Mar 132011

Because of what I do for a living, I have a pretty decent understanding not only of how the NHS has worked throughout the past couple of years, but also of how it is envisioned to work under the reforms now being discussed in the Commons.

And I do not see that these reforms amount to selling off the NHS piecemeal and having sick people dying in the streets.

What I see, primarily, is two things.

First, a step is being eliminated in the commissioning process with the abolition of the PCTs. This doesn’t mean that GPs themselves, with all of their other workload, will also be sending the commissioning paperwork to the secondary care providers; it means that the PCTs will be, in effect, split and absorbed into the newly-forming GP consortia. These consortia are groups of GPs who have voluntarily banded together because they share a geographical area or a particular patient demographic and thus have excellent collective knowledge of the populations whose health they deal with. These GP consortia are already consulting deeply with their PCTs and, from what I’ve heard, most plan to absorb not only the function but also many of the staff.

This restructuring, therefore, allows voluntary groups with similar knowledge to take responsibility for commissioning the healthcare appropriate to that knowledge and to those patients. This is a massive improvement on the PCTs, which are region-based and have no frontline exposure to the population and patient groups in their regions.

Second, all NHS trusts are being compelled to become, or join, foundation trusts. For those not familiar with foundation trusts, they are locally-established and locally-accountable, fiscally independent hospital or healthcare trusts. They are governed, ultimately, by a membership consisting of local people, and they are required to demonstrate the involvement of that membership in major decisions. This makes foundation trusts both more democratic and more responsive. Some of the best trusts in this country—such as Guy’s at St Thomas’s—are foundation trusts and have been since the Labour government brought in the concept.

Every other part of these reforms is incidental and, incidentally, is what seems to have the “Save the NHS” and “N4S” (Not 4 Sale) campaigners so worked up. OMG, there will no longer be a cap on private-patient income for foundation trusts! So what? FTs can’t make those kind of changes without the agreement of their membership. And if the membership wants the FT to take more private patients, who are you to stop them? OMG, care might be given by non-NHS providers! So what? GPs are not technically part of the NHS; neither are care homes, many mental health centres, many home carers, and so on. Provision doesn’t have to be done by NHS bodies, and there is no proof whatsoever that private providers will give a lower standard of care, or that NHS commissioners will choose the cheapest private providers at the expense of patient wellbeing.

In fact, lately there have been a lot of, erm, questions (let’s be nice about it) surrounding the quality of care the NHS itself provides, particularly when it comes to (a) old people and (b) hospital-acquired infections, and therefore I see no reason to cling so tightly to this idea that NHS provision is automatically a good, or better, circumstance for patients.

In the end, none of these reforms alter the vital fact that the NHS is still free at the point of use for everyone, which I believe was the object in the first place: that sick people would have access to care regardless of income. However the back-end management works, this salient fact will still be true, and there is good reason to believe that these reforms, particularly the commissioning reforms, will help to improve that care, as the people responsible for looking after these sick people will have a much better understanding of their patients’ needs, both individually and as part of a particular community, and thus be much able to direct both budget and resources where they are needed, instead of distributed evenly across the board without reference to patient and community health profiles.

Mar 032011

Sean Gabb, director of the Libertarian Alliance and prolific author and commentator on British politics and society, has written a novel of mayhem, adventure, and alternate history: The Churchill Memorandum.

I don’t know Sean Gabb personally, but I have read other works on his recommendation (notably those of Richard Blake), so when the review copy of his novel arrived, I dove into it with great anticipation and devoured it in one afternoon, taking assiduous notes between incredulous outbursts of ‘He just… did he really just do that? WTF?’ Anyone who has read the novel will probably recognise this frequent reaction.

Even though this was several weeks ago, I waited to publish this review because I had a feeling, which turned out to be correct, that the novel would be somewhat controversial. In that interval, Gabb has been accused of being, variously, anti-American and an English national socialist, all because in his novel the United States is a fascist horrorville and Hitler wasn’t a mass murderer. As an American myself, I’m rather more sensitive than others to whiffs of anti-Americanism, and I didn’t get any as I was reading. I certainly don’t think Gabb is an apologist for Hitler or the Nazis. And I suspect that to make these sort of assumptions about an author based on the characters or settings in his novels is to indulge in more than one cognitive bias.

Sometimes, a novel is just a novel.

Or, in this case, a crazy drug-trip into an alternate universe where Hitler dies in a car accident in 1939, the pound sterling is still sound money in 1959, and Winston Churchill ‘did nothing big after Gallipoli.’ Be thankful for this back-cover exposition, because you, the reader, are a genius. If you know nothing about Europe of the Second-World-War era, expect to spend half your reading time delving around the murkier recesses of La Wik.

Our hero is half-caste Anthony Markham, historian of the feeble sideshow that is Churchill in this universe and unwitting possessor of a document that numerous plotters, including Germans and Indians who smell persistently of curry, desperately want to get their hands on.

Why do I characterise the book as a crazy drug-trip when others have described it as ‘Hitchockian’ and ‘noirer than noir’ (which I’ll also buy)? It’s hard to say without giving too much away, but here are a few bullet points to whet the appetite, or bring smiles to the faces of those who have read it:

  • Chekhov’s Buttcheek.
  • Alan Greenspan is shot within hearing of a bunch of air commuters, and nobody bats an eye.
  • CS Lewis as archbishop of Canterbury.
  • Goering is giving nukes to the Jewish Free State.
  • Having been framed for murder, our main character goes on the run—and promptly murders someone. Not even an important someone, so this doesn’t count as a spoiler.
  • Who the hell is actually behind this convoluted plot, anyway?
  • Michael Foot’s acid baths.

The importance of the titular document is wholly drowned in the gunfights, the multi-transport chases and escapes, the sheer insanity of staid types you once knew and loved such as Harold Macmillan—who, incidentally, tries to corral the main character just as said hero has been mistaken for a Labour Party candidate in a town hall meeting and is delivering a triumphant speech:

‘Brothers, let it never be said that the Labour Party was at all exclusive in its welcome to speakers. You’ve heard me put the socialist case for our national future. If you want to hear the other side, be aware that our Foreign Secretary—Harold Macmillan himself—is standing just outside this room, and is waiting to answer all your questions in person.’

Cue the mob.

Markham’s publisher’s daughter and a mysterious Major who doesn’t officially exist are also part of the dastardly plot, and Enoch Powell turns out to be the shadowy badass whom all the plotters fear.

Y’all, this book is further down the rabbit-hole than Alice, and I dearly wish that instead of a review wherein I praise the author for his audacity and imagination, I was publishing verbatim the notes I took. You would not believe this book.

That said, there are some deep author-avatar moments, and without doubt Gabb can create characters who are horrifyingly realistic. Markham, protagonist and first-person narrator, is a remarkably unsympathetic character, callous and cowardly by turns and buffeted along by events entirely out of his control. His attempts to take refuge in a sense of loyalty or duty to his country are constantly shown up as stupidity by people who possess neither, and his actions neither drive the plot nor resolve it. Much like real people, in fact, warts and all. And the realism is necessary in light of the fact that most of the other players stepped straight out of a Bond film.

More importantly, the more you hear from Markham, the more you realise that despite having access to his internal monologue, you do not know this guy at all. There is no mention of friends, family, background, previous life, or romantic involvements (apart from whoever gave him Chekhov’s Buttcheek.) His thoughts revolve around two things: nebulous politics and immediate circumstances. He’s like a random guy in a pub telling you a random story, and when you stagger out you’re none the wiser.

To me, this makes him possibly the most unreliable narrator in fiction. This is what really makes the novel worth reading, though of course it is exciting and inventive as well. But I feel compelled to draw your attention to the fact that the insanity all starts in chapter six, and when you remember what Markham does at the end of chapter five, well…

…that’s my theory. And I’m sticking to it.