Monday, 13 February 2012

Does the Standard have a trust problem?

Is the Evening Standard back to its old ways? Last month this blog highlighted a few examples of where the Standard appeared to be slipping back into its pro-Boris groove, whilst not being as hysterical as it was under its previous owners.

The picture since isn't looking much better. As Adam Bienkov pointed out, Boris' pledge to bid to run outer London rail services received a significantly higher level of coverage to a near identical pledge from the former mayor.

Meanwhile, Livingstone was recently accused by the Standard on two occasions of being a reactionary homophobe - quite a spectacular turn around for a man that the right-wing press has castigated for being a leftie-liberal for the last two decades.

The latest YouGov poll gives Boris the same lead that both Comres and YouGov gave Ken a few weeks ago and provided the Standard with the chance to demonstrate further where its sympathies lie. Obviously the topline figures were useful - Boris ahead, hence a nice headline opportunity. No real story there. But it is the selective way in which the paper reported the detail that is telling.

On three out of four key issues Ken is favoured by voters - by 15-16 points on addressing the cost of living and on improving transport - and he also leads by a smaller margin on job creation. Johnson, meanwhile, is marginally ahead on dealing with crime.

However, the Standard chose to focus on a supposed 'trust deficit' that they argue is costing Livingstone support. It is true that one aspect of the poll shows that 44% thought he could deliver his (popular) pledge to use TfL surpluses to reduce transport fares, not far ahead of the 40% that did not.

But they chose to omit one small problem with this contention, which is that exactly the same poll showed that Ken was trusted by more voters than Boris to deliver his pledges across the piece - with 47% trusting Livingstone to implement fulfil his campaign pledges overall against 45% for Johnson. Worth noting too that the online edition of the Standard chooses not to display the results to this question.

It will be a close race, and the impact of the Standard will continue to be influential - at this rate, it seems likely that it will choose to pursue a path of soft support for the Mayor, whilst steering clear of the ridiculousness of the paper during the 2008 elections

Sunday, 12 February 2012

Patient choice and competition? Forget it: advice on haggling with your doctor in America

David Cameron wants to usher in a new era in health care for England. At the centre of all of this is the right for every 'consumer' of health care services to have the freedom to choose, from a variety of competitive service providers.

There is one problem with this vision. It's total tosh. And there are a number of very good reasons why.

Still, the best way to illustrate why is to trawl the array of helpful 'consumer' advice columns across the Atlantic dedicated to shopping around for the best deals on health services. They are basically like Readers Digest, but aimed at cancer patients.

Now, a cynic would argue that it is really very difficult indeed for any consumer to exercise real choice if the product they are buying is too complex to understand. Or, worse, still, to do so with comparatively little data with which to make informed decisions.

How many people really know their Acebutolol from their Atenolol? Or their Penbutolol from their Propranolol? And yet, the free market, to operate efficiently, requires consumers to exercise informed choice.

So, how are users in the USA advised to make informed decisions? Well, the first step is to talk to your doctor. Simple enough in theory, except:
"Your physician may be just as uncomfortable with these conversations as you are. That’s because... doctors are simply not trained for this".

Oh, and besides, "for a variety of reasons, doctors are likely to suggest the most expensive options first".

But you have that hospital appointment looming... what with that massive tumour you've been ignoring for the last four months sticking out of your leg. Well, first things first:
"check if your company lists average prices for various treatments, tests and procedures online".

Not a bad idea. Except "data isn’t great, and prices can vary significantly from one provider to another".

Well, this might all be irrelevant if you are one of those awkward customers that don't tell the hospital you are coming first, you selfish sod. You could be the kind of guy that "lands in the hospital without the benefit of any planning and gets slammed with a huge bill, say $15,000 for a coronary angiogram, and insurance ends up covering only a fraction of the bill."

But, at the end of the day, the very least you can do is check your bill and see if you are getting a fair deal. Right? Well, it's not quite that simple:
"Be especially vigilant about hospital bills since they tend to be complex and may contain errors" (this seems to be quite an issue - another advice column reiterates the point that you should "closely examine each bill to identify errors, which are common").

Oh dear. Not helpful. But assistance is at hand (at a price), because "having your doctor on your side in a dispute with a hospital can swing a lot of weight".

That's good. Well, if you can trust your doctor, that is, as "some doctors are in practices owned by hospitals, adding a potential conflict of interest".

Sigh. And factor in the health insurance company and: "Sometimes it seems consumers* are caught between two entities protecting their own financial interests and agreements"

Still - it could be worse, folks. You could be uninsured! In that case, first, tell your doctor "that money is tight or your health coverage leaves you on the hook for a big portion of the costs should compel the physician to tailor treatment to your needs" (that is a euphemism for getting rubbish treatment. Although, if you are very lucky, it might be conversely that you avoid in this instance getting over-treated by some self-interested physician. In this brave new world, both the insured and uninsured can get screwed).

And if you are uninsured, you will get the double slap in the face of having to pay out of pocket for your medical treatment and, to add insult to injury (very apt phrase in this case) you will have to pay MORE than someone with insurance. Why? Well, because:
"What’s happening is that people without insurance are paying full price, while insurance companies, with their high volume of patients, can negotiate steep discounts. For patients paying for care out of their own pockets, it’s important to let everyone you encounter know that. The next step: ask for the discounted rate... the reality is, you may not have as much leverage as the big insurers. But it almost always pays to ask".

I'm sure we cannot wait for Cameron to bring us lucky Brits this wonderful world of choice and competition.... and hopefully we'll all remember who brought it to us at the next election.

*that's 'patients' to us.

Saturday, 11 February 2012

Why the Right is losing the NHS debate

That so many Conservative-leaning commentators (witness a recent blog by David Herdson over at PoliticalBetting) focus narrowly on the political ramifications of the Health & Social Care Bill betrays two facts about the modern right-wing commentariat, which in turn explains their problem over the NHS in the mind of the public.

First, so very little of the noise from right-wing circles focuses on the arguments for and again reform. There is ample evidence that the NHS in its current state is one of the most efficient of any developed health system and consequently the UK spends a lower proportion of GDP than numerous other western nations and yet health outcomes here are improving faster than in many of those nations. Additionally, both internal performance and patient satisfaction are improving (or at least they were until very recently). Yet none of this often makes its way into their thought processes - this aspect of the debate is rarely even mentioned. As this blog has argued before, it is a fact of the modern right that their ideological commitment to reducing the size of the state trumps any rational arguments as to what works best for service users. In this sense, their ideology is closer to a religion than a political theory.

Second, what is instructive about the modern right is how much they underestimate the fact that the central moral principles of the NHS  - that health care is a right for everyone, not a commodity like a car or TV available only to those that can afford it - have been accepted by the vast majority of the British public. The left-wing theorist Stuart Hall, in a recent interview with the Guardian, actually himself underestimated this when he declared that "The principle that someone shouldn't profit from someone else's ill health has been lost". In fact, this principle still carries a great deal of sway for many people beyond the left and centre-left, although in reality it has been chipped away at somewhat in recent years.

Then there is a final problem for the modern right, and an Achilles' heel in some regards. The NHS (and, in fact, the BBC) are seen as very British institutions. This gives them an appeal beyond the left, to those that value nationalism and have pride in British culture. In other words, the Tory Party has a central problem with regards to both these institutions in that in undermining them they will be seen as undermining British cultural institutions - difficult for a party that builds so much of its support from regular appeals to nationalism.

Tuesday, 7 February 2012

Why haven't the government's Health & Social Care Bill problems shifted the polls?

This week another health group, this time Londonwide Local Medical Committees, came out against the Health and Social Care Bill.

This adds to the stream of organisations that now oppose the Bill, including the Royal College of Radiologists, the British Medical Association, the Royal College of GPs, the Chartered Society of Physiotherapy, the Royal College of Psychiatrists, the Royal College of Nursing and the Royal College of Midwives.

The Bill has also been castigated by the Lancet, both by contributors and in an editorial; its been slated in the British Medical Journal and a joint editorial in the Health Service Journal, British Medical Journal and Nursing Times called for it to be withdrawn.

To compound all of this, the reforms themselves weren't explicitly mentioned in either the Tory or Liberal Democrat manifestos or in the coalition agreement, so have little or no democratic mandate. All in all, they look like an ideological project disguised as patient-focussed reforms.

Couple this with soaring waiting times - with patients waiting more than 18 months up a staggering 43% since the general election of 2010 - and you would expect to see Cameron and the government suffering in the polls.

Except they aren't, if the latest YouGov poll (and the recent polling average) is anything to go by. The big question is why? Has the complexity of the Bill and its implications not broken through into the public consciousness? Have the predominantly right-wing media helped to distort and disguise the problems in the Bill? Or do people instinctively trust Cameron at face value?

Time will tell whether this will change. For one thing, if this Bill does go through, there will be ample evidence of its implications for everyone that uses the NHS.

Sunday, 5 February 2012

The testimony that should serve as a warning to those that want to privatise the NHS

Watching the Secretary of State for Health endlessly bluster on about choice, competition and innovation that private companies can bring to health care, I was reminded about this video (courtesy of Michael Moore). A few words of testimony from a former medical reviewer for US health care company Humana that should serve as a warning of the utter folly of the American health system - and that the direction that the current UK government wants to take health care is a slippery slope.

Wednesday, 1 February 2012

The wrongs or rights of the BBC or NHS don't matter to the modern right - only that they cease to exist

In 1985, the then Labour Party leader Neil Kinnock took on militant - most notably in a now famous speech - and set in train a process of reforming the Labour Party that was taken, via John Smith, to its conclusion by Tony Blair. Although a good deal of the focus was on developing presentation and communication, the crucial change was that the party moved ideologically. In effect, it jettisoned the left-wing of the Party and became one of the political centre.

Blair's mantra, 'what matters is what works', did in fact demonstrate one of the key changes in the Labour Party - that would be no ideological objection to private involvement in public services as long as it improved them and supported the goal of greater provision for everyone. The only ideological barriers (theoretically), was where private sector involvement would be detrimental to social justice. 

However, in practice there was a flaw. New Labour, despite increasing spending in health and education, failed to take Blair's mantra to its logical conclusion. 'What matter is what works' should be a two way street. So, for example, on the high street, private competition tends to work very well for consumers, and therefore makes sense. But what about where it clearly does not? The privatised train system, for example, is more expensive and provides a poorer service than a number of state-run systems elsewhere in Europe. However it was (and remains) rarely suggested that such a service could move from a private to public system, even where clear failures are evident. In essence, then, the mantra provided a route for the privatisation of key public services but little else.

So what about the Conservative Party? The introduction of private enterprise into aspects of the public services enables the modern Tory Party to argue that a raft of their changes are merely building on the foundations laid by Labour. They argue that they are taking Blair's reforms forwards, in a similarly pragmatic manner. 

But there is a crucial difference between the Tory Party of 2012 and the Labour Party of 1997. Cameron never changed his party's economic policies. In fact, he never intended to. His 'reforms' were merely the first component of those seen under Blair's mid 90's Labour Party - concerned narrowly with presentation and communication. The second, ideological change, never occurred. In fact, if anything, the opposite did: centrist, one nation Conservatives like Michael Hesletine are now a minuscule part of a party dominated by neo-liberal, anti-European free marketeers. This is part of a trend that has been witnessed across the channel. As the left moved to the centre, the right has moved ever rightwards - or, as Bill Maher put it, 'moved into a mental institution'. 

The most important aspect of the modern right to bear in mind is therefore this - for them what works doesn't matter. Ideology trumps everything.

This is crucial in understanding Andrew Lansley's health reforms. It doesn't matter that the US health system he is trying to emulate has huge inequalities and is quite obviously unfair. Nor does it matter that the US system is hugely - cripplingly - expensive for both 'consumers' of the service and (ironically) for US taxpayers. It doesn't even matter that the NHS has been demonstrated to be more efficient than other developed world health systems.

Social justice, affordability - even efficiency - aren't important to modern right. The only key value system is one that revolves around the pursuit of profit - a notion that James Murdoch summed up neatly a few years ago. Expansion of private enterprise into all aspects of life - even those where its involvement may be detrimental to the lives of most citizens - is a goal that must, at all costs, be pursued. The state should never provide more than the bear minimum it needs to to avoid industrial and social strife - merely just enough to avoid riots on the streets.

Therefore arguments over whether the NHS serves cancer patients, or those with heart conditions, better than other health systems are ultimately unimportant. 

It is also why the BBC, despite the immense cultural benefits it brings to the UK, and the influence it allows a country as small as the UK to wield abroad, must be attacked. In this context, a commercial channel providing nothing but US imports and reality TV is always preferable to a non-profit provider of Frozen Planet and Birdsong, Thick of IT and Sherlock, Wonders of the Universe, Radio 4 and 6 Music.

The cultural icons the BBC has created, from Basil Fawlty to Alan Partridge, David Brent to Malcolm Tucker, are valueless in these terms. It doesn't even matter that a country the size of the UK could not hope to sustain a commercial channel with the means - let alone desire - to make anything like this range or quality of programming.

The truth is British culture doesn't actually matter to the modern neo-liberal right: nationalism is merely a fig leaf, a convenient veneer to give the impression that they hold values beyond their narrow economic goals (and. better still, to convince millions of people to effectively vote against their own interests).

It is in this context that the government operates and in this context that its actions should be understood. Any small gestures - on executive pay, or on energy bills - are just that; gestures to prevent public unrest... ideally just enough to ensure that the ideological project can continue unabated.