The Bedpan: The NHS after capitalism

“If a bedpan is dropped in a hospital corridor in Tredegar, the reverberations should echo around Whitehall” – attributed to Nye Bevan

This week: Paul Mason, an award winning journalist and film maker, who is one of the intellectual driving forces behind the resurgent radical left.

Why he matters: There’s the small matter of 600,000 Twitter followers which gives him the reach of some national newspapers. There’s also the best-selling book, PostCapitalism which, the Guardian said, made Mr Mason a “worthy successor to Marx” in his ability to “spark the imagination and provide frequent x-ray flashes of insight into the way we live now”.

“The NHS was difficult enough to run when it was a top down, well-funded system moving at fairly slow technological pace. Now it’s that, plus a rationing system and a dysfunctional internal market. And you have to run it at the edge of chaos – with one bed left – which squeezes innovation and makes it difficult for the NHS to keep pace with even the pretty shabby private healthcare systems.”

It is fair to say Paul Mason is not one of those left-wing figures who thinks the NHS should just be better funded and then left to its own devices.

In a surprising echo of the views of health secretary Matt Hancock, the journalist turned economic futurist is a champion of new technology as the catalyst for radically reconfigured and improved health services. (In fact, prevention and workforce – Mr Hancock’s second and third “priorities” – appeal to Mr Mason’s other preoccupations too).

New forms of technology, particularly those powered by big data and automation, are at the heart of the thesis encapsulated in Mr Mason’s latest book, ‘PostCapitalism’. This Guardian article (shared nearly 600,000 times) provides a summary.

A set of crude headlines might run: Technology is profoundly affecting work and will eventually “hugely diminish it”; at the same time “abundant” information (for example, that created by the falling cost of genome sequencing) is undermining the “market”, which relies on scarcity to set prices; and, finally, new forms of “collaborative production” are emerging to replace it.

Mr Mason does not claim to be any kind of health policy expert – though his partner is a senior nurse and he seems familiar with the NHS reforms of the last two decades. He also specifically denies reports that he would be one of “the first 10 people through the door of Number 10” should Labour win the next election.

But he wields huge influence in the part of the Labour party that is less interested in refighting battles of the 1980s and more in creating a radical alternative to the “neoliberalism” of the last 30 years. Once a Labour government has exorcised its demons by rushing through ‘anti-privatisation’ legislation and needs to start developing its own vision for healthcare, the kind of thinking set out by Mr Mason will be increasingly influential.

It’s not just millennials, we’ve now got 35-year-olds with families whose basic attitude to everything is like going to Starbucks. Individualism has been baked into people over last 30 years

Neoliberalism’s mistake, says the former BBC and Channel 4 reporter, is the “conviction that state control, targets and management could ever modernise the NHS”. He adds: “That comes from seeing it as a machine.

“Reforms [with this mindset] always start out with focus on local and small. But in what is almost a microcosm of Marxist theory of the market, big [then] drives out small, [and] competition leads to consolidation.”

As examples, he cites both Lord Darzi’s ill-fated polyclinics policy, and the way commissioning reforms under both the Conservatives and Labour have started with a desire to increase local influence, but quickly moved to amalgamation.

This environment has cut innovation off at the knees, he claims. “What technological innovator is going to be able to innovate in a – in one sense – totally predictable and staid internal market, while at the same time understanding that every four or five years the whole thing fails anyway and gets changed.”

In contrast, Mr Mason says the NHS should be treated as “an organism, an eco-system”.

He wants to persuade future Labour governments that their mission is not (just) to stabilise an under-funded system - but instead to recreate the NHS as a “social institution” which can deliver “holistic care” and whose practice and example produces a more “positive society”, in which “people won’t cut each other up at the lights”.

No return to the 1980s

Mr Mason’s vision is of services driven by “innovation on both sides” – technology, and the “human models” of service planning and delivery. They key dynamic is the “interaction” of small, innovative and diverse local services with significant community input; with step change technological advances overseen by government, but with significant private sector involvement.

For those who want the NHS to readopt the paternalistic model of the past – of whom there are plenty on the left – Mr Mason suggests they think again.

“You can’t take the NHS back to the 1980s,” he states. “It’s not just millennials, we’ve now got 35-year-olds with families whose basic attitude to everything is like going to Starbucks. Individualism has been baked into people over last 30 years.”

He thinks this will change over the course of this century, but the message is clear that people are no longer prepared to accept simply what they are given.

Mr Mason’s is of the view that the health and social care system has to “treat the whole person”.

This mission has been undermined, he argues, not only by the intrusion of market mechanisms, but by a state and a medical establishment – he calls these the “great technocratic levellers” – focused on promoting uniformity of care delivery and standards.

Mr Mason instead wants “to configure services around a much more individually demanding human being with a good knowledge of their own needs” and recognising that the means for doing so will not be the same, because “individual or community x is not the same as individual or community y”.

This might mean – moving to more familiar political territory – that the clinically-driven centralisation of services is to be avoided for societal reasons.

“The huge [social] deficit in Britain is in small towns – left behind, [lots of ] old people, poor education, no infrastructure – and all the NHS has done for them is take their hospitals away.”

He adds: “People just don’t feel safe if they are more than 20 mins away from an A&E – their levels of political security feel very bleak.”

This inequity also extends to access to care. At present, he says, only the “very lucky and very articulate” can get the best from the NHS. Hence the need for community driven service models supported by a national public education programme of the kind last seen in the 1980s.

The working class “are not used to insisting on quality and they’re easy to get rid of from A&E, from a GP surgery”, says Mr Mason. “I want to teach people how not to be easy to get rid of.”

While the 20^th century may have represented “a necessary period of factorisation” in healthcare, he says the 21^st century should see societies “employ technology to humanise healthcare”.

When one speaks to private healthcare bosses what they say is that on a level playing field the NHS always out competes them – it’s bigger, has tax advantages – [but] it will just be slower doing it

He wants staff to focus more on patients’ holistic needs as technology does more of the heavy lifting on clinical diagnosis and treatment.

Mr Mason is well aware how challenging his views are for many on the left who see the NHS as something too sacred to “tinker with”.

He is also very clear that, on day one of taking power, a Labour government should announce an emergency budget which would “fund the NHS properly”. This would include paying NHS staff more, “making their lives less miserable” and giving them the space “to innovate and be creative”. Money should also be spent on returning a “public health mission in Britain”.

All this would, he happily admits, “eat up a lot more the £20bn”.

The big question

As befits the former economic and business editor of BBC’s Newsnight, Mr Mason has a more sophisticated view of the role of the private sector in public services than many on the left.

His biggest beef is that from the early 1990s onwards UK governments decided to engineer “profit making opportunities for a private sector that was not producing them itself”. He adds: “It’s not the state’s job to hand easy quantifiable profit-making opportunities to companies that would not exist unless it did.”

He cites Virgin Healthcare as a business that “would not exist unless the state provided it with a market” and says: “When one speaks to private healthcare bosses what they say is that on a level playing field the NHS always out competes them – it’s bigger, has tax advantages – [but] it will just be slower doing it.”

But Mr Mason does not preach a cliff-edge approach too private involvement in the NHS. He talks of giving firms time to repurpose their businesses and of the NHS as a “publicly owned, funded and managed system – [but with] lots of room for private sector innovation in it”.

On social care reform, he notes that a Jeremy Corbyn-led government would needs to make sure its “labour market reforms do not destroy the social care system” which is largely delivered by “small companies doing a decent job”.

However, by far the most important public-private relationship in Mr Mason’s eyes is the creation and exploitation of data sets, which in turn may lead to the development of artificial intelligence solutions to major healthcare challenges.

The NHS – because of its size and cohesive nature – is uniquely advantaged to contribute to new discoveries whose impact on national and, in some cases, global health would be profound. It is therefore also well placed to benefit from the health, social and financial upsides they could produce.

But this opportunity is already widely recognised and, in some quarters, faces opposition.

“The key question facing society in 21^st century,” he says, “is how much data should be owned, monopolised and taken private for private profit and how much should be kept in public domain as a public good. The PostCapitalism project thinks as much data as possible should be kept public.”

This is necessary to “massively increase the social impact of positive network effects” that can be derived from mining big data sets.

ID register

Mr Mason explains that this tussle over ownership cuts to the heart of the tension between the way markets work at present and whatever is to come. The unprecedented value of businesses like Google, Facebook and Amazon is derived from the fact that they own all the data they collect and can enjoy almost all the upside from exploiting it.

But to get real value out of the data collected by the NHS and other healthcare systems, he says it is necessary to create an ID register with identifiable data. According to Mr Mason, “Silicon Valley wants to hold [that] ID registry but knows it can’t ethically do so”.

Therefore, it must come to an accommodation with governments, who in turn need access to the expertise the tech giants have developed.

This leads to the next challenge - “to overcome people’s natural suspicion of the state owning the data”.

Mr Mason is directly helping to tackle this issue in one of the west’s most interesting political experiments – the city of Barcelona.

He has helped the city government develop the idea of “revocable permissions”. To be a citizen of the city and benefit from the services it provides you must be identifiable – in large part so you can be taxed appropriately. But you are also given a series of “permissions” over how the information about you is used, which can be withdrawn.

In an aspiration shared with many leaders in health tech, Mr Mason hopes the NHS will get to a place where it “looks after your medical record and has a duty of care [not to abuse it]”, but where the individual grants permission for it to be used for the public good.

Next week: John O’Connell, chief executive of the Taxpayers Alliance.

Coming up - three very different MPs: Luciana Berger, Sarah Wollaston and Johnny Mercer 

If there is any political figure you would like me to interview, please leave suggestions below or email Alastair.mclellan@wilmingtonhealthcare.com