Biopower and the NHS

Here in the UK, we are increasingly seeing biopower at work in the national health system (NHS). A target driven culture allows patients to be treated like numbers or labelled as disease entities. It is common place to hear of people referred to as ‘Diabetics’ or ‘Asthmatics’ rather than understood as a person, with a name, in a particular life context and set of relationships who has diabetes or asthma. In my area of work, that of general practice, a huge part of our income every year comes through meeting ‘QOF’ (the quality and outcomes framework) targets. The idea behind such targets is to ‘drive up standards’ and ‘improve patient care’. In real terms, however, people can end up having various changes and increases to their medications, so that their blood pressure meets a government target, for example. The ill effects of this, particularly on old people has been recently well documented. Clinicians work hard to get everybody’s blood pressure below a certain value, but due to a lack of research and understanding behind the targets set, especially for people over the age of 75, lowering the blood pressure too much has been causing an increase in falls, fractures and long hospital stays! This is one of many examples where ‘payment by results’ is actually subtracting from patient centred care.

In the recent top down re-organisation of the NHS, which has cost more than £2billion, despite a government promise that such a reorganisation would not happen, more services are being driven out of a traditional hospital setting into the community with no extra resources or time provided to do this work. The new clinical commissioning groups (CCGs) are the new local governing bodies, which have replaced PCTs (primary care trusts). The idea behind this is that GPs, clinicians who know their patients and areas well, should be those who commission services rather than non-clinically trained managers, as they potentially have a better knowledge of the needs of patients. However, it transpires that if the government don’t like decisions being made, they can simply dismiss a board and replace it with another one which will comply with their wishes or cause them less of a political headache.

The implication of the EU-US trade agreement has opened the NHS in a way, like never before, to the forces of the free-market. This is based on a philosophy that competition drives up standards of care, and that private providers should be able to bid for services. At first this sounds like a credible and plausible idea. If another provider can offer the same service for less money, surely this is a good thing? Actually it is problematic on two levels. Firstly because the philosophy is deeply flawed. Competition does not drive up standards. It increases stress and breaks apart well integrated services. It destabilises services which currently work well in a symbiotic manner. For example, if Spec Savers offer a cheaper hearing aid service than the local hospital, then they can win a bid to provide this service. But it destabilises the hospital audiology department, which then has a knock on effect to the ENT department. The private company benefits, but in the long term the local population does not. Secondly, when companies limited by shares become the providers of care, care begins to play second fiddle to the need to make money. And here is a major stumbling block. The marginalised poor and the chronically sick do not make good financial sense, and share holders who live in another part of the world care little for their needs, but care a lot about making more money for themselves. So, we will find that those who need care the most will be unable to access it, as greed becomes the driving force. This is sadly proven in the US health system, where this philosophy is rife and 50 million people cannot afford healthcare and 40,000 people died last year as they could not afford the operations they needed. It is only media hype that causes some to believe the US to have the best health system. Most consider it to be inequitable and highly wasteful of resources.

The Complex Commodification of Healthcare

Not the most eye catching title, but bear with!

I’ve been thinking quite a bit about what on earth has happened and is happening to healthcare, particularly in the UK, but globally, also. My musings are being particularly influenced at the moment by the writings of William T Cavanaugh, Georgio Agamben and Michael Foucault. More from WTC and GA another time (when thinking more about healthcare and the nation state)….

Foucault, speaks of biopower, i.e. the commodification of life itself, so that even what would have been considered within the private sphere of our lives, is now the fodder of the economic machine. Truthfully, healthcare has become utterly commodified and in such a complex way that we find ourselves entangled in a sick web and it takes some major diagnostic work to make sense of what is happening.

Firstly, the system of healthcare has become commodified and is itself driven by economic greed. I have yet to find any clinician who thinks that the top down reorganisation of the NHS in the UK at the hands of Andrew Lansley, (but started by the government of Thatcher and most certainly compounded by Tony Blair’s team) has been in any way a good thing. It has cost literally billions of pounds, and has led to and will lead to more private companies, limited by shares, owning and running the health care services. This is driven by the EU-US trade agreement and is based on an utterly flawed philosophy that competition will improve patient care. Except, it won’t. The problem is that share holders don’t give a toss about the needs of the chronically sick or the marginalised poor. Rather they want to protect and guarantee their ‘income’. So health care will worsen. The WHO recently stated that the NHS is the best health system in the world and yet our government has thought it best to dismantle it! The claim is that the system is costing too much money! The thing is that the NHS is and has been ‘in profit’ for a long time. It isn’t run badly. All the cuts that are being made (which the Tories won the last election by promising they wouldn’t make) are in part due to the fact that many corporations are paying such little tax, and also because we have such an utterly corrupt banking system. The reason that successive governments have not stood up to the banking sector or these corporate giants (and are now cutting public services instead of challenging them) is because they are not really the government! The banks and the corporations are (well they are not either, but they act as though they are)! That is why the healthcare system itself is becoming more commodified! At a corporate level it is simply fodder.

Secondly the patients have become commodities. Do not be deceived. We have a healthcare system based on a Pasteurian philosophy of healthcare. Kill the disease. You are a commodity. Your children are a commodity to the advertising companies, cheap supermarket trash and fast food chains, which are driving up childhood obesity and diabetes, whilst we take exercise out of schools. You are a commodity to the pharmaceutical industry and when you reach 40, if you’re not there already, you will be offered a free NHS health check, which will tell you that your BP, Blood Sugar and Cholesterol are too high, so you will shortly be needing some medication to control it all. But here’s the thing…..it’s mainly too little, too late. What happens in our early life far more affects our health in older age. We need to be majorly cheerleading the promotion of healthy living to our kids, especially our young women, as the health of your mum whilst she is pregnant has a huge impact on your future health, far more so than drugs you take after your mid-life crisis. You are also commodified by the breakdown of the welfare system. We don’t have time or money, apparently, for you to be off sick. We need you back in work to get the economy going. You will notice that most therapies are being extremely cut back – we don’t have time for you to get really healed, we just want you functional……

Thirdly, there is the commodification of the health-workers. Burn out, low morale, tired and flagging. The pressures are mounting and we are not taking care of our staff, and the sad truth is, it will get worse and not better. One reason is that we are becoming increasingly self-centred and demanding as people, due to a multiplied sovereignty in our history, which leaves us feeling like we have the right to behave like mini-emperors. Another is a kind of learnt helplessness due to the breakdown of community. A third is the anxiety driven nonsense we find daily in our media, a kind of chicken-licken hysteria about every mild ailment. And fourthly, there has been little foresight or planning to think about where on earth our workforce is going to come from if we don’t train them. We have a 50% trainee doctor shortage in the Emergency Departments. We will shortly have a national shortage of over 30000 GPs (and yet the government is promising 7 days a week cover, 8-8, just incase you want to discuss your piles on a sunday afternoon), but little thought is given to exactly where we will magic the workers up from. And if we take them from the EU? What then of healthcare in those countries? Ah yes…..multiplied sovereignty, we don’t really care. That’s why we continue to complain bitterly about the health services in this country, and yet we have the same population as South Africa, and ten times as many doctors. How do like them apples? Try being grateful!

Complicated, huh?

So we and our health are commodified. So what? How does knowing do anything except add to our already felt sense of powerlessness?

Well, we have some choices and some options.

We can choose to subvert the system wherever possible.

We can create some exciting alternatives.

We can protest.

We can radically love Andrew Lansley

We can vote out this government at the next election, though we must press for a new way of doing government, and allow our selves to completely reimagine how we do life.

We could have a revolution.

We can treat patients as sacred beings and refuse to treat them as commodities.

We can treat workers as gifts and not use them or abuse them.

We can be thankful that we have the best health system in the world and change our attitude somewhat.

Reimagining Money aka Sacred Economics

For a long time I have been convinced that we cannot reimagine the future if we do not redefine our relationship with money. A number of years ago I read a book by a chap called Alan Kreider in which he was talking about how we foster community. He said that the sad truth is, until we’re able to talk about money in a free and open way and sort out our finances, we can never truly learn to be community.

Since the financial crash of 2008, I have been fascinated to watch the unfolding interplay between the banking sector and the ‘political elite’. We suffered a massive earthquake, the after shocks continue and serve as a warning that more disaster is on its way; but we have an hilarious situation in which the politicians tell us that by some weird combination of printing more money, tightening our belts or spending more (depending on who your finance minister is!), punishing the poor and ‘regulating the banks’, whilst bailing them out, we  will somehow recover from this trauma, so that we can continue business as usual. But it is business as usual that caused this crisis and it is business as usual that will lead us back into one.

I have been disappointed by the lack of alternatives discussed in the public political arena. In my mind, it matters very little which party is in power, as the general direction of all of the current alternatives is towards future growth of the economy with more of humanity and the earth itself becoming fodder to the ever hungry machine. Here in the UK, the conservatives tell us that austerity is the answer, and we must particularly blame the ‘feckless poor’ for the mess we are in. The labour party tell us that actually spending more is the answer, but the responsibility must lie with the ‘greedy rich’. The liberals are lost at sea and seem to have forgotten what liberalism is, (at least for a while) and then UKIP arrive to offer the ‘heroic’ idea that what we really need is self protectionism, independence and more patriotism. Kill me now.

And yet, we remain in an amazing moment of anomy, in which many, the commons, the multitudes are undeniably calling into question meaning and purpose at a profound level. We are at the fullness of what Foucault calls ‘Biopwer’ – the commodification of life itself. And people are sick of it. People are sick of feeling like they are being eaten rEVOLutionup like bread in order to keep the economy going, to keep the targets met, to keep the debts serviced. I see teacher after social worker after nurse after builder after sales person have breakdowns in my consulting room, because they can no longer stand under the rod of their oppressors. I see managers and directors having breakdowns as they realise they are losing touch with their own humanity and for what? Is this what we were made for? Is this the best we had hoped for? But it is in these moments that we must allow the songs of ‘Les Miserables’ to become our own – “Do you hear the people sing, singing the songs of angry men, it the music of a people who will NOT be slaves again….”

There is a sound emerging in our hearts, there is a rumbling in the people, there is a hope rising in our hearts that this dog eat dog world of violence and suffering is not the future we must endure. There is an alternative. There is a possible future of peace and love, but raging against the machine and losing our voices shouting at it may not accomplish very much – at least that is what I am learning! I have ranted to myself and others many times, but what has it achieved? Perhaps a stirring of hearts, perhaps a rising of hope, perhaps a new determination that life can and will be different for the multitudes. But ranting will not suffice, nor dreaming alone. It is time for brave acts, to disregard the powers and to begin to be creative.

But our creativity must be both prophetic and practical, experimental and pragmatic. We call for a new future and we live differently. And so, we must redefine our relationship with money, not do away with it, but refine what we mean by ‘money’ and ‘the economy’. With that in mind, I want to do some blog posts on a phenomenal book I have just finished entitled ‘Sacred Economics’ by Charles Eisenstein. It gives voice to Sacred Economicsmany things I and others have thought about but lacked the understanding or language to communicate. I cannot recommend it highly enough. Charles believes in the creative commons, when it comes to copyright – (check out their website), so I am free to copy passages of his book where that is helpful, but I want to honour the brilliant work he has done. He gives a brilliant history lesson in our relationship with money, how it has led to an age of separation where community is broken down and we have lost relationship with one another and the earth, how we recover a ‘gift economy’ and how we practically move forward to “the more beautiful future our hearts tell us is possible.” I hope the coming blogs are inspirational, encouraging and practical.

The photo “revolution is taken by Tim Pierce. http://www.flickr.com/photos/qwrrty/6209634263/