Could Disobedience Be the Path Ahead?

By Howard Waitzkin, M.D., Ph.D.
Medscape, May 20, 2016

“A person can become free through acts of disobedience by learning to say no to power…. At this point in history the capacity to doubt, to criticize and to disobey may be all that stands between a future for mankind and the end of civilization.”

– Erich Fromm, On Disobedience¹

Disobedience

I confess: I am a disobedient doctor.

After a career in academic medicine and public health, I decided to work part-time in a rural health program. There I began to understand the loss of control over the conditions of medical practice that has affected so many doctors. Administrative demands multiplied and constrained my ability to care for my patients in the ways I thought best.

So I decided to disobey. A seemingly minor training requirement for the International Classification of Diseases, 10th edition (ICD-10), became the administrative demand that pushed me over the line to disobedience. But the struggle might have involved any other segment of clinical medicine, where employer mandates infringe on a doctor’s freedom to practice.

Proletarianization

Intrinsically, I have nothing against being a proletarian. I supported much of my education by working as a proletarian—for instance in a tire factory, where I learned first-hand about life as a worker in our capitalist society. Throughout my medical career, I have befriended many “nonprofessional” health workers—wonderful people whose services usually go underappreciated. Such people spend most of their waking lives doing tasks assigned by supervisors, and they enjoy little or no control over the conditions and rhythm of their work.

Medicine, I thought, would provide a way to seize control of my own work process and creativity by organizing at least a large part of the work week as I preferred. A position in academic medicine actually did allow me that liberty, despite the challenges of university bureaucracies—though there, too, autonomy started to erode, a phenomenon usually linked to financial shortfalls and measures of productivity.

However, entering the world of a nonacademic medical employee revealed the awesome scope of proletarianization—a change in doctors’ previous social class position. Until the 1980s, doctors for the most part owned or controlled their means of production and conditions of practice. Although their work often was challenging, they could decide their hours of work, the staff members who worked with them, how much time to spend with patients, what to write about their visits in medical records, and how much to charge for their services.

Now the corporations for which doctors work as employees usually control those decisions. Loss of control over the conditions of work has caused much unhappiness in the profession. Early on, an esteemed clinician and mentor described medical proletarianization when it was first emerging as “working on the factory floor.”² Most doctors have become highly paid employees of hospital and health system corporations,³ and around one half of doctors report feeling burned out.^4,5 Owing to the mystique of professionalism and their relatively high salaries, doctors often do not realize that their discontent reflects in large part their changing social class position.

Deciding to Disobey

As a doctor-worker, I got into trouble by expressing concerns about the training that our health network (hereafter, referred to as “OHN”) was requiring for ICD-10 implementation. Until then, I had received praise and little negative feedback, and had just been reappointed.

OHN had contracted with a corporation (hereafter, “$Corp”) to help cope with the transition to ICD-10. This corporation was one of hundreds that have emerged to sell consulting services to healthcare organizations facing the challenges of information technology. Such challenges include electronic health records (EHRs), quality assurance, accountable care, and similar arenas. All involve “metrics” that try to make quality quantifiable, a goal that has generated wide debate.

$Corp’s training for ICD-10 took multiple hours of unpaid time, and I decided to disobey the requirement. One reason involved my desire to spend time with a dying friend, which made me even more aware that each moment of life is too precious to waste.

After I previewed the $Corp training, I concluded that its educational quality was poor and that it implicitly encouraged “upcoding,” which could generate more payments for OHN. Brief discussions with other practitioners confirmed universal contempt for the training, as well as disgruntled universal compliance. I decided to protest the training.

The Slippery Slope to Fascism

My subsequent interactions with OHN administrators surprised me, despite my knowledge about medical proletarianization. The chief medical information officer (CMIO) at OHN wrote that “Practitioners with incomplete ICD-10 coursework at midnight on 10/7/15 will be suspended until the coursework is completed.” In response, I sent an email message asking him to explain the rationale for the training requirement. Copying the chief executive officer (CEO), the CMIO pasted his responses into the text of my original message:

1. Please provide evidence that additional training in ICD-10…improves any measurable patient outcomes, costs, or collections.

Not a debatable point. This is a requirement by OHN, so, sorry to say, whether you agree with it or not, it must be done.

2. Please provide the costs to OHN for the training.

Not relevant, as this is a requirement.

3. Please provide quantitative estimates of the financial benefits of the training for OHN.

Not relevant, as this is a requirement.

4. Please give a concrete description of the process by which you concluded that “completion of this training allows us to achieve both appropriate care and remain fiscally responsible—part of OHN stewardship.”

Not relevant, as this is a requirement.

This response pressed one of my alarm buttons, which I might call the “fascism button.” In my response, I explained the slippery slope to fascism,⁶ when people do what they are ordered in their jobs without understanding why. Such unjustified requirements, I argued, deserve our conscientious questioning and sometimes noncompliance.

Standardization

The CMIO was unimpressed with my argument about incipient fascism in the workplace, so I next appealed to practicality. I proposed coming to the office, unpaid, and practicing ICD-10 within our EHR. His reply? “OHN’s transformation is a movement to ensure process consistency and standardization…. Therefore, your request for an ‘exception’ is outside the organization’s expectation.”

Again, the CMIO’s reply pressed an alarm button. I must behave like an automaton in a medical assembly line, “the factory floor” foreseen by my mentor.

I then requested a face-to-face meeting and details about my forthcoming suspension—including, most importantly, a plan of coverage for my patients. I repeated my concerns about authoritarianism in the medical workplace and the extensive evidence that standardization actually may reduce quality, creativity, and productivity.

Punishment

My moral predicament deteriorated quickly. On the next morning, the CEO sent an email message asking for my resignation effective within 1 week, despite packed schedules that included many unstable patients. Then, 5 days before the deadline for suspension, I received a letter stating that my office hours with patients had been canceled until further notice. Because I needed to respond to lab results and urgent messages, I tried to connect with the EHR but found that I had been cut off.

I now faced the apparent abandonment of hundreds of my patients, many of them unstable, who had not received any alternative plan of care. Medical abandonment is unethical according to the American Medical Association Code of Ethics⁷ and is illegal in many states. I contacted the chief of the medical staff, who got me reconnected to the EHR so that I could manage acute problems for my unstable patients.

Because I was not willing to abandon my patients, I also persuaded an administrator to get me reconnected to the ICD-10 training, which I completed under protest late the next night. On the following morning, a Sunday, I received an email message from the CEO thanking me for completing the training and stating that my breach of contract had been “cured.”

Redemption

As a doctor-worker, I faced a challenging ethical situation that included loss of professional autonomy, authoritarian practices in the workplace, and apparent abandonment of patients. My first suspension in more than 40 years of practice also raised concerns, such as: Would a report about the suspension from OHN to the National Practitioner Data Bank affect my medical licenses or ability to practice in other settings? Was it my responsibility to blow the whistle on OHN’s practices to licensing, accreditation, and insurance agencies?

My small act of conscientious disobedience eventually led to some unexpected responses. My contract and state law required that OHN convene an external review to examine possible interference with my professional judgment, and the coordinator of the state agency that licenses health facilities expressed willingness to investigate this issue and the abandonment of patients.

Facing the probability of external review, the CEO finally met with me in person, and I proposed a formal mediation process. Instead, the CEO composed a document that included an apology, a statement that information about breach of contract would be removed from my personnel file, a commitment to consider individual physicians’ preferences in meeting future training requirements, and a promise to meet individually with a physician when a suspension is considered so that patient care would not be disrupted.

Where is the path toward a noncorporatized vision of what we know medicine can be at its best? I don’t think that path involves our continuing acquiescence. I confess that I have decided to approach these problems through personal acts of disobedience. For a person like me, closer to the end of my medical career than the beginning, such acts don’t risk much. For others, overcoming the risk will require a more organized approach to disobedience.⁸ Dare I encourage disobedience in unison? To paraphrase someone else: Doctor-workers of the world, unite!

Dr. Howard Waitzkin is Distinguished Professor Emeritus of Sociology at the University of New Mexico and Adjunct Professor of Internal Medicine at the University of Illinois.

http://www.medscape.com/viewarticle/863297

Supplementary Material

“eDocuments of Disobedience,” available on request, includes memoranda intended as illustrations for doctor-workers to use when contemplating or executing acts of disobedience.

“Resources for Organizing Among Doctor-Workers” is available upon request and contain links to additional readings and pertinent organizations.

Acknowledgments

I am deeply indebted to my deceased friend, Mark Teismann, PhD, who provided inspiration, encouragement, and critical feedback for me as I wrote this article while he was dying; and to my partner and co-conspirator, MiRa Lee, MD, who offered constructive suggestions and reminders that disobedience can transform the world.

References

1. Fromm E. On Disobedience. New York, NY: Harper; 2010.

2. Stoeckle JD. Working on the factory floor. Ann Intern Med. 1987;107:250-251.

3. Peckham C. Medscape physician compensation report 2016. Medscape. April 1, 2016. http://www.medscape.com/features/slideshow/compensation/2016/public/overview?src=ppc_google_rem_salary&gclid=CJ_si83OqMwCFZKCaQodSlAH5w#page=1 Accessed April 24, 2016.

4. Peckham C. Medscape lifestyle report 2016: bias and burnout. Medscape. January 13, 2016. http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview#page=1 Accessed April 24, 2016.

5. Caplan AL. Physician burnout is a public health crisis, ethicist says. Medscape Business of Medicine. March 4, 2016. http://www.medscape.com/viewarticle/859300 Accessed April 24, 2016.

6. Arendt H. Eichmann in Jerusalem: A Report on the Banality of Evil. New York, NY: Viking; 1968.

7. American Medical Association. Opinion 8.115—termination of the physician-patient relationship. In: Code of Medical Ethics. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion8115.page Accessed April 24, 2016.

8. Scheiber N. Doctors unionize to resist the medical machine. New York Times. January 9, 2016. http://www.nytimes.com/2016/01/10/business/doctors-unionize-to-resist-the-medical-machine.html?_r=0 Accessed April 24, 2016.

By Steffie Woolhandler and David Himmelstein
The Huffington Post, May 22, 2016

Last week we posted a critique of the Urban Institute’s (UI) absurdly biased report that claimed Sen. Bernie Sanders’ proposal for single-payer health reform would cause a massive increase in health spending. Now, the report’s authors have issued a 12-page rejoinder to our criticism. But that response is riddled with distortions, misinterpretations and glaring factual errors. Moreover, they now make it clear that they didn’t even try to estimate the costs of Sanders’ (or our) single-payer proposals. Instead, they made up their own reform proposal and costed that out.

Our critique identified three main problems with the UI’s projection that implementing single payer would boost total health spending by $519 billion in 2017. First, UI ignored about 75 percent of the administrative savings that single-payer reform would achieve. Second, it substantially underestimated single payer’s savings on prescription drugs. And finally, it posited an absurdly large increase in the utilization of health care under single payer, far more than could possibly be provided by the current supply of doctors and hospitals.

Below, we briefly discuss the UI’s response to those criticisms, and the facts of the matter.

1. Administrative savings, Part 1: The original UI report projected that single payer could cut insurance overhead from the current 9.5 percent of health spending ($341 billion) to 6 percent ($215 billion). As they now admit, they were modeling a compromised single-payer system, in which private managed care insurers like UnitedHealthcare would continue to play a major role, as they do in the Medicare Advantage program. (Neither we nor Sanders have suggested such a continued role for private insurers.) We pointed out that Canada’s single-payer system runs for 1.8 percent overhead (a figure they impugn, but which is taken directly from Canada’s official health statistics), and is similar to the overhead in the traditional Medicare program. Reducing our insurance overhead to the Canadian level would mean cutting it to “only” $65 billion. There’s no reason to believe we can’t be as efficient as Canada if we, like Canada, proscribe participation by private insurers.

The UI rejoinder argues that “it would be inadvisable to cut administrative costs so much that important functions could not be carried out effectively under a new system. Such functions include rate setting for many different providers of different types facing different costs across the country; quality control over care provision; development, review, and revision of regulations; oversight for fraudulent activity; provider oversight and enforcement of standards; bill payment to providers; consumer services; and more.” Of course traditional Medicare (and Canada) are already doing all of those things, and the UI response gives no reason why $65 billion can’t do the job.

2. Administrative savings, Part 2: The original UI estimate projected that single-payer reform wouldn’t realize any savings on the vast amounts hospitals and doctors currently spend on billing and paperwork. Yet, Sanders’ (and our) proposals would enormously simplify this billing and paperwork. We noted that reliable studies published in the most respected medical and policy journals have documented these provider administrative savings, and that numerous single-payer estimates by the Congressional Budget Office, the Government Accountability Office and private consultants have all assumed that these savings would occur.

In response, our UI colleagues continue to project zero administrative savings for providers, but say: “We agree that administrative costs would fall, but we do not agree they would be close to zero as HW [Himmelstein and Woolhandler] assert.” Actually, we never asserted any such thing. We wrote that “U.S. hospitals spend one-quarter of their total budgets on billing and administration, more than twice as much as hospitals spend in single-payer systems like Canada’s or Scotland’s. Similarly, U.S. physicians, who must bill hundreds of different insurance plans with varying payment and coverage rules, spend two to three times as much as our Canadian colleagues on billing.” Our estimate that cutting U.S. providers’ administrative costs to Canadian levels would save about $2.57 trillion over 10 years was based on this well-established (and peer-reviewed) data.

3. Drug prices: The latest UI piece restated their conviction that a U.S. single-payer system could get only half the discounts that single-payer systems in other nations have gotten from drug companies (and would actually raise drug prices for patients currently on Medicaid). They continue to offer no reason why the discounts would be so small. Moreover, they now claim that Himmelstein and Woolhandler “argue incorrectly that we ignored savings from paying less for prescription drugs.” In fact we didn’t ignore their estimated savings, but said they should be two-fold higher than the 25 percent they projected.

4. Utilization of care, Part 1: The original UI report estimated that single-payer reform would cause a $519 billion increase in health spending in 2017, even accounting for some savings on administration and drugs. But we noted that there just aren’t enough hospital beds or doctors to meet the huge surge in visits and hospitalizations they predict. To back up our claim we cited data from Canada (when its single-payer reform was implemented) and the U.S. (when Medicare and Medicaid were implemented). These data document that no, or very modest increases in society-wide use of care, occurred, and that instead care shifted from the rich and healthy to the sick and poor.

In response, the UI rejoinder says: “Contrary to HW’s [Himmelstein and Woolhandler’s] claim in their article, health care use and spending for the elderly population did increase substantially once the Medicare program was implemented in 1965.” Here (as in their claim about our statement on providers’ administrative costs) they have misquoted us. We wrote that “between 1964 (before Medicare) and 1966 (the year when Medicare was fully functioning) there was absolutely no increase in the total number of doctor visits,” and that “the same thing happened in hospitals.” While we are well aware that utilization by the elderly and the poor went up after Medicare and Medicaid were implemented, the point is that there was a compensatory, slight reduction in utilization by other Americans, reflecting the limitations imposed by the existing supply of hospital beds and doctors (most of whom were already working full time).

Here’s the actual data on the number of doctor visits per person (not just the elderly) before and after Medicare/Medicaid:

And here’s the actual data on the total number of hospitalizations:

 

In sum, we were correct in stating that the overall utilization of care showed no surge.

5. Utilization of care, Part 2: We noted in our critique that the lack of a surge in overall utilization in Canada, or with the start-up of Medicare/Medicaid, reflected a shift of care, with the newly insured poor and sick patients getting more of the care they needed, and the healthy and wealthy getting less elective and unnecessary care.

The UI rejoinder disputes that such a shift could occur. “HW [Himmelstein and Woolhandler] indicate that use would increase for the newly insured but would decrease by a similar amount for those already covered as physicians cease unnecessary services for those otherwise covered and perform additional necessary care for those otherwise uninsured. This assumption is faulty for two major reasons. First, no uniform definition of what is necessary and unnecessary exists in medical care; if such a definition existed, insurers would stop paying for all unnecessary care under our current health system. Second, there is absolutely no reason to believe that higher-income, currently insured individuals would lower their use of care under provider supply constraints.”

Their puzzlement displays a lack of familiarity with the considerable literature on variability in the utilization of care between different areas in the U.S., as well as the actual practice of medicine. John Wennberg and colleagues long ago observed that the number of surgical operations in a community showed only modest correlation with needs of the population, but was strongly correlated (r=.64) with the supply of surgeons.

As any doctor knows, doctors play a large role in regulating the amount of care they deliver. If we have no free appointment slots for the next month we’re likely to put off seeing our healthy patients a bit longer. Gastroenterologists often perform unnecessary screening colonoscopies. That’s not something many patients would demand. Indeed, the Aday paper referenced (to support a different point) in the UI rejoinder makes exactly our point: “After Medicare and Medicaid were introduced, providers may have begun to ration the number of visits by the ‘well-to-do’ to accommodate the influx of low-income patients with newly acquired purchasing power and a backlog of unmet need.”

In sum, there’s considerable evidence that doctor routinely adjust the utilization of care by their patients, and that when many additional people gain coverage, doctors shift care to this newly insured group, and compensate by reducing unneeded care for the wealthy and healthy.

6. What system was the UI analyzing? The UI researchers claimed to be estimating the budgetary impact of Sen. Sanders’ proposal. Yet now they tell us, “To be politically acceptable, compromises would have to be made, and those compromises are reflected in our assumptions.” In other words, their estimates are not actually based on the reform that Sanders (or we) have recommended. Instead they assume that the insurance and drug companies are too powerful to really rein in.

Overall, the UI response misrepresents key elements of our critique, and fails to address the erroneous assumptions that underlay their original analysis. Single-payer systems elsewhere provide more and better care at a lower price than we pay. The administrative bloat of our market-driven payment system accounts for much of the difference. While we recognize that a transition to a true single-payer system faces stiff political headwinds, it’s medically and economically feasible. And as Sen. Sanders has shown, political climates can be changed.

Drs. Woolhandler and Himmelstein are internists in the South Bronx, professors at the City University of New York School of Public Health at Hunter College, and lecturers in medicine at Harvard Medical School. The opinions expressed do not necessarily reflect those institutions’.

http://www.huffingtonpost.com/steffie-woolhandler/urban-institute-errors-single-payer-costs_b_10100836.html

Britain’s junior doctors’ strike isn’t just about pay – it’s about preserving a health system based on need, not profit

By Adam Gaffney, M.D.
Jacobin, April 26, 2016

Today [April 26] in England, “junior doctors” – post-graduate physicians akin to residents and fellows in the United States – are walking out. This two-day strike represents a major intensification of actions that began in January. It was precipitated by last year’s breakdown in negotiations over a contract that the Conservative government of David Cameron has now proclaimed it will impose come hell or high water. But the stakes of the junior doctors’ strike are much higher.

Physicians’ strikes, it’s worth acknowledging, do not always seek progressive ends. The 1962 Saskatchewan Doctors’ Strike aimed to torpedo the province’s milestone single-payer legislation. But the current action in England, endorsed by a near-unanimous vote last year, is something different. Fundamentally, it’s aimed at the preservation – not the derailment – of universal health care.

The travails of the junior doctors are one part of a much larger campaign. Against austerity, of course. But also for the perseverance of the United Kingdom’s unique health care system – in substance, not merely in name – in the twenty-first century.

A Cracked Foundation

Every nation’s health system is split along a rights-commodity axis, ranging from a public system that provides a universal right to health care according to need, to a private enterprise that profitably provides care according to means. When the National Health Service was founded, notes scholar Rudolf Klein in The New Politics of the NHS, it was the first system that universalized government-provided care, and it thereby skewed health care toward the “rights” side of that axis. As he puts it,

“It [the NHS] was . . . the first comprehensive system to be based . . . on the national provision of services available to everyone. It thus offered free and universal entitlement to State-provided medical care. At the time of its creation it was a unique example of the collectivist provision of health care in a market society.”

In the 1980s, however, Margaret Thatcher’s government began an attack on the principles of the NHS that has not yet subsided. As public health doctor and scholar Allyson Pollock describes in NHS Plc: The Privatisation of our Health Care, Thatcher’s government imposed intermittent austerity funding and the incremental imposition of market-based reforms such as the “internal market” and the “private finance initiative,” signaling a retreat from the NHS’s initial collectivist provisions and a partial move toward commodification.

The Labour government of Tony Blair, as she notes, continued down the road first paved by Thatcher. However, Blair’s government did eventually initiate a much-needed increase in funding: to just under seven percent a year, almost twice the historical average of four percent. This overdue boost, however, would not survive the Great Recession.

In 2010, David Cameron’s Conservative-led government was elected and destabilized the NHS through two great upheavals. First, the government reorganized the NHS through the passage of the 2012 Health and Social Care Act; second, it instituted a period of funding austerity the likes of which the NHS had never seen.

The changes wrought by the 2012 law are complex, and the full ramifications not yet entirely clear. Health policy scholar John Lister described the law in a phone interview as a “massive top-down reorganization of the NHS” that pushes it further onto the free market, effectively displacing (some) care provision into the private sector.

And as Pollock and lawyer Peter Roderick – both supporters and advocates for a fully public NHS – wrote in the British Medical Journal last year, the law calls for a number of “reductions and restrictions [of health care that] pave the way for mixed funding arrangements and a gradual shift to private insurance and charges to patients.”

Essentially, they argue, the law “marked the end of the NHS in England” not only by encouraging further privatization and fragmentation, but by effectively ending the Health Secretary’s legal duty to provide comprehensive health services throughout the nation.

The Scrooge Model

Whether the law will fully undo the NHS or simply prove to be another incremental step remains to be seen. The more immediately harmful trend – and the one largely responsible for the junior doctors’ strike – has been the draconian austerity that the service now faces.

In the United States, discussions around health policy generally revolve on how best to reduce excessive spending (especially the public variety). Globally, however, and particularly in low-income countries, insufficient public spending is frequently the larger problem. This is now also the case with the NHS, which was already quite efficient before the Cameron government came to power.

As a percentage of GDP, the United Kingdom currently has the cheapest health system among thirteen other high-income peer countries:

Moreover, health spending in the UK as a percentage of GDP has actually fallen since 2009. As Klein wrote in an article last year, while historically NHS funding had grown at an average rate of almost four percent yearly, it is currently growing at a bit under one percent. Given population growth, he notes, such a rate of “increase” is in fact a per capita reduction.

Indeed, as John Appleby, chief economist of the Kings Fund noted in a blog post, spending increases under the Cameron government are the lowest of any government since the end of World War II. At that point, however, Great Britain was essentially penniless and in virtual ruins. Today, Ebenezer Scrooge–level miserliness has replaced frugal funding as a matter of choice.

What is obvious is that while the United Kingdom ostensibly maintains a social right to health care, the foundation of that promise is cracking.

The First Cut

It was amid all this tumult, Lister notes, that the government decided to move to what it called a “seven-day NHS,” extending the availability of (non-emergency) clinical services throughout the week. While not necessarily a bad idea – though there has been considerable controversy regarding the actual benefits of such a transformation – the change requires more money, not less. That is, unless you have junior doctors around to pick up the slack.

Increasing weekend staffing means “you either over stress the staff who are currently doing it or you actually reduce the cover during the week as a result,” Lister says. Although the government’s proposed contract would increase junior doctors’ base pay, it would also reduce existing premiums for night and weekend work. “Ministers have promised to protect the pay of existing doctors for the first three years,” the BBC notes, but at the same time “new doctors starting their career in the NHS under this contract may be worse off.”

Contract negotiations between the government and the British Medical Association (BMA) collapsed late last year over these issues, leading to a November strike vote with 76.2 percent turnout and 98 percent support. The first strike took place January 12 and the last was April 6. Today and tomorrow’s actions, however, raise the bar considerably: they are full walkout strikes, with emergency care provided by covering consulting physicians, some of whom have loudly expressed solidarity with their striking junior colleagues.

Like their American counterparts, junior doctors work hard and long hours. “I regularly work weekends and nights,” one said in a series of interviews published by the Mirror. “So far in the last 7 days I have worked over 80 hours, I will work at least another 10 hours tomorrow before I get a day off. I am absolutely shattered.”

Among strike supporters interviewed by the Mirror, a concern over pay was not prominent (indeed, one said he would financially benefit under the new contract). Instead, they emphasized patient safety, quality of care, and the potential for greater workforce strain caused by the changes.

The broader point, as Lister emphasizes, is that the move against the junior doctors may be the first stage in a larger campaign to save money by squeezing the health care workforce. “[B]ehind the junior doctors’ dispute,” he notes, “is the much bigger apple that they’re after which is to strip away the weekend enhancement payments and out-of-hours payments for over a million other health workers.” In other words, in the quest for NHS austerity, junior doctors may only be the first on the chopping block.

Which leads to another question: can the junior doctors’ strike advance the larger campaign to preserve and restore a fully funded, fully public NHS, or will it remain an isolated battle?

A Bigger Fight

Perhaps the most critical factor that will shape the battle over the NHS in coming months and years is the human impact of continued NHS austerity, which could produce grassroots protest.

A February report from the Kings Fund gives a clear sense of the service’s dire fiscal straits and some of its ramifications:

• The report estimates that NHS trusts (provider organizations like hospitals) will be in the red by £2.3 billion by the end of the financial year;
  .
• It reports a rising sense that patient care is worsening: for the first time, a majority of trust finance directors surveyed believed that patient care in their region had deteriorated over the past year;
  .
• It notes a failure to meet targets for waiting time for care, including for cancer treatment.

None of this, of course, is particularly surprising: it’s the all-but-inevitable consequence of trying to squeeze more money out of an already lean healthcare system. The NHS’s current budget crisis and declining quality of care don’t reflect the flaws of a public approach to health care, but rather the penny-pinching prerogatives of a government committed to the preservation of concentrated wealth above good health.

In order to deal with the massive projected deficit, Lister emphasizes that at least some cuts in services will take place, as indicated by discussions to close A&Es (ERs) in the rural county of Lancashire.

Such reductions may become critical focal points for local grassroots movements: “[T]hese types of cuts,” he notes, “when they are made, they do have the power to mobilize all kinds of people who would never normally engage in any kind of political activity at all.”

Even though local battles against reductions in services or hospital closures may serve as important loci of resistance, action on the national level will be necessary to reverse course on NHS.

The election of Jeremy Corbyn to the leadership of the Labour Party could be a game changer in this regard. His campaign website calls for a “fully-funded NHS, integrated with social care, with an end to privatisation in health.” But Lister suggests that Labour, even under Corbyn, has been disappointingly tepid in its support of the NHS.

He notes that the party did not champion a bill drafted by Pollock and Roderick, the NHS Reinstatement Bill, which aimed to “fully restore the NHS as an accountable public service by reversing 25 years of marketization in the NHS.” (Corbyn, however, has supported it as an individual.)

Looking forward, Lister hopes to press Labour to adopt the bill’s principles, whatever they want to label it. More broadly, he hopes to see a coalition of NHS activists, labor unions and, one day, the Labour Party joined together in a “united campaign to challenge the Tory offensive.”

Defending the health care work force, restoring previous levels of health funding, rolling back privatization, and ejecting the powerful corporate health care sector from the NHS will clearly be a formidable feat. No doubt it will require a coalition of health workers, activists, politicians, parties, and unions to achieve it.

Like the fight for a single-payer health care system in the United States, health care activism necessitates a multifocal yet united movement. Neither campaign is impossible, but neither will be easy.

Finally, cooperation and solidarity among activists across national borders may provide yet another source of support: health care capital operates transnationally, and so too must like-minded health care workers, activists, and scholars.

The British NHS can only survive insofar as it can continue to provide, universally, the highest quality health care. But austerity makes that increasingly untenable. The junior doctors’ strike rejects this neoliberal squeeze. If successful, it might help lead the way to something more: the end of a series of setbacks for the NHS, and the first of many victories for those who believe in its basic principles.

Adam Gaffney is a physician whose work has appeared in Salon, Dissent, and In These Times. He blogs at theprogressivephysician.org.

https://www.jacobinmag.com/2016/04/nhs-junior-doctors-strike-health-privatization/