Why Voting No threatens Scotland’s NHS

This weekend, another key battleground in the independence referendum emerged.  As big as, if not bigger than, currency wars.

Findings from a Panelbase poll commissioned by the Yes campaign demonstrates the importance of Scotland’s NHS to voters.  Asked if the privatisation of the NHS South of the border with its consequent impact on funding for Scotland’s NHS made it more or less likely for participants to vote Yes or No, people made their feelings clear.  46% would be very likely or quite likely to vote for independence, 35% very or quite unlikely to.

It resulted in rebuttal from Better Together, with Jackson Carlaw MSP, the Conservatives’ spokesperson on health, claiming that the Scottish Government is spending more on private healthcare too.

It’s complicated, but it is possible to shed a little light on the situation.

First, how does what is going on in England with the NHS impact on Scotland?  It’s all about the money, innit.

The Barnett formula determines what money we receive from Westminster.  Think of it as a big bag of pocket money to spend on devolved issues, including health.  Westminster hands it over and the Scottish Government divvies it up across all spending areas.  If Westminster decides to put more into funding public services, then we get more too.  Except that in recent years, it has been putting less in and we get handed a smaller bag of cash.  If Westminster cuts the budget by £100 million, we get £10 million less.  Indeed, since 2010, Westminster has taken 7.2% out of the Scottish block grant, putting real pressure and strain on our public services.  The Scottish Government gets to decide what to spend the pot on, but not how much to put in it, even if we in Scotland want more to spend on public services.  It can only make the money it receives stretch as far as it can through prudent management but cuts have been inevitable.  Except in health.

Until now, the UK Government has chosen to ringfence health spending and increase it in line with inflation – Scotland’s NHS has benefited from this too.  And from a separate Scottish Government decision not to pass on any of the 7.2% cut in overall grant to health.  It has chosen to keep increasing frontline health spending in real terms, acknowledging the value placed by us all on health and the need to keep tackling the levels of ill health in Scotland.

But thanks to the actions of the Conservative-Liberal Democrat coalition government at Westminster, the budget for health in Scotland is under threat.  Largely, due to the Health and Social Care Act passed in 2012.

This Act opened the door to private companies bidding for health service contracts south of the Border.  It’s a move that the Chairman of the British Medical Association (the doctors’ union effectively) called “market lunacy” which offered “a bumper year for multinationals”.

At the same time, the legislation also removed statutory responsibility for health care from the government, handing it over to local commissioning agents.

Thus, the framework has been established to enable privatisation of the NHS in England.  Private companies can now “bid” for health contracts that would previously have been delivered by the NHS (publicly owned and accountable).  How do you suppose firms go about winning these contracts?  By bidding lower than the local NHS trusts and bodies to deliver the service.  So the funds that Westminster needs to spend to provide such services are reduced and the UK Government can cut its budget on health.  Indeed, it has already stated that it is committed to cutting health spending in England by £1.1 billion a year – enabling private companies to run services will help achieve this.  Last year, 70% of new contracts for core NHS services were awarded to companies like Virgin Health.  Together, so far, the services either won by private health companies or being bid for are worth £1.22 billion, covering services such as GPs, end of life care and cancer care.

And how does this affect Scotland?  It’s the money – again – innit.

If health services are being run by private firms at reduced costs (we won’t even begin to talk about quality – that’s a whole separate issue) then the UK Government spend on health goes down.  And because we only get what Westminster allows to spend based on the Barnett formula, it can – and will – cut the money it gives us in Scotland to spend on health, even though we want to keep our NHS in public hands and make different policy decisions on health.  Because Westminster controls the purse strings, it puts under threat our ability to continue to fund our NHS and provide all the services publicly we want from it.  Cute huh?

It gets worse.

If a private company wins a contract say for cancer care, it not only has to take the staff already employed in this service in the NHS over to its new service but often also gets to run its new service from the previous NHS facility. So equipment, beds, buildings that would be lying empty because the NHS “lost” the contract get handed over to the private company, either at a knock down price or no price at all.  That’s facilities bought and paid for by the taxpayer.  That’s staff qualified and trained in their skills by taxpayers.  That’s all that experience lost, just handed over to private firms. Again, it reduces the cost of health care to the English budget.

And when the contracts come up again in three to five years’ time, there will no longer be an NHS England version of that service to put in a bid or to put the service back into public hands. It is a one way journey to breaking up NHS England.

There’s more.  There is nothing to stop any of these private companies recouping the cost of running their services by applying charges.  Indeed, a recent report by the Nuffield Trust stated that 50% of health and care leaders believe that within 10 years, the NHS in England will no longer be free at the point of use.  And there is cherry-picking going on with the easiest health care contracts to deliver the ones the private companies most want.  NHS England is being left to deliver the most complex and expensive services, putting many trusts and hospitals into debt.  Making them all seem like financial basket cases that need to have their financial taps turned off, to prevent them “over spending” and the private sector brought in to “rescue” them.  It is a perfect, dystopian cycle of potential destruction of one of the building blocks of our welfare state.

But it gets worse still.

At the same time as all this is going on, there is an international trade agreement being negotiated between the EU and the US.  This agreement is about free trade and allowing US companies the right to bid for services and trade in key areas in the EU market, of which the UK is part.  The agreement is known as TTIP – Transatlantic Trade and Investment Partnership.  Opt outs and exemptions are allowed; many EU states are choosing to exempt and therefore, protect public services, like health, from big US based multi-nationals.  Guess which member state has not asked to exempt health from TTIP?  Yep, the UK. This means that US healthcare firms could come into the market in England (and indeed, potentially Scotland as we don’t get a say in these negotiations and have no way of exempting NHS Scotland from its application as the UK gets to make the call).

Now, of course, we can continue to protect NHS Scotland from such private companies coming in, if we continue to elect devolved governments that will stand up for Scotland’s interests and for a publicly owned and delivered health service.  But any devolved government’s ability to do so is going to be constrained if the block grant is still being slashed – and there are £5 billion of cuts coming our way in the next two years that we already know of.  Moreover, the pockets of big global private healthcare firms are deep – they wouldn’t be averse to going to court to insist upon TTIP being applied across the whole of the member state which signed up to it.  And who knows if we would be able in the next five to ten years prevent Scotland’s health service being opened up to private companies as it is being in England.  Whether we want this to happen or not.

Yet, the Conservatives claim the private sector is very much playing a role in the NHS in Scotland today.  At the margins.

The amount spent by NHS Scotland on private sector involvement in 2012/13 was £80 million – that’s less than 1% of the total amount spent in Scotland on front line NHS services.  To put it in a slightly different context, that £80 million is much less than the £220 million a year in charges the Scottish Government has to shell out for PFI contracts.  If anyone has allowed the private sector into our NHS in Scotland it’s been Labour – the Scottish Government is locked into these contracts and has no choice about paying out these funds, thanks to Labour bringing private firms into our health service.

The accumulated £400 million spend over six years quoted by the No campaign has been massaged to include the use of locum doctors and agency nurses – temporary staff brought in to cover shortages, holiday periods and the like.  The use of private agency staff in such situations is common and longstanding – if there’s more of this going on than there used to be, then that’s a separate policy and workforce issue.  But the spend on it should not be used to suggest that the SNP Scottish Government has allowed the private sector more say in running health services. It hasn’t, it has done its very best to limit the use of private businesses and only brings them in to carry out specific functions, such as to bring down waiting times on straight forward procedures, and in particular health board areas where such an issue has arisen such as to bring down waiting times on straight forward procedures.

It is vastly different from giving contracts to private businesses to deliver whole services, which is what is going on in England.  None of the private providers in NHS Scotland are contract holders.  In Scotland, we have not opened the door to private companies bidding for health services.  We don’t have a Scottish equivalent of the Health and Social Care Act 2012 – indeed, our most recent health legislation, the Health and Integrated Social Care Act focuses on improving the service people get from public services, trying to join up health and social care provision across the NHS and local government.  The entire focus in Scotland – from the limited input of the private sector in certain fields and geographical areas to the statutory framework around service provision – is to put the patient first.

If Scotland votes No on 18 September, our health service, NHS Scotland is at risk from the actions of the UK Government.  First, by bringing in the private sector to run whole swathes of NHS England at lower cost than in the public sector, it can cut the overall budget for health.  That will have a knock-on effect to our block grant, making it difficult for Scotland to maintain spending levels on health – the sort of spend we all want to see on health as a priority issue will be under threat.  Second, by refusing to exempt health provision in the UK from the TTIP, US private healthcare firms – and there are lots of them and they are huge – NHS Scotland could find itself subject to tendering for key front line services, with many of them being taken over by big business.  No matter who we vote for in Scotland, no matter how much we want to keep our health service in public hands.

That’s the threat voting No poses to our health service – and indeed, our nation’s health.

Which is why if you want to save the NHS, you need to vote Yes.


Thanks to Jeane Freeman and Philippa Whitford, of Women for Independence, for providing much of the content of this post. 




Putting the powerful in handcuffs would be a start

We need more people in handcuffs… there’s not nearly enough people in handcuffs”  Michael Portillo’s choice of words on BBC political programme, This Week, might have caused Jacqui Smith to titter, but he was spot on.

What Portillo was questioning was a culture in which people at the top – in private and public sector roles – can get away with it and are not only not held accountable for their actions, omissions and failings, but that they are not subject to any kind of sanction, civil or criminal, for their behaviour.

And not for the first time, did I find myself nodding in agreement with this former Tory and wondering how that happened.

It happened because no longer cowed by the need to play the game because he stepped away from it, Portillo is now liberated to say what the rest of us think and to view the goings on at the summit of British culture and society through the same kind of real life spectacles the rest of us wear.  Even he can’t believe the audacity of claims that there is little to be gained from sacking or prosecuting miscreants.

So what do you have to do to get arrested or at the very least, the sack?  As Michael Portillo noted, not a single person from the top to the bottom in the NHS has resigned or been disciplined over the Mid Staffordshire Trust scandal.  Hundreds of people died needlessly as a result of substandard care and staff failings at two hospitals for which the trust was responsible, concluded the inquiry report.  The details make uncomfortable reading.  Afterwards, current affairs programmes discussed how it could come to this – how did people paid to care forget to do so? – and representatives of the various parts of the NHS workforce blanked the question in an elaborate game of pass the parcel.  Not us, but them or the favourite fall guy, the system and the culture is to blame, they reckoned, conveniently ignoring that culture is shaped by people and their attitudes and behaviours.

In Scotland, we glanced cursorily and concluded somewhat smugly that it couldn’t happen here,.  In Scotland we have different values at work with a care-oriented and patient-centred health service which is the envy of others.  Really?  For every example of beyond-the-call-of-duty, exemplary care any of us can relate, we can all also suggest one that didn’t quite make the grade.  In truth, there is little that is patient-centred about the way hospitals and community services are run: if they were, for a start, we’d have basic services available in the evenings and at weekends as a given.

Take a look at recent agenda-setting attempts by the NHS in Scotland to see how institutionalised and focused on producer interests, our great health service actually is.  Two weeks ago, research suggested that hospitals with 100% single patient rooms would be a very bad thing, with some patients agreeing that they feared if they were in a room on their own, they would get forgotten about or not be able to get help when they needed it.  Practitioners and volunteers agreed.  Yet, the issue here is not single patient rooms but the inability of the NHS to rethink how it might go about providing for patient care in such circumstances.  The very fact that some patients fear dying alone because no one will come should tell us something is far wrong with the current system.

Today, health experts are calling for the morning-after pill to be made available in Scotland’s schools to bring down the number of underage pregnancies.  This kind of top down, medical fix it approach is much beloved of health practitioners and will solve nothing, for it fails to address the underlying complex social, economic and cultural issues behind the high rates of teenage pregnancy in some parts of Scotland.

Admittedly, it is but one suggestion in a package of proposals from an expert group singled out to create a headline, but to suggest that allowing greater accessibility to contraceptive measures in schools is prevention at work suggests an alarming mis-understanding of what preventative, early intervention activity truly is.  It might fix an immediate problem, and helpfully enable the NHS to meet its targets on teenage pregnancy, but it will do nothing to address the propensity of teenagers in Scotland to engage in increasingly high risk behaviours in substance use and early sexual activity as they move through adolescence, particularly in comparison to their peers in other European countries.  Where are their more thoughtful solutions to this?

Elsewhere, the horsemeat scandal is so tangled and layered, that no one can really unravel it to get to hard facts.  That job is made more difficult by the existence of powerful actors and players who are adept at pointing the evidence trail away from themselves.  Since BSE and foot and mouth, Scotland has lost much of its infrastructure which enables us to keep locally grown and produced food local.  Getting raw produce into the supply chain often requires sending ingredients on journeys to England, Europe and in the case of shellfish, Thailand before it ends up back on our supermarket shelves.  Producing food is a global business and complicit in it all are the supermarkets.

Yes, we need to find out how horsemeat found its way into beef products but let that be the start, not the end of a process of critical examination of the food chain in this country.  And if that examination concludes that we need to regulate more and invest in enabling more people to eat more, locally produced food at an affordable price, then so be it.  The supermarkets, in particular, have argued for light touch regulation, yet have largely failed to remove all manner of nasties from our food.  It’s time to make laws which require them to do so.  It’s not just our well-being at stake here: if global food companies and their purveyors can get away with this kind of thing in highly sophisticated markets, imagine what corners are being cut in much poorer parts of the world.

One thing we can discern is that this scandal came about because far too much leeway was given to producers at the expense of consumers.  They have all treated us – and especially poorer families and individuals – with contempt.  Just like the NHS, if the food industry truly was people-centred, it would look and act quite differently.

And this upside down approach to well, everything has created a rotten and rank culture in which those with little power at the end of the supply chain, be it a private or public sector one, have to put up and shut up.  Even if they die as a result of the decisions taken by the omnipotent.

It won’t do.  And we must use the opportunities created by these crises and more to re-configure the power structure.  We can start by holding to account those who fail, cheat, lie and break the law.  Putting more of them in handcuffs would be a start.

Is breastfeeding a form of state sponsored sexism?

The following is a guest post from Mairi Campbell-Jack, who blogs about poetry at www.alumpinthethroat.wordpress.com and spews out whatever thoughts randomly come into her mind on Twitter @lumpinthethroat .  All comments and views, especially differing ones, welcome!

There is one area of life, I have discovered, in which you will find women driving themselves to masochistic extremes to achieve an ideal which other people (mainly women) are pushing them to. It’s not the catwalk, or any magazine. It’s breast feeding.
I can’t actually believe I was stupid enough to swallow all the hype myself. I’m middle class and I have always been terribly middle class in my tastes, so when I became pregnant with my daughter there was no question about how I would feed her. “Breast is best” is the mantra drummed into women, and so I believed.
Until I came across a catalogue of mothers and friends who had the most terrible time feeding their first children. The mother who couldn’t breast feed because of the antidepressants she is on due to terrible postnatal depression. Every time she was told that breast is best, and encountered the army of people intent on persuading her so, her already low self esteem took another blow.
Then there was the mother who had low milk supply (not calorific enough) and so her baby fed every hour and a half– that’s every hour and a half of the whole twenty four – right through the night. Exhausted, she asked her midwife if she could use a bottle, the midwife advised no, and the baby ended up in hospital on a drip because she was so dehydrated.
Another mother who had a biopsy due to a lump, whose baby refused a bottle, had to feed her on a freshly biopsied breast. Midwives and health visitors tell you not to give a baby a bottle until four weeks because of nipple confusion, (stop sniggering at the back – and read this Daily Mail article by a midwife casting serious doubt on nipple confusion and other tactics used to increase breast-feeding) by which point many babies will refuse a bottle because they know it’s not mum. Delaying mothers from trying a bottle aims to extend the time during which a baby is exclusively breast feed.
That biopsied woman was me. It was utterly excruciating. At the time I said I would rather give birth than go through those feeds again – and I gave birth without any drugs. 

It got me thinking, talking to other mums, doing a bit of research. Why would health professionals tell women to breast feed no matter what, even when not good for the mental or physical wellbeing of the mother and in some circumstances, downright dangerous for the child?
The reasons, as I see them, are complex and political. There are breast feeding targets set by the Government. To measure these targets, how a baby is fed is recorded, health visitors’ statistics are collated and then trotted out to prove how hard government is working to give every child the best start in life.
Why the targets? Scotland has a very low breastfeeding rate, although breastfeeding rates in many western countries are also low. Breastfeeding provides health benefits for the mother and the infant, well into adult life. Breastfeeding is regularly touted as a “silver bullet” for all manner of problems, such as being a bit thick, being allergic to stuff, obesity, diabetes, cancer… the list is endless, almost as impressive as all the stuff you can make out of a whale. Not only should every mother breast feed their child, but any mother who does not might actually be in dereliction of duty! The attitude towards women’s ownership of their own bodies has shifted from lie back and think of England to sit down and squirt for Scotland.
However, there is disquiet among many medical professionals about breastfeeding being promoted as some kind of cure all, and some, such as Michael Kramer, professor of paediatrics at McGill University, Montreal and Sydney Spiesel, clinical professor of paediatrics at Yale University School of Medicine, have started to question the evidence.
Joan B. Wolf, a mother and academic – who did breast feed – has also conducted research into publicly funded campaigns to promote breast feeding. Woolf’s study covered Northern America, but here in Scotland there is public money being pushed into breast feeding campaigns which are very similar to those she studied.  Wolf casts serious doubt on the ethics behind these campaigns, and the way they treat mothers.  Some of the claims for breast feeding that we see in America, Scotland and Europe were described by Michael Kramer, professor of pediatrics at McGill University, in the article above as “false information” – a polite euphemism for lie. To me, the current approach to breastfeeding amounts to little more than state sponsored sexism.
Current guidelines issued to pregnant women on breastfeeding don’t just propagate the “false information”, but they also ignore the difficulties that can be faced when breastfeeding. They give women even less of an accurate picture.
Benefits for babies touted by NHS Scotland include protection against illnesses such as “diabetes in childhood” and “obesity”, while breastfeeding helps the mother “return to your pre-pregnancy weight” and protects her from “hip fracture in later life, caused by the bone disease osteoporosis.” Research has shown all these effects to be “negligible” or “there was no relationship”.   Apparently, “Breastmilk is always best”, ignoring when it is clearly not always best, due to recurring infections, mental ill-health, drug addiction or very low milk supply. This begs the question, best for whom? Best for meeting your targets?
The same NHS Scotland publication quotes happily from the World Health Organisation, conveniently ignoring the fact that its recommendations are global and are most pertinent for mothers who live in areas where good available diet and clean water can not be relied on.
The chapter on Expressing your Milk fails to mention that not every woman is able to store expressed milk due to an excess of the digestive enzyme lipase – a problem, incidentally, that no medical effort has been made to research and resolve.
Low milk supply? Not addressed. Instead, the focus is on Poor Weight Gain with the language used implying blame rather than offering manageable solutions.  The prevailing feeling that is given to new mums is that if they haven’t breast fed their child they have somehow failed, failed as a mother, at the beginning of what is a very long process. We take these kinds of things to heart, they are upsetting.
One reason why we have woefully low breastfeeding rates is to do with the sexual objectification of women’s bodies. I’m sure I don’t need to explain this. This low rate combined with the “benefits” of breast feeding is why we now have government set targets to increase the number of mothers who breast feed and why we have such a push to get mothers to breast feed their children exclusively. This push is why women are not being given the whole picture on the benefits or the difficulties of breast feeding and being supported in making a choice which is best for them, and their family’s individual circumstances. It amounts to sexism: either we choose not to breastfeed and give into cultural sexism or breastfeed and give into state sponsored sexism.
To not give women full or proper information is to infantilise them and fails to recognise that in most cases, given full information, the best person to make a decision on how a baby should be fed is the mother herself. Sometimes, when mothers are not able to make what is seen as “good” decisions for her child, there may well be under-lying issues more substantial than a decision between bottle and breast. She should be supported rather than chastised. Anything less is treating us like cows.
So what do I want? I want to see the Scottish Government (whomever that may be after May) revaluate all the scientific evidence on breast feeding, completely. I want to see arbitrary targets, which pressurise women at a very vulnerable time in their lives, scrapped. I want to see midwives and health visitors not puritanically preach whatever the latest approved message is, but to genuinely help individual women to understand information, without propaganda, and to treat their decision in a holistic manner. I don’t think it’s a lot to ask, that we be treated as people and not statistics on a chart.
Mairi Campbell-Jack