pre-election promise that his Conservative Party would do no such thing.
The main ideological change was that the Secretary of State for Health’s obligation to “provide a nationwide, universal service” would become a duty merely to “promote” it. More practically, the paper announced that the PCTs, which commissioned services from public, private or third sector providers, as well as managing GPs, nurses, hospitals, mental health services, patient transport, screening, dentists, pharmacists and opticians, and ensure close links between local health organisations and authorities, would be abolished in favour of Clinical Commissioning Groups (CCGs) led by doctors rather than specialist commissioners.
We were stunned. There had been no indication that this was going to happen, after David Cameron’s promise, made before the General Election, that his Conservative Party would “cut the deficit, not the NHS”, and the commissioning teams were angry and scared. On the whole, we liked our jobs – in particular the chance to do innovative work with intelligent people – and didn’t want to lose it. In clandestine chats, we asked: what was their mandate? What would this mean for us? Let alone the service? When would that discussion even start?
For now, we had to follow it like everyone else, through newspapers and that were trying to make sense of the announcement. It was presented as putting GPs in charge of the £70bn budget, just as the opening of the competitive tendering process of services to “Any Willing Provider” from the voluntary, third and private sectors was sold as increasing patient choice. The continued role of public funding allowed Lansley to argue that this wasn’t privatisation, although from the inside, it was clear that taxpayers’ money would be used to fund an organisation through which services were bought from profit-making providers, increasing their role until the concept of the NHS became meaningless.
This concept – of a publicly-funded service that would be free at the point of use – had been compromised from the start through its part-funding by prescription charges, and then the removal of free dentistry and eye tests in 1951. Indeed, the 1946 NHS Act, on which the service was based, made provisions for private patients to be treated in public hospitals. The numbers fluctuated over time, but in 2006 a cap had been set to cap private income at the levels of three years earlier – for most hospitals, this meant 2 per cent, but in a handful of cases, it went as high as 22 per cent. Those reforms allowed a limited level of private involvement in order to protect the fundamental principle: the white paper proposed the removal of this cap, a change that worked in a completely different spirit.
It also proposed that public health services be taken over by local Councils: I’d started in Health Promotion, a sub-set of Public Health, but as I’d moved into Primary Care Commissioning, effectively working as a Personal Assistant to two women but labelled a Team Administrator to keep me in a lower pay band, I would be staying with the majority of my colleagues in whatever the PCT would become.
Two things, I realised, had allowed Lansley to float these reforms to a manageable level of opposition: popular suspicion towards any perceived bureaucracy; and the arcane nature of NHS management.
In October 2008, out of principle, I registered with a temp agency who specialised in public sector jobs, and they sent me on various dead-end assignments – a fortnight at a mental health hospital here, a month in the Council’s parking department there. Even if my roles lacked focus, the purpose of these institutions was obvious, so I was surprised when they offered me a contract with a Primary Care Trust, as I had no idea what that was.
The PCT, I was told, was the central management function of the city’s health services. I’d have known this if I’d paid more attention in the Government and Public Affairs module of the NCTJ course I’d finished earlier that year, when we’d had a baffling and boring hour about the structure of the NHS which I’d instantly forgotten. Perhaps this was because I’d internalised that opposition to “bureaucracy”, finding it far less inspiring that my undergraduate History lessons covering Aneurin Bevan’s battle to found it. Replacing the old district and regional health authorities, the PCTs were set up in July 2000 under the Labour government’s NHS Plan. There were 152 PCTs, answerable to 28 Strategic Health Authorities which covered larger regions – in part, they were a delayed response to the NHS and Community Care Act 1990, which created an internal market where health organisations bought services from each other.
The 1990 Act also introduced GP fundholding, aiming to detach government from responsibility for clinical services; this was optional, and abolished in 1999. In its place, Labour promoted “Practice Based Commissioning” to involve GPs in service provision, the idea being that they would know best what their patients needed. But, as Charles West points out in his chapter of NHS SOS (published by Oneworld Publications last year), demands varied wildly across practices and GPs weren’t experts on specialist services, and didn’t have time to become so, let alone fulfil the PCT functions while still looking after their patients.
In the same volume, Stewart Player explains how Tony Blair’s government introduced private insurers into the NHS through the World Class Commissioning programme, which would involve companies such as UnitedHealth, McKinsey, Aetna and BUPA in service planning, “reconfiguration” (which, Player says, usually means cuts) and referrals. This motivation was hidden behind Orwellian language: the Department of Health’s archived webpage on WCC, one of the numerous acronyms that populated our working landscape, talks plenty of “transforming the way health and care services are commissioned” with little concrete detail.
More obvious – and more resented – was the presence of management consultants, with rumours about how much they got paid more prevalent than any understanding of what they actually contributed, besides endless repetitions of buzzwords such as “going forward”. (“He gets £700 a day,” someone once whispered to me, looking at a consultant, “and just sits on the internet!”) Their costs and benefits were the subject of a House of Commons Health Committee report (pdf) in April 2009, stating that junior consultants from a range of firms could cost £400-£500 per day, and seniors over £1,000. Nicholson defended this on the grounds that while they did not generate ideas to improve the service’s financial balance, they brought the skills to carry out cost-saving schemes ratified by NHS staff.
All this reminded me of the three years I’d spent doing dismal data entry assignments from 2004-2007 at Legal & General – one of the major ex-student recruiters in Brighton & Hove along with American Express and Lloyds TSB – during which I felt like the archetypal Blairite “graduate without a future”, wasting my days doing the work which, as my friend Matt put it, “the computer finds too boring” because the company’s expensive system didn’t check tax figures sent to policy holders properly. Besides making me never want to work in the private sector again, it taught me that the Tory line about the private sector being more efficient was bollocks: after six months of verifying pension providers with three other temps, I was told that the task had been pointless, but to complete it anyway. The lie about efficiency worked purely because private finance is never held up to the same scrutiny as public funding – and because it was (and still is) presented as fact in the mainstream media.
Despite the creeping corporate culture, I found the PCT environment infinitely preferable: I soon made friends, sharing a sense of humour and political outlook with many of my co-workers. Being alongside people who’d started as administrators and worked their way up to become project managers or commissioners, I felt like I had a future for the first time, and that I was working for the wider good. I took minutes at meetings on everything from smoking cessation to sexual health, with commissioners discussing innovations such as the introduction of opt-out HIV testing in GP surgeries with doctors and local sexual health services.
Feeling supported by Human Resources, I started my transition there, and then sat on the Trans Health and Wellbeing Strategy Group with several commissioners, the Equality and Diversity Manager, and people from Brighton & Hove City Council, Sussex Partnership Mental Health Trust and Spectrum, which informed, consulted and represented the city’s LGBT community. The PCT’s Transgender Working Group had devised the local reassignment pathway which referred people to the Gender Identity Clinic (GIC) in London, and there were questions about that, but this group allowed us to focus on wider issues: safe housing; relations with the police and other public bodies; support for trans people in employment; and access to physical, sexual and mental health services. Ambitiously, we aimed to secure funding for trans groups such as the Clare Project drop-in centre, better training for GPs to meet our needs, and possibly even a local gender identity clinic. In the meantime it allowed us to air our concerns directly to the South East Coast Commissioning Group, who worked with the GIC in London. It felt like a stable, settled environment, run in the best interests of the people, aiming to ensure not just that their basic needs were met, but also to explore possibilities for better futures – but that was about to change.
Just after the financial crash of summer 2008, there had been this saloon-bar wisdom that public sector jobs were safe under Labour, even if the Tories had been pushing for a General Election after Gordon Brown became Prime Minister and were certain to win the next scheduled one in May 2010. Despite the right-wing media insisting that Brown was responsible for the global economic disaster, the Conservatives couldn’t secure an outright majority, and I briefly let myself hope that the Liberal Democrats might form a coalition with Labour (still just about the lesser of two evils, I thought) before Nick Clegg opted to side with David Cameron. The day that Cameron took office, I wore black to work: one of the few Tories in our office laughed at me, triumphantly, making the weird assumption that my loathing of her party must mean I was a Labour partisan. Before it got too ugly, an older colleague broke us up, telling us that “we’ll have plenty of time to discuss this in the dole queue”. We talked about something else, trying not to think about how right he might be.
I’d not believed that the NHS would remain untouched, especially after Tory MEP Daniel Hannan told Fox News that the service was “a sixty-year mistake”. The Conservative Party distanced themselves from Hannan’s comments, less out of ideological disdain, perhaps, than because they let the mask of commitment to public healthcare slip. As Michael Portillo told Andrew Neil in 2011: “[The Conservatives] did not believe they could win an election if they told you what they were going to do because people are so wedded to the NHS”. Given that they still didn’t win, I was taken aback by the rapidity with which the white paper was issued – clearly, it had been planned for years.
Despite its fact sheet boasting that “We’re removing targets that tie NHS staff up in red tape and we’re getting politicians out of decision-making”, the opposition to Lansley’s proposals was vociferous. Labour’s Shadow Secretary for Health, Andy Burnham, said it would “unpick the very fabric of the NHS”, while Dr Sarah Wollaston, a former GP who had become Conservative MP for Totnes, later remarked that it was like “tossing a hand grenade” into local healthcare structures. Wollaston also worried that the Clinical Commissioning Groups were “doomed to fail” with their function then likely to be handed to the private sector – perhaps, I thought, through management consultants.
I spoke to several GPs who regularly visited our offices. The most interesting counterpoint I heard to Lansley was that doctors were one of the last groups who were broadly liked: few trusted politicians, journalists, the police, or other public figures, but people respected their medical knowledge, forming warm relationships with their GPs. This doctor told me that “this depends on our separation from commissioning” – in future, GPs could no longer tell patients that they weren’t responsible for flaws in the services they used, and as was the case in the 1990s, had neither the expertise to commission services, nor time to learn.
In practice, it was unlikely that would GPs remain in charge of the budget rather than outsourcing it, either to former commissioners, or management consultants – something that would make the resultant loss of trust even more galling. They were already involved with weekly GP-led commissioning sessions, but my job of trying to organise further conversations with senior PCT staff about the reforms was almost impossible given how little space they had in their diaries, meaning that my irritation at repeatedly setting up and then cancelling meetings compounded my fury at being demanded to help facilitate the changes.
Like me, many of the staff could have earned more money in the private sector but worked for the NHS because they believed in the concept. Saddened and humiliated, they tried to continue with their programmes, meeting the slashing of healthcare budgets and the two-year pay freeze on any public sector worker earning over £21,000 per year with anger, resignation and gallows humour. (My one consolation was that my salary could still go up.) The commissioners knew they would be accused of self-interest if they criticised the proposals, and anyway, there was little point: long before the white paper was introduced to Parliament, we had attended several meetings at a nearby hotel to discuss our new structure.
There were audible gasps and moans when it was first unveiled: it was weighted so heavily in favour of corporate governance that it had to be revised after commissioners, many of whom clearly stood to lose their jobs, took their complaints to the union. When one director told us of her impending move to the Middle East, stating that her job would be kept open for her even though she wasn’t sure she’d want it again, a friend suggested that we “go and kick the fuck” out of anyone who’d voted Tory – that impotent rage felt like all we had left.
To bring down staff numbers, we were told that anyone who left would not be replaced unless they were “mission-critical”, with their workloads absorbed by those who stayed. We were invited to apply for the Mutually Agreed Resignation Scheme (pdf): not all applications would be accepted, but those who were would receive a pay-off, proportionate to how long they’d worked for the Trust, with the condition that they could not work for the NHS again for three months at least. Everyone remaining would re-apply for their jobs, often in competition with their colleagues as there would be fewer posts, with those who missed out being made redundant.
This prevented me from considering any action; there was little I could do anyway, besides refuse to organise meetings, which would mean that my re-application for my own job would likely be declined. By then, I was writing about my gender reassignment in the Guardian, relying on the Gender Identity Clinic whose practices I was documenting to provide access to hormones and surgery, and anxious that this might jeopardise them: I desperately wanted to use that platform to cover these changes to our working conditions, but to put my increasingly precarious job at risk through my journalism felt like piling too much pressure on myself. So I stayed, now feeling myself thoroughly complicit, but my hopes of combining my writing with a commissioning career were shot: the ladder that might allow a climb from my Band 4 administration post via Band 5 and 6 project management positions was taken away, as I never got to take the training for those that had been offered just before Equity and Excellence was published.
Once this was done, the predominant sense was one of confusion. Commissioners in meetings talked endlessly of “the new world” without any real idea of what that would look like, and disagreed (sometimes bitterly) over how much we should be opposing the reforms, with the organisation being renamed NHS Brighton & Hove and then NHS Sussex as it merged with other former PCTs to cover a larger area with increasingly overworked staff. The emphasis was put far more on patient survival, with any work that might improve quality of life being postponed. I asked the Equality & Diversity Manager if we’d do any more work on the Trans Strategy Group: it was not abandoned but on ice, he said, although I didn’t expect to hear any more of it. Soon after, the Spectrum LGBT forum which organised and invited local community members was disbanded, and I wondered how many other similar projects were lost, delayed or scaled down across the country. (Most of this work, at least, was eventually done by the Council (pdf), three years later.)
The white paper was introduced in Parliament as the Health and Social Care Bill (pdf) in January 2011, and the opposition intensified: the British Medical Journal called it “Dr Lansley’s monster” whie the Royal College of Nursing attacked the removal of the cap on private income, which was eventually re-set – at 49 per cent. In response, several colleagues and I travelled to London for the Trade Union Congress protest against the coalition’s cuts two months later, but it felt futile, and not just because of the lingering memory of how Blair had blithely ignored the mass movement against the Iraq war. Following the pre-agreed route, heavily policed until we got to Hyde Park, we marched in the sad knowledge that persuading the electorate that the NHS reforms were aiming towards privatisation would be difficult: although we knew that Lansley was destroying its foundations, we couldn’t be clear on exactly how they would affect healthcare provision, so how could we put forward a persuasive critique?
The creation of the NHS is perhaps the greatest example of a British government doing exactly what it should: standing up to commercial interests to create something that improves the lives of those who elected it, despite Britain then being as ideologically committed to free trade, and as bankrupt, as it was in 2010. Now, the idealism of Aneurin Bevan and the left wing of Clement Attlee’s Labour Party seems worlds away from the brutal selfishness that underpinned the radical conservatism of Margaret Thatcher and her successors, including Tony Blair, whose Public-Private Partnerships and Private Finance Initiatives effectively ended any parliamentary resistance to large-scale corporate investment in the NHS. Blair’s government outsourced radiology, surgery and transport services, along with cleaning contracts (meaning that I started my first job, as a Domestic Assistant at East Surrey Hospital in 1997, working not for the NHS like my mother, but the private sector). His administration also made plans to hand over commissioning to management consultants through the Framework for procuring External Support for Commissioners scheme and it’s hard not to feel that the compromises and cultural changes enacted by New Labour made the post-2010 devastation a formality.
Using rhetoric that curiously echoed that of Hungarian Stalinist dictator László Rakosi, Thatcher boasted of slicing things she opposed like salami – piece by piece, each cut seeming too small to oppose until nothing remains. Her Conservative successors have moved beyond salami tactics: perhaps expecting just one term, they have tossed a hand grenade into the welfare state, confident that effective opposition from the radical left, the unions, the Labour Party, or even moderate right-wingers has been crushed, aware that resistance will be less effective if it has to fight every battle at once. This is especially true in the NHS: the endless struggles needed to prevent individual hospitals and services from closure keep campaigners away from the war over the concept, not least as it’s easier to rally people behind local concerns than structural ones.
Make no mistake, though: these reforms, for which nobody voted, are as big an affront to democracy as the invasion of Iraq or the corruption exposed by the Leveson Inquiry – certainly, the lack of any pre-election announcement and Lansley’s insistence that his plans did not mean privatisation aimed to stave off the popular revolt predicted by Tony Benn in Michael Moore’s documentary Sicko. Public satisfaction with the NHS and its GPs was recorded at record high levels before the election, and “consultation” on the white paper provoked 6,000 responses, nearly all negative, from patient groups, medical professionals, trade unions and public health experts. My colleagues and I knew that the ‘listening exercise’ that followed the outcry against the Health and Social Bill after was a sham – the changes it demanded were a fait accompli, no matter how hard Lansley had to work to force it through parliament.
The Tories had a well-rehearsed strategy to explicitly private the health service: run it down by starving it of funding and destroying its centre, constantly releasing negative stories until sufficiently few people retain what Bevan famously called “the will to defend” the NHS. But in 2010, they to be more subtle about their intention for the NHS than they had been with British Rail or British Gas, partly because those reforms failed to deliver the promised “choice”, or lower prices as a benefit of competition. The energy providers fixed rates between them, while the early years of privatised rail were marked by several high-profile disasters, the later by fare hikes that rose well beyond inflation, with passengers (or “customers”) more captive than ever.
The fight against this needed organised, high-level political support, and I desperately hoped that the Liberal Democrats might use their place in the coalition to torpedo the Bill. I was disappointed: Charles West describes how their Party constitution forbids “wrecking amendments”, and how Clegg’s negotiations failed to rescue the Secretary of State’s responsibility for healthcare – eventually the Bill removed the Secretary’s ability to direct either providers or commissioners, winning a battle that Thatcher had begun more than twenty years earlier. Members tried to submit an emergency motion against the Bill at the autumn 2011 party conference in Birmingham, but lost a vote on whether it should be discussed by 235 to 183.
Finally, on 20 March 2012, the Bill ascended through the Commons and became the Health and Social Care Act, predictably passing through the Lords – an investigation by the Daily Mirror suggested that forty had direct interests in NHS privatisation, while the Social Investigations blog speculated that this number may have been as high as 142.
Shortly after the Act was passed, Andy Burnham called for a future Labour government to scrap it, but European Union competition laws make it difficult for states to take privatised services back into public ownership, so the only route to additional revenue is through private medicine. By 2016, John Lister writes in NHS SOS, “commissioning support services” must be “externalised” (put out to tender), which will likely deliver them to consultancy firms such as Ernst & Young, Capita, PriceWaterhouseCooper and McKinsey, who gleefully predicted a £200bn UK healthcare industry by 2030.
It’s hard to place much faith in Labour, partly because of what Blair did to the health service but also because it’s becoming harder every day to envisage political challenges to corporate power, with the Tories ignoring calls to exempt the NHS from the Transatlantic Trade and Investment Partnership (TTIP) agreement with the European Union and the US and even the tamest reforms proposed to the lawless property market meeting with uproar from those invested in London’s scandalously high rents and house prices.
It’s vital, however, that such resistance is envisaged and enacted. Without wishing to be too nostalgic for the “spirit of ’45”, this is the point at which Labour must be brave and offer an alternative to Thatcherism. If Ed Miliband can put public healthcare (and housing) at the heart of their 2015 election manifesto, and find a way of conveying the need to repeal the Act through the tabloids, then there may yet be a little hope.
Which is desperately needed: “choice” under a private healthcare system would most likely be as meaningless as it has proved on the railways, with patients having no say over which franchises are awarded contracts, and no option but to use whichever wins them. Under such circumstances, prices would be unlikely to remain affordable, especially as “customers” can hardly refuse to use the services, and if there was any meaningful “choice”, most people would be kept too ill-informed or simply too ill to exercise it. The stakes, however, are even higher than wide-scale redundancies or the loss of treatment that is free at the point of entry. The moment at which a future Conservative government announces the privatisation of the NHS will constitute a huge ideological victory, and then, people like us will look back at the destruction of the PCTs, the blocking of access for the lesser-off to universities and the creep of private interests into schools as another crucial step in securing their hegemony, destroying the sites where alternatives to their ideology might even be discussed, let alone developed.
Before Lansley’s reforms were passed, I’d quit the Clinical Commissioning Group, having realised that my job would only become more unrewarding. I moved to London in October 2011 to try to establish myself as a freelance writer, but, aware that this had become more difficult than ever, needed regular work. My previous experience meant that I landed a temporary post at the Strategic Health Authority, NHS London. I arrived just after it had announced that 31 of London’s 38 CCGs would work with private firms for “intense organisation support” on governance, finance, market analysis and self-assessment tools; my contract, meanwhile, would be renewed on a monthly basis. With the future of the organisation unclear – it had originally been announced that the SHAs would be disbanded in 2012, but everyone knew that was now unlikely – I tried not to get too attached, keeping my distance from my new co-workers in the knowledge that we wouldn’t be around each other for long.
In March 2012, just as the Bill went to vote, it was hoped that the release of the Risk Register covering the impact of the reforms might sink them. It briefly struck me that I might be access this, or find someone within the SHA who could, and try to leak it – but I knew that this would result in losing my job, at best, and just wished that someone else might. No one did, and soon, ministers blocked its release. At the same time as the Bill became law, our financial year ended, and I was told that I would not be kept on. Days after yet another round of “leaving the NHS” drinks, I went to Tower Hamlets Jobcentre to sign on. Defeated and dispirited, I glanced sadly at my fellow claimants, or “customers” as we were starting to be called: we were all in this together, we understood, but some of us deeper than others, and sinking ever further.