I had always intended to read The Citadel, the 1937 novel by doctor and writer A.J. Cronin. Now, having received a copy as a Christmas present I have finally got around to it. So why is it important?
One of Cronin’s first posts in the medical profession was in Tredegar in South Wales during the 1920s and a large portion of The Citadel novel is directly based on his experiences. Now an exile, I was born and raised in the town (though a little while later!), but quite apart from the personal connection, it is a vital read for anyone interested in protecting a freely available citizen-centred Health Service.
The novel tells the story of a young assistant doctor, Andrew Manson who cares for the miners and their families. Later in the story, Cronin candidly examines the ethical background to the dysfunctional system by having his protagonist move to London and falling to the temptation of money.
The Citadel pulled no punches in detailing the iniquities and incompetence of the medical profession as encountered by Cronin. Greed and quackery is rife. Predictably, the book was controversial and made enemies in the medical profession. The British Medical Association was driven to reply to Cronin’s accusations and there was a determined effort by one group of specialists to get The Citadel banned. One critic dismissed it as “dramatized pamphleteering.” But A.J. Cronin was insistent, telling the Daily Express in an interview:
I have written in The Citadel all I feel about the medical profession, its injustices, its hide-bound unscientific stubbornness, its humbug … The horrors and iniquities detailed in the story I have personally witnessed. This is not an attack against individuals, but against a system
Today we take it for granted that there is a large cadre of dedicated doctors and consultants. Whilst private patients are still with us the clinicians have a good reputation and the men and women in the white coats generally are highly respected. But Cronin’s work reveals a dangerous aspect of a privatised health service; greedy and lazily incompetent doctors. In such an environment the rich may be able to take them to court for malpractice, but what of the rest of us?
Warnings of a fully privatised health service where the only protection was afforded by working men grouping together to collectively purchase medical services must not be dismissed lightly. They are stark. The Citadel may be fiction, but the evidence from the United States demonstrates that the warnings are real.
Click here for my The Leveller article on why external privatization isn’t the only threat to the National Health Service. Looking closer at internal market reforms, we can already see the disastrous effects of a consumerist approach.
Although Jeremy Hunt can be accused of many things, dissembling, incompetence and duplicity amongst them, it is my opinion that he actually works very hard. Unfortunately for us the aim of his efforts have not been improving the National Health Service but in managing the news to deflect the justified criticism of his actions and instead place the whole blame on the staff of the NHS or, incredibly, on us the users of the service Hunt is not looking for solutions to deep seated NHS difficulties, but rather to make HNS itself look unsalvageable. Here is how he is achieving this goal.
Missed targets are nothing new
This winter the NHS, especially its Accident and Emergency Departments are rarely out of the news. The main focus for the media has been the increasing inability to meet the target to treat 95% of A&E patients within 4 hours. The scale of the problem was leaked to the BBC last month. As a result Health Secretary Jeremy Hunt suggested that he may consider relaxing the four hour target.
I wanted to pause a moment and reflect, before the history books start to be written, before the entry which ends with ‘succeeded by Teresa May’ is written as if this happened as naturally as night follows day, to assess David Cameron’s contribution, his legacy. It’s all been said before, nothing new here, but I wanted to collect some of it together, before we all move on and forgot some of it. How bad it was.
He walks away with a little hum, and a ‘right, yes’, saying he’s going to leave ‘the s***’ he’s just navigated us all into to others to sort. It’s a day at the office for him, another day. Sometimes it’s been like a game for him and his chums (they are all ‘chums’ in the Tory party, apparently, when they are not stabbing each other in the back in the scramble for power). Nick Robinson compared it to Game of Thrones, and he should know because he was a close friend of all the Bullingdon boys. Nick could have been there sharing all that power with them if he wasn’t busy producing a stream of right-wing propaganda for the national news organisation which helps keeps them in power. He helps to share the power in his own way, by stifling other views.
It has been a series of days in the office. But it’s really been all about power. Sadly that job, that office Cameron has held has had the capacity to effect people’s lives. With the potential to harm them. And that Cameron seemed to enjoy. Or was it just collateral damage? What kind of man pursues austerity so that people who work long hours caring for the sick, disabled and disadvantaged can barely afford to feed themselves? And does this whilst diverting money to the rich in the form of tax breaks and bonuses for bankers? What kind of man has a disabled child and loses that child, (a tragedy that would ruin many people’s lives for ever), but then goes on to demonise the sick and disabled? Who refuses to help children escaping war who then drown in the sea, who sells off the profitable bits of the NHS and lets the rest rot away for lack of investment, and sanctions a system which classifies people with terminal illnesses as ‘fit to work’ so that the money they rely on for food can be reduced? What kind of person can do that, having had that tragedy happen to their family, even for power? Is there no conscience there? Just does it and then dismisses it all with a Pooh hum.
But there is more, lots more. Letting racism, intolerance and hatred breed, and pretending it’s nothing to do with you. But then acknowledging it, because it is part of people’s ‘legitimate concerns’ and moving your stance ever further towards more intolerance, more hatred, more dislike of anyone who exhibits any difference to your tribe. Drip-feeding this hatred through the media, watching a party form to exploit this directly and split the vote against you so that you can hold ever more tightly onto power. This after you have destroyed a liberal (‘Lib-Dem’) party with a great tradition of opposing such reactionary forces, destroying it by bribery and two-facedness, offering a bit of that treacherous power to a man gullible enough to take the offer, and then destroying him and that liberal tradition and that party without mercy. Clearing the field so that you can have a stronger hold on that power.
Then when you’re close to the end, when you think you might be getting bored of these days in the office, when the game is getting a bit tiresome, thinking you might have a final fling. Seeing if you can finish off a rivalry you started at university, when you were both in a club where drinking and destroying things whilst drunk was the prime directive. The stakes are a bit higher now, but you’ve got that party of hatred willing to help you split opinion and pour more hatred on to fan the flames against Europe. That’ll make this game more interesting. And yes, the old mate takes the bait, because you all love the prospect of power nearly as much as the realisation of it. And the press will help with more lies and hatred, and you know the left-wingers will struggle with their principles to know where to place themselves, and their discomfort adds to your pleasure. And gives your party a stronger hold on power.
It all goes pear-shaped in the end, but what the hell. Old rival doesn’t know how to deal with getting what he pretended to want, but no matter because you have a party full of people who’ve learned at your feet how to be even more greedy for power than you are. So you can go off with your ‘Ho-hum’ in less than three weeks. And it was a breeze really. There was the odd tedious day at the office. But overall, you and Gideon seemed to be having a good time. PMQs was, I think, for you one of the best bits – all that rowdy sexism, bullying, personal abuse – just like being back in the Oxford Union. The photos of you ‘having a laugh’ there say it all really. And the lucrative and very easy after-dinner speaker circuit awaits. More privileged drinking clubs. So you’ll never have to worry about money. Thousands of other families will, including those with disabled children, directly because of what you did. But not you, so that’s OK.
I’ll stop there. As he does. Retire gracefully. No longer pumped up for the fight. It’ll probably get worse for us all before it gets better. But I for one am glad the game is largely over for him. I hope he has days of regret, of conscience, in the time left to him. I hope occasionally he thinks of those other families, and wonders whether it was all worth it. When he is old and his health fails, and he starts to become like those he despised and tried to get us all to hate. I hope he wonders if it was worth it. For the power, the very brief and fleeting power, it doesn’t last. But the damage does.
In February 2016, NHS whistleblower Sarah Hayes revealed the chaotic state of the NHS 111 service in the South West of England. The story, picked up by the Daily Mail in a series of articles including this one , was associated with a scandal involving the death of baby William Mead in Cornwall. Hayes told of exhausted staff sleeping on the job and calls being handled by teenagers who had just finished their GCSEs with no medical training. Understandably, defenders of the NHS were quick to criticise the newspaper’s angle of the story, claiming the unacceptable level of service to be a consequence of privatisation. But the situation complicated by the fact that the NHS 111 service in the area in question was contracted by the local Care Commissioning Group and being run by a public organisation, the South West Ambulance Foundation Trust (SWAFT). Rather than being a straightforward case of the dangers of external privatisation the story tells us something more general about the market model in large organisations, private as well as public.
Leaving aside the whole issue of external privatisation, we have lived with an internal NHS market in some form or another for 25 years. We have been told so often that the way to promote service innovation and drive down costs is via competition that many people accept it uncritically. But does it work? It is interesting to start by looking at the private sector where, surprisingly, internal markets are not popular. This 2013 articleby Steve Denning outlines the problems. Denning’s article is focussed on innovation rather than service provision but the principles are the same since the whole point about delivering more medical services for less cost relies on creating or adopting innovative ideas. Denning mentions the case of retailer Sears whose chairman Eddy Lampert is an enthusiastic proponent of internal business units for driving innovation. As Denning says,
An outspoken advocate of free-market economics and fan of the novelist Ayn Rand, [Lampert] created the [business unit] model because he expected the invisible hand of the market to drive better results. If the company’s leaders were told to act selfishly, he argued, they would run their divisions in a rational manner, boosting overall performance.