Excluding vulnerable patients from the NHS
In June 2019, the candidates in the Tory party leadership were quick to distance themselves from innuendo that the NHS market could be opened up as part of future trade negotiations with the US. Yet, that hasn’t stopped us from quietly experimenting on the vulnerable and disenfranchised. Substance misuse services were, in effect, privatised over a decade ago. There is nobody to shout and scream for them. No newspaper headlines excoriating the architects. Clare Gerada is a notable exception. In 2011, as Chair of the College, she highlighted how users are: ‘Rejected by the health service. They are the unworthy ill.’ 1
The Advisory Council on the Misuse of Drugs published a report in September 2017 on the commissioning of substance misuse services.2 The findings were damning: re-procurement is damaging care before, during, and after commissioning for prolonged periods. It’s been a race to the bottom and short contracts perpetuate the dismal cycle. Valued staff leave the system and barriers are created between core NHS services for ageing users who desperately need high-quality primary care. The churn has devastated continuity of care and, although it scarcely seems possible, marginalised this group further.
The freedom to be denied life-saving medicine
Neoliberalism is an all-pervasive creed, an ideology, and it has become so successfully ingrained into our thinking that we barely even acknowledge it. Since Thatcher’s era it has become normalised. Chant robotically after me: the markets know best. The central fallacy of neoliberalism is that economic freedom and political freedom are bound together. It is a powerful message that resonates with many people.
Yet, what’s often on offer is the freedom to be refused health care if the market decrees you unprofitable, the freedom to be made homeless, or the freedom to be denied a life-saving medicine such as methadone and die of an overdose.
Powerful forces are lined up in support of neoliberal policies and they pose an existential threat to the NHS.
The Adam Smith Institute, a powerful think tank that refuses to reveal its funders, is openly neoliberal. It was a significant player in the establishment of GP fundholding and the opening of an internal market in the NHS. It supports the abolition of national pay bargaining that will pit trust against trust as they compete for staff. Across the board it advocates increased competition and private provision in the NHS.
Commissioning is a neoliberal beachhead
Substance misuse services bear the scars of long years of privatisation and we would do well to regard them as the canary in the coal mine.
The Health and Social Care Act 2012 extended market-based approaches and there is evidence that this resulted in more contracts being awarded to private providers,3 although the King’s Fund has pointed out that overall NHS spend on private contractors seems to be static at around 10.9%.4 I remain wary of commissioning. It is an essential requirement of high-quality primary care that we have some measure of control over the services we provide to communities, yet often commissioning looks like a fortified neoliberal beachhead on the NHS coastline.
We have to build the case for evidence-based policies that achieve more than enriching the rich; the most vulnerable should never be allowed to be the subject of creeping privatisation. The UN report from the Special Rapporteur, Philip Alston, on extreme poverty and human rights found that 1.5 million in the UK experienced destitution in 2017.5 He suggested the social glue has been replaced by a ‘harsh and uncaring ethos’. It’s the inexorable logic of the market. We are all consumers now: consuming goods, consuming the planet, consuming the most vulnerable.
This is the bleeding edge of neoliberalism at its most pernicious.
- © British Journal of General Practice 2019
REFERENCES
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(2018) Is the NHS being privatised? (King’s Fund), .
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