What it is: Under the Knife is a new, crowd-funded and Keep Our NHS Public-supported documentary.
Why it matters: The film presents arguments that the NHS is being deliberately underresourced and privatised. It has been backed by many senior Labour figures and celebrity supporters, and may well play an important role in any forthcoming general election
“For those who like that sort of thing, that is the sort of thing they like” – Muriel Spark, The Prime of Miss Jean Brodie
Having written several times for HSJ about why I don’t buy the NHS privatisation argument, Under the Knife was always set to be a lively watch.
The NHS has used the private sector to deliver healthcare since its inception. GP services have always been supplied by independent contractors. High street dentistry, pharmacy and ophthalmology are all privately provided, as is much higher-tier mental health provision.
The documentary is on solid ground on the underresourcing of the service, going back almost a decade now, and presents some clear-eyed testimony of the impact of austerity. There is no intellectually coherent argument that the NHS has the resources it needs to function safely. There are about 100,000 staff vacancies, nearly 40,000 of them in nursing; and the NHS estates backlog currently runs to the tune of about £6bn.
Access to care is becoming harder and waiting times are rising. The NHS also has problems with a bullying tendency in its culture, and its treatment of whistleblowers remains atrocious.
All of these are big and real problems.
However, privatisation of NHS-funded healthcare is neither a big problem, nor is it a real one. But it is the central charge of Under the Knife.
The BBC notes “NHS spending with private sector providers in England was just over £9bn in the 2016-17 financial year – that’s 7.7 per cent of the Department of Health’s revenue budget, a figure similar to the previous year”.
More to the point, the NHS as it currently is does not look like an attractive proposition to the private sector (including to the often cited “giant US healthcare companies”). The implication that a sector of massive public interest, with a near 10 per cent staff vacancy rate and a huge capital backlog constitutes a great business opportunity implies very little understanding of how the private sector works.
‘The end of the NHS’
The film leaves extremely questionable assertions by Allyson Pollock hanging. She claims, for example, the Health and Social Care Act 2012 “really was the end of the National Health Service” – something which might surprise most of its 1.4 million employees.
The film’s arguments about privatisation also take no account whatsoever of current NHS policy, which is focussed on increasing the integration of the NHS – and, by default, removing market mechanisms. The inconvenient truths that the Conservative Party included a commitment to end the internal market in its 2017 manifesto and that Matt Hancock has said he would support NHSE proposed legislation to effectively do that, are simply ignored.
There is neither mention of nor engagement with the several peer-reviewed articles by Carol Propper, Zack Cooper and John Van Reenen showing various performance gains from market mechanisms in the NHS, even once controlling for funding increases.
When the film shifts from healthcare provision to the private finance initiative, it is much more convincing.
Sir Robert Naylor, formerly the chief executive of University College London Hospital Foundation Trust, which has one of the NHS’ biggest PFI redevelopments, says “the problem with PFI is that, although you get the facilities today… the government don’t actually have to pay for them until the future, so the cost is really being borne by future generations”. UCLH is now trying to buy out its PFI and has accused the Treasury of inflexibility.
Indeed, it is now widely accepted PFI provides poor value for money and fails to meaningfully transfer risk. The most recent National Audit Office summary is worth reading.
What PFI successfully did do was get many hospitals built relatively quickly, and without the traditional NHS building cost overruns which ensured UK taxpayers got two hospitals for the price of three. What it failed to do from the taxpayer’s point of view was get the right price for the very low level of risk transferred to contractors, and to anticipate that refinancing the debt element would be extremely lucrative for the (mainly offshore, and so non-taxpaying) PFI operating companies. In other words, it was a cock-up, not a conspiracy.
In any case, even the Conservative Party has now abandoned the idea, so where is the future threat?
Both Andrew Sturdy and Private Eye’s Richard Brooks make fair points about the worst tendencies of the Big Four management consultancies.
Number 10 or number one
The film begins with the statement: “The NHS was the envy of the world, the gold standard for healthcare… but today it has slipped way down in the world ranking. This is the story of how the NHS reached its tipping point.”
The flash of a graphic showing NHS rated 10th in the world cites the Commonwealth Fund’s July 2017 Mirror, Mirror analysis. Of the 11 countries the study analyses, the NHS does indeed rate 10th for outcomes – but in the Commonwealth Fund’s overall ranking, the UK rates first of these 11 countries. This is because the Fund rated it number one for care process and for equity. Nor does the film note that, relative to the other 10 countries, the Commonwealth Fund study has usually rated the NHS poorly for outcomes – important context when you allege it has slipped in the world rankings.
In slightly extraordinary interviews, James Le Fanu and Lord David Owen both mischaracterise the pre-Griffiths running of the NHS. Dr Le Fanu claims in the early 1970s, Whipps Cross “ran itself… there must have been about three or four senior administrators”. This seems extremely improbable.
Lord Owen, meanwhile, talks about the NHS being led by dual hierarchies between civil servants and doctors. This ignores the actual pre-Griffiths approach to running most NHS organisations, which was ‘three at the top’: the chief’s medical officer, the chief nurse and the chief administrator.
Alluding to the reforms set in train by Sainsbury chief executive Sir Roy Griffiths, which created NHS general management as we now know it, Raymond Tallis describes “the grocer’s daughter [who] asked a grocer if he would look at the health service”. The relevance of Margaret Thatcher’s father’s profession is not obvious and there seems to be more than a hint of snobbery about “people in trade” coming into the NHS with their strange ideas.
The snobbish tone continues in Dr Le Fanu’s comments about general management “bringing in a new class within the health service, a managerial class that hadn’t existed there before. The doctors were stripped of their power, so they were no longer involved or consulted. They were told what clinics to do; they were told how to run their wards. It was a serious blow to their self-regard and their sense of themselves as being a liberal profession.”
The ideas that doctors were made compliant and servile by general management is way wide of the mark and will bring a sardonic smile to the lips of many HSJ readers.
Dr Le Fanu’s comments about doctors’ self-image do hint at the cultural problem in NHS medicine of clinicians resisting the legitimacy of management, an attitude which is still alive and kicking today.
In footage from the press launch of his report, Sir Roy says “not enough is done on the perceptions and requirements of patients as compared to a business operation, where the service to the customer and to the community is in fact paramount and central to the whole management activity”. Putting patients at the centre of the NHS in this way still sounds like a good idea in late 2019 – maybe we should try it?
The film has a number of pertinent errors. Stephen Dorrell is described as serving as a Conservative MP between 1979-1997. In reality, Mr Dorrell served as an MP until 2015, becoming health select committee chair in 2010 – a post in which he proved arguably the most effective critic of the Lansley reforms.
John Appleby of the Nuffield Trust is captioned as “chief columnist”, which is a bit mystifying.
Director Susan Steinberg keeps the film moving at a cracking pace. It is crisply edited (Steinberg was an editor on Robert Frank’s infamous classic film about the Rolling Stones, Cocksucker Blues). Editor Alex Jones has worked regularly for the BBC and the archive material is interwoven skilfully with the narrative. Director of photography David Chilton was nominated for a BAFTA for his work on ITV’s Breadline Britain. Technically, the film is well-made.
But editorially, its bias is its downfall. There is no mention of the enormous achievement of the managerial-led efforts to reduce waiting times during the New Labour years, in which market mechanisms played some role. The film asserts the 2012 act unlocked a route to NHS privatisation. But, seven years later, that has quite simply not happened and, indeed, appears to be ever more unlikely.
As a polemic, Under the Knife lacks even a fraction of the first-person energy and wit of the films of Michael Moore or Louis Theroux. It’s a shame, as there is ample room to make a good polemical film about the problems facing the NHS. But Under the Knife is not it.
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Coming up: Domestic abuse campaigner and Labour MP Jess Phillips and Manchester mayor and former health secretary Andy Burnham
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