14. How can they be so stupid? The Plot Against the NHS


[This is the 14th in a series of 14 posts. I suggest you scroll down and start with Number 1]

The Plot Against the NHS is a book by Colin Leys and Stewart Player; I would recommend it, read it and judge for yourself.

Briefly, their thesis is that a ‘concordat’ was negotiated in 2000 by the Independent Healthcare Association with Tony Blair’s second Secretary of State for Health, Alan Milburn. ‘The Association’s leading negotiator, Tim Evans, was very clear on the ultimate aim of the concordat. He looked forward, he said, “to a time when the NHS would simply be a kitemark attached to the institutions and activities of a system of purely private providers.”‘ (page 1)

The authors document the steps that were taken to further this aim. They call it a plot because it was covert, never made explicit, never debated. ‘Neither parliament nor the public have ever been told honestly what was intended. Misrepresentation, obfuscation and deception have been involved at every stage.’ (2)

Some excerpts:

‘So in spite of it great popularity Britain’s most famous postwar oscial achevement was unravelled through a series of step-by-step ‘reforms’ each creating the basis for the next one, and always presented as mere improvements to the NHS as a public service. They were billed as measures to reduce waiting times, to offer more ‘choice’, to achieve ‘world class’ standards, to make the NHS more ‘patient-centred’—anything but the real underlying aim of the key strategists involved, to turn the health care back into a commodity and a source of profit.’ (5)

‘Each of the so-called reforms involved persistent, behind-the-scenes lobbying and fixing by a network of insiders—inside the Department of Health, above all, but also by a wider network, closely linked to the Department: corporate executives, management consultants, ministers’ ‘speacil advisers’, academics with free market sympathies and a taste for power, doctors with entrepreneurial ambitions—and the House of Commons Health Select Committee, packed with just enough compliant back-benchers and deliberately insulated from advice from expert critics of the market agenda. Not to mention a large and growing corporate lobby.’ (5)

‘Each ‘reform’ needed its own quantum of dissimulation and occasionally downright lies. The culture of the Department of Health was radically transformed. In place of old-fashioned ideas of accountability and fidelity to facts the priority shifted to misrepresentation and spin. This was accelerated by the fact that from the late 1990s onwards more and more private sector personnel were active inside the Department, often in leading roles.’ (5-6)


These are just a few excerpts. I have bought and read the book. To me it helps make sense of DOH behaviours which are otherwise mind-bogglingly stupid.

If you understand the ‘Choose your GP’ policy as aiming to de-regulate English general practice and open it up to for-profit companies, then it is rather clever, not stupid. But it does rely on the public being duped, and not seeing through the duplicity and deception; and the journalists, and the GPs, and other health professionals.

13. How can they be so stupid? Corporate lobbying?


I put a question mark after corporate lobbying simply because I have no direct proof myself of this activity. I am close to certain that this activity has taken place over time with respect to the issue of GP practice boundaries, and I think it is likely that this plays a central role in driving this policy. The politicians talk about patient choice, but underneath it all is really an aim to de-regulate English general practice and open it up in quite a new way to for profit companies.

How and why?

At present practices cover a limited geographical area. This limits the number of patients. Remove this factor, make registration free of geography, then it opens up an entirely different model which can be exploited by companies like Virgin Care.

These companies can set up medical centres in major cities, wherever is most profitable. They will attract a clientele of mobile, essentially healthy professional people. They will not have to deal with these patients when they are actually sick because they will be too unwell to travel to their centres; someone else will have to visit them. The elderly, people with chronic diseases, will remain registered with local GPs.

It will be convenient for the mobile and well, and profitable for the firms. But it will not deliver primary care in any real sense, and will in essence be a virtual asset stripping.

12. How can they be so stupid? Brain damage


While on holiday recently I read a book on the neuroscience of pleasure (David Linden, The Compass of Pleasure). The idea came to me that in some sense the policy to abolish practice boundaries and extend patient choice is actually ‘brain damaged’.

In this sense: the book discusses the way in which various pleasures (sex, certain foods, drugs, behaviours like gambling) activate discrete parts of our brains, which we then experience as pleasurable. The author highlights situations where, under the influence of certain pleasurable experiences (such as falling in love) there is a distortion of our critical faculties, a ‘deactivation of the prefontal cortex’, the judgement, planning, and evaluation centre. Money, cocaine, heroin activate these pleasure centres.

It occurred to me that possibly the thought of choice, the promise of choice, somehow activated the pleasure centres, and led to a deactivation of the prefrontal cortex, a distortion of our critical faculties.

This is perhaps just a metaphor. But it certainly seems to me that certain policies from the DOH appear to be ‘brain damaged’, that is to say that important thinking steps are simply left out.

11. How can they be so stupid? Cognitive Muddle


At the heart of this issue of patients’ choice of their GP practice there is a significant amount of cognitive confusion and muddle. What I mean is the sentences used are disconnected from reality, there is a disconnect. It is as though if the sentence sounds ok, then just go with it. Don’t actually try to see what it means in real life. There is an ignoring of the paradoxes.

It is as though a potician were to say: ‘I believe wholeheartedly is a strong family life and a lifelong committed marriage to my wife, and also having the choice of which mistress I have on the side at any given time.’

So Andrew Lansley says to the RCGP:’I’m not abolishing practice boundaries…I’m intending to extend patient choice.’

Many do not seem to be aware that there really is no choice, it is illusory. Current GP practices are all working at capacity, there is not significant spare capacity. If the practice area were suddenly to become the whole of England (or just the whole borough), there is no way that the practice could register the patients. This is such a basic reality, such a simple fact, and yet the muddle persists.

Another cognitive muddle is the argument that opening up practice areas will result in competition and improved quality of the poorer practices. But again, this is absurd because of this issue of capacity. Yes, a few patients might move from practice x to y, but it can only be limited. This is not same type of market as hamburgers and mobile phones.

10. How can they be so stupid? Wishful thinking….


If you are offered something attractive by someone, you naturally hope that it is what you are going to get. You hope it ‘will come true’, that it will not be illusory.

The property bubble and the disastrous crash in 2008 was at least in part built on ‘wishful thinking’. Bernie Madoff’s ponzi scheme went on as long as it did at least in part due to ‘wishful thinking’ on the part of his investors.

If Andrew Lansley is going to offer you choice, why turn him down?

‘I mean choice, at no cost, it can only be a good thing, right? We have the Department of Health’s assurance on this, right? I’ve read the leaflet, what’s not to love about it? Sure, I’ll go with choice, it’s a no brainer.’

9. How can they be so stupid? Being duped…


If there is a deception being carried out, then there have to be people being deceived, being duped.

If a politician promises something that he or she knows cannot be delivered, and a citizen believes this, then the citizen has been duped.

If a politician promises something thinking they can deliver it, and a citizen believes this, has the citizen been duped?

In the case of the GP boundary issue, I think it is likely there are some politicians who think it is perfectly practical (in which case they are stupid, and not participating themselves in a deception) and are unaware of the unintended consequences; if they promise their constituent to deliver this is the citizen being duped?

A concrete case: on 30 December 2011 (is there a significance in such a date) the Department of Health launched the ‘Choose Your GP’ pilot. Almost immediately a number of articles appeared in the online press (Telegraph, Express, Oxford Times, and others). These ‘articles’ were essentially all the same, they all repeated what the DOH ‘Media Centre’ told them. They all more or less lifted the text from the DOH webpage. The articles did not say ‘All this content is from the Department of Health as they are giving it out. I cannot guarantee the veracity or reasonableness of the content.’ Nor did any of the articles analyse what was being offered, ‘promised’. They just presented it. A citizen reading the article could be excused for thinking the content, the promises, were reasonable and achievable.

So in this case, the journalist is being duped, and in turn, unwittingly, is duping the public.

(I checked this with one of the journalists, and offered some additional information which critiqued the content of the DOH webpage; the journalist said that he/she had had to rely wholly on the DOH content; and had he/she been aware of what I had told him/her, he/she would have written a different story. There may be more on this in the future).

DOH ‘Media Centre’ Launch

Two examples (there are at least 5 others):

Oxford Times ‘article’

Express ‘article’

8. How can they be so stupid? Duplicity


Duplicity:Oxford Dictionary of English: deceitfulness; archaic the state of being double.

Andrew Lansley gave a speech to the Royal College of General Practitioners’ annual conference in October 2011. I did not attend but fortunately the speech is available on video, as are the questions and answers after the speech. So I was able to listen to these. What he had to say about GP boundaries was actually not unreasonable, he seemed to have understood the problem (‘Now I’m clear that whatever we do general practice must always remain rooted in local communities and that clinical commissioning builds on this.’; whatever was done had to work, they had to find ways that worked; ‘I’m not abolishing practice boundaries…’). But I was sceptical: let’s see what happens. A few weeks later the GPC signed a contract for 2012-13 which agreed to a pilot on GP practice boundaries, and for asking practices to create ‘outer practice boundaries’ which retained patients who moved from within the practice boundaries. This was not unreasonable, but I remained sceptical: how independent and probing would the ‘independent evaluation’ of the pilot be?

Then came the launch of the pilot, at the end of December 2011:

It allows patients for the first time to choose whether to register with a practice close to their workplace or home, without worrying about practice boundaries.

Health Secretary Andrew Lansley said:

‘Many patients are happy with their local GP practice, but a significant minority have problems registering with a practice of their choice. This pilot will mean patients taking part can access the high quality care they deserve in a place and at a time that suits them.

‘That’s why I believe patients should have the freedom to choose a GP practice that suits their lives, and not be restricted by geographical boundaries.’

He did not really believe what he said to the GPs in October. He was intelligent enough to know what sort of thing he had to say in order not to be eaten alive, but his intention was, and still is, to plough ahead with the abolition of practice boundaries. And this is how it was reported in the press.

In this sense, he is duplicitous, ‘double’, speaks with ‘a forked tongue’. Not to be trusted.

(For text of what he said to RCGP)