Before I tackle some ideas about the NHS I want to take a step back to view the wider context. This is important because, as we all know, there is constant tinkering to make the NHS more ‘efficient’. But all the changes, I would argue, are predicated on control of budgets, of different ways to deal with crises, of cuts, which must happen. It’s not about need; it’s about transactions between administrators to restrict services. And never, ever overspend, because it is the way of the world. (I mean, let’s think what a hospital or a commissioning group might be doing when it overspends – they are in the business of saving lives) No, this is how it is – you stick to the budget and cut again and again and again. Meanwhile, we who want not just a better NHS, but the NHS to continue, as some might say, as it is, (which is an unfortunate way to think as it is well on the way to privatisation) we also tinker around the edges wanting this A&E to continue or that local hospital to remain open, or this local service for older people or that activity for children with disabilities to continue (and don’t forget the latter two are run by the local authority). Consequently, we write letters to our councillors and our MP, we join interest groups, we campaign and we march.
But let’s take a look at the wider context and what we know, and ask what is this thing that is our everyday reality? What is considered the ‘norm’?
One thing is clear – we’re in the midst of austerity, which is all about cutting our coat according to our means, everything must be judged by cost, everything cut to the bone. It is the way it is, and how things are. Or, is that so?
Austerity. So, where does it come from? It all goes back to that crash of 2008 when the over-confident de-regulated banks, with too much credit sloshing around in their system, looked for investment opportunities and found it in bundles of securities invested in risky high-interest mortgages given to people who could ill-afford them. The prevailing ethos was that this was ‘safe’. But credit began ever so slowly to be wary of this, and was ever so slowly withdrawn. Banks and the financial institutions themselves investing in these worthless ‘bundles’ became unsafe. The collapse of Northern Rock in 2007 was the first overt indicator that something was wrong, and then there was the crunch with Lehman Brothers gone in September 2008. I read that this was different to other crashes, when credit disappeared from one area (e.g. dotcoms) but appeared elsewhere. This time, in October of that year the financial system teetered on the edge of, I’m not sure what, as credit evaporated – everywhere. Which meant that all banks could have failed.
We don’t know what could have happened if the banks had failed because, apparently, the only remedy to ward off this total failure of the financial system was to (and I think we all know the phrase) bailout the banks. And this is the fundamental problem for us, who were outside this mess and could only watch as a small number of politicians decided on this action, we don’t quite understand why it was so necessary, and if it was necessary why no one took the blame, and why, several years on, not one of these elite bankers and financiers got prosecuted? Because we are living right here and now, ten years later, with the consequences of this crash.
The immediate consequences “led to a [worldwide] contraction of credit, which in turn led to economic shrinkage, which in turn led to declining tax receipts for governments, which were suddenly looking at sharply increasing annual deficits and dramatically increasing levels of overall government debt.” John Lanchester. After the Fall. London Review of Books Volume 40 Number 13 5 July 2018
And furthermore, across the developed world governments decided that austerity was the way to restore their depleted finances. When our new government came to power after winning the 2010 general election, this was their opportunity to continue the contraction of government spending, because not only was it the ‘thing to do’ because of the financial crash, it was also, I would argue, their opportunity to contract and shrink that dreaded thing that the right actually hates: the ‘state’ and in particular, the municipal, public services provided for the population by the local authority (LA).
The state: it is such a loaded term, which has different meanings for different groups. Is it benevolent and a ‘structure’ to uphold society or is it something to be wary of? I would argue that for those who wish to shrink the state, it is an overbearing nanny who should be ushered off the premises, because we can manage without you, thanks very much. Really? So, looking at local government: you can do without parks, buses, schools, libraries, social housing, cemeteries, rubbish collection, youth services and social care for children plus services for older people, of which this latter function (or increasingly non-functioning part) of the local authority is key to understanding some of the difficulties the NHS faces.
Look, don’t write a letter in your community newsletter about the loss of a school music service (saw just such a letter last week) or demonstrate outside the council offices and harass councillors because after-school activities for children with disabilities is being shut down (happened this week). Instead let’s open our eyes to the death of public service, and how the state is being unmade. And in a clever ruse, note that decision-making on how money is spent has been devolved down to these LAs, but not, unfortunately, the money to deliver that particular service that we’re so angry about as it closes its doors. So, go demonstrate outside No 10 Downing Street where the blame really lies.
Local councils get the majority of their money from government (64%) and the rest they raise from us through council tax and other stuff like rents and parking tickets and so on. And understand this, the money from government is no longer sufficient to deliver what most people want. The Local Government Association notes that councils are going to face £9.9 billion unfunded costs by 2019-2020. And while it’s the arts, youth services, Sure Start centres and our libraries that attract a great deal of attention as they reduce their hours and/or close, at this point, it is the care of older people that interests me. Criteria for these services is becoming higher and more stringent, so that low or moderate needs are unattended. Getting help will often depend, not on your need, but on whether you can pay for it privately. If you can’t pay then you won’t get, and it’ll be your daughter, or nothing. Although note that the lack of social care in the community is also compounded by lack of (private sector) care and nursing home beds, which are closing because the statutory amount contributed by the state (for those in financial need) doesn’t cover their costs. Which is why, in a nutshell, people are not being discharged from hospital and adding to the ‘crisis’ in the NHS.
But, the argument goes, we cannot afford this reliance on the state. Be real, there isn’t the money for all this. Well, all decisions on monies spent is political – apparently submarines and aircraft carriers are fine, go ahead, you can have them. But care in the community and our local hospital? No. The thing is, while it doesn’t matter who we vote for locally, nationally, oh yes, it matters which party we vote into power.
It matters also what we, as a country, think should be a viable welfare state. And yes, this should be accompanied by a realistic look at how we pay for this welfare. Actually, I would argue, we need more tax revenue.
Of course, governments could gain more revenue through taking a Keynesian approach and invest in infrastructure to create jobs for its citizens, and gain tax revenue that way. This is the tax revenue from the many, which is needed, and could be done. But it’s small potatoes. The real money that could fund a fairer society is floating away either into tax havens, (this is money that we know exists) or there’s the money we don’t see and know nothing about (but see below).
It is estimated that trillions of money escapes taxation – possibly £8.7 trillion. This is not the little people escaping paying taxes (Have you submitted accounts to the tax authorities? I have and you don’t dare get a thing wrong.) No this is, the 1% of our society, the corporations, the big, big, media conglomerates, the hidden trusts, the so-called elite of the world who don’t pay their taxes and their dues, who in effect, abdicate from society.
There needs to be significant redistribution of this wealth, not just on a national scale but at an international level – it could be done, whether there’s will to do this, is another matter.
Look at it this way. Being literal, think of high walls and a serene sky surrounding our thoughts like the reality of the man in the Truman Show – what is real? As well as austerity being the only solution to rectify the financial crash of 2008 there is much that is hidden away from us ordinary people.
I mean, let’s start with Quantitative Easing, which seems to be a government inventing a new set of accounts with which they then buy bits of their debt and saying it’s real. And apparently is very necessary these days, but with that comes the downside that it inflates prices and distorts housing markets for a start. I can’t say that I understand this at all!
And have you heard of shadow banking? This is the lending and transferring of money, executing payments and so on, all done, not by banks, but by other financial bodies like credit card companies, insurance and the mysterious institutions that as one author said, lend money back and forth to keep the banks going. I mean what do we think is the ‘market’ that is meant to regulate the international financial system? It’s not a place, but wires and cables and data running in and out of numerous hedge funds and data centres in millionths of seconds to the tune of, one estimate, $160 trillion. And I can’t quite work out what that number means apart from a source saying that’s twice the GPD of our planet. And all unregulated, as in, no one agency is overseeing all of this.
Meanwhile we join groups, we write letters, we campaign, we march for our beloved NHS. But services cannot be saved while we live in this miasma of ‘common-sense’ unaffordability, and all those trillions of magic money that floats around unseen and unregulated. We need a much more radical kind of politician who can face up to this.
And mainstream thinking has to change. Do you remember the demos against the banks in 2011 otherwise known as the Occupy Movement? A movement that was international and is apparently still working to change society and make it a fairer world? But, they were all woolly liberal hippies weren’t they? Actually, we all need to think that the banks and the wider financial system has to change. We need to realise that we are the 99% and demand that change from our politicians, and ask them to regulate and tax the 1%.
Now that would be getting at the root, and at the source of the increasing inequality in the UK (and elsewhere) and the decline of our much-loved public services.
Penny Kocher, 8th August 2018
John Lanchester: After the Fall. London Review of Books Volume 40 Number 13 5 July 2018
Tom Crewe: The Strange Death of Municipal England. London Review of Books Volume 39 Number 24 15 December 2016