10 minute read
As the NHS represents the fullest expression of working-class gains following World War II, its recent defence by the trade union movement appears surprisingly quiescent, not to say tokenistic. But closer examination reveals that its position is co-opted, with the health unions working in partnership with government and NHS England to secure most major elements of healthcare policy.
These include the NHS long-term plan, sustainability and transformation partnerships (STPs), integrated care systems (ICSs), and, most recently, the health and care bill itself, all of which, arguably, aim to break up the service and place English healthcare within a US-led global market. Form and ritual, though, have to be observed, and rather than admit to their inclusion within such a consensus, the unions must be seen to be protecting the NHS. The squaring of this particular circle is the subject of this article.
Social partnership forum
The Social Partnership Forum (SPF) was set up in 2006 by then health secretary Patricia Hewitt, and brings together the Department of Health and Social Care, NHS England, NHS Employers, and the leading healthcare trade unions, including Unison, Unite, GMB, and the doctors’ union, the British Medical Association, in order “to contribute to the development and implementation of policy that impacts on the health workforce”.
Periodically updated to ensure “agreed external positions” with regard to major legislative proposals, the forum seeks to find “collective, partnership solutions to the challenges faced by the healthcare system”.
Following the introduction of the white paper in February 2021 – the first stage within the overall passage of the new health bill – the forum now includes a special integrated care systems (ICS) transition partnership group (TPG). As stated in the group’s terms of reference, it aims to “shape the direction of travel for organisational change resulting from the ICS transition and provide clarity in relation to how this will relate to the legislative process”.
The forum is obliged to support the health bill
Forum members are bound to strict confidentiality. The purpose of this TPG subgroup, as with all the others, is to “support a smooth transition and minimise disruption” within overall policy development.
This clearly operates on two levels. Firstly, it ensures working terms and conditions are secure within the new formats. Secondly, but more importantly, it entails a consensus on policy presentation and implementation. In other words, support for the new bill is very much assumed within the organisation and subgroup terms of reference.
The bill, and its centrepiece of the 42 regional-scale ICSs, continues a long process of fragmenting the NHS and reconstituting it to serve global regimes of capital accumulation. This presents a problem for the unions – how to assist this policy whilst convincing their members and the public alike that they remain committed to publicly provided healthcare.
Amendments serve to strengthen the bill
The main means of achieving this appears to be through assembling a series of ‘talking points’ – a well-known public relations tool, particularly for policy communication – which offer a platform around which ‘opposition’ can be mobilised and which can be subsequently tailored for different audiences. These are then framed and presented as calls for amendments to the bill, removing its worst excesses, and seeking to ‘improve’ it.
The use of amendments serves several functions, often simultaneously, though always with the overarching aim of embedding the policy. By intending to try to ‘strengthen’ the terms of the bill – rather than issue an outright rejection – such terms, particularly the ICSs themselves, are increasingly taken as a given and only require some tinkering to make them more effective. They are also subsequently reinforced by each new stipulation. This offers a semblance of debate and democratic process, and indeed the impression that the government is capable of being responsive, when in fact they are pre-agreed by all members of the partnership forum.
As far as the bill is concerned, these talking points include:
- Insisting that the NHS must be the default provider for all new ICS contracts
- Workforce planning to avoid shortages
- Stakeholder representation and/or leadership, particularly independent clinical leadership, being embedded at every level of ICSs
- Ensuring ‘place-based’, local ownership and control as opposed to increased powers of the secretary of state
- Welcoming the repeal of Section 75, which signals an end to market development and a shift towards integration
- Ensuring robust transparency and accountability of decision-making and composition of Integrated Care Boards (ICB) and private sector representation
- Safeguarding the NHS from wasteful and destabilising outsourcing and privatisation
(On the penultimate point, members of the Commons bill committee have proved equally adept at encouraging the adoption of amendments in order to ‘strengthen’ the bill.)
Paying lip service to consultation
As mentioned, the use of amendments can be adjusted for different audiences. While the British Medical Association (BMA), for example, stated that it opposed the introduction of ICSs prior to the white paper, by the second reading of the bill the BMA’s submissions to the bill committee merely called for amendments to “ensure [that] clinical leadership is embedded at every level of ICSs”.
The BMA was also concerned that the bill risks undercutting “truly representative clinical leadership by failing to retain some of the positive elements of CCGs [clinical commissioning groups]”, though it should be remembered that such leadership was often left to career-minded GPs seeking a second income and willing to rubberstamp decisions made by global and domestic consultancies and insurers.
For the mainstream workforce more traditional homilies are offered, with an emphasis on ending outsourcing and privatisation, whilst maintaining that the “Tories cannot be trusted with our NHS”. The umbrella organisation Health Campaigns Together, which welcomes “affiliation from trade union branches (NHS and non-NHS), and political parties opposed to NHS cuts and privatisation”, has produced a collation of union briefings on the health and care bill. These state that, “We need to fight for amendments to the bill that will root decisions in local communities wherever possible, and give the public a say over the direction of their local services”. They also demand “no private sector involvement in NHS decision-making bodies” and that integrated care boards (ICBs) must include representatives of patients and health workers.
Ineffective union campaigning
In Unite’s campaign information, Jacalyn Williams, Unite’s national officer for health, said that the bill was a “Trojan horse for more privatisation, cronyism, austerity and a licence for politicians to run down and sell off the NHS”, adding that, “Unite is opposed to this disgraceful bill and we will lead a serious and effective campaign to ensure this bill is stopped”.
Yet, as stated in the ICS TPG’s terms of reference, Williams is the union’s representative in the forum’s ICS TPG, which aims to smooth the implementation of the bill and ensure support for “ICSs to create their own internal partnership structures and have them up and running from day one, sharing good practice and learning”.
Indeed, based on Unite’s own campaign information, the campaigning referred to by Williams, aside from a rally outside parliament, appears to amount solely to signing petitions and writing to members of parliament or the Lords – which is hardly equivalent to a “serious and effective campaign”. It is also worth mentioning the use of minutiae and technical language in such briefings – for example a whole page on paragraph 78 – a known means of dulling fundamental political antagonisms. Again, it’s not the stuff to rally the troops; nor is it meant to be.
Forcing through the government’s healthcare privatisation plans
Amendments can also serve as rallying points to achieve what the government intended in the first place. This is particularly evident with regard to the proposed increased powers of the health secretary, with all union and employer respondents arguing instead for less-centralised prescriptions and more local powers of decision-making. But full devolution is precisely what the government seeks – under supervision from the health secretary – with ICSs serving as fiefdoms for a policy elite drawn from US consultancy giants, an old guard heavily involved in global market formation, including David Nicholson, Chris Ham, and Patricia Hewitt herself, as well as a younger cadre schooled by US insurers.
Indeed, within the forum’s wider group meeting, the government told the members that it wanted to “retain flexibility in the legislative framework and avoid over-prescription” in the bill itself, and that “ICSs should have flexibility in setting their own constitutions”. The employers’ body, the NHS Confederation, added that, “system leaders are supportive of the de minimis approach”.
Concerted action to guarantee the bill’s passage through parliament
Further evidence of the concerted nature of the process can be seen in the maiden address of former NHS England chief executive Lord Simon Stevens to the House of Lords on 7 December when he called for significant changes to the bill.
Demanding greater transparency in the letting of contracts to the private sector and a curb on the powers to be given to the health secretary, Stevens also backed an amendment proposed by Commons health committee chair and former health secretary Jeremy Hunt, insisting the government publishes independent workforce projections biennially.
Stevens rejected the idea that the bill encourages privatisation, though he said the legislation should be strengthened to ensure the process of awarding contracts to the private sector is “transparent and fair”. He also added that the bill should not centralise decisions “best made locally”. In other words, the speech contains almost the entire menu of talking points, indicating the likelihood of Stevens himself as the key source of their content.
Parallels with organised labour in the US
It is also clear that the management of the policy process has become more refined and adept; far less heat has been generated in comparison with the passage of the Health Act of 2012.
Again, complexity has greatly assisted in this; all forum participants have known exactly how to add to the confusion, arguing at once to reject and strengthen the bill. And, as may be expected, the unions’ ‘offensive’ against the bill has been scaled up as the legislation passes through the House of Lords, secure in the knowledge that it will have no impact whatsoever. In fact, unions’ support for the NHS is now primarily rhetorical, and bears remarkable similarities with the actions and alignments of organised labour in the US, which has been a main culprit in the repeated defeats of proposals for universal healthcare, and the retention of private insurance, within that country.
At the very least, all the union leaders involved owe their members, and the public alike, some clarification as to their real position with regards to the bill.