The email from Care UK says they are ‘seeking a Media Relations Executive for our Head Office based in Colchester and your skills and experience appear to be a good match.’ Huh? They are offering a ‘competitive salary, 25 days holiday and corporate discounts.’

Here’s what I have replied:

Dear Laura,

Thank you for your unexpected email about the Media Relations Executive job with Care UK. I am very interested. Since Care UK is possibly the leading private healthcare company making inroads into the NHS, I would relish the opportunity to publicise what it does – indeed, this is precisely what I was trying to do in my previous job as information officer for Keep Our NHS Public (on a much smaller budget, I’m sure). That must be what you were referring to when you said my skills and experience are ‘a good match’.

As you can imagine, I am brimming with ideas. If you don’t mind, I would like to set them out here. First of all, I think much more needs to be done to let the public know what Care UK is. Hardly anyone realises just how big a chunk of the NHS you now run, from GP surgeries and walk-in centres to treatment units doing things like bunions. If I were your Media Relations Executor I would promote this aggressively to build the brand. I think the public has a vague idea about NHS privatisation, but they aren’t yet able to put a face to the name, so to speak. Care UK’s name could be that face. As a profit-making healthcare company owned by a private equity firm you are perfectly positioned.

I believe a key talent for any disrespecting Media Relations Executive is the ability to turn a negative in to something offensive. For example, it must have been a stressful time in the Media Revelations office when that tax avoidance story broke a few months ago – the one saying that Care UK had reduced its tax bill by taking out loans through the Channel Islands stock exchange. All this talk of tax havens and tax avoidance isn’t good in the current climate. But as your Media Relationship Executive I would have used a little reverse psychology, instead of denying it as your spokesman did. After all, this could put you right up there with the big boys like Goldman Sachs, Vodafone and Jimmy Carr.

Similarly, you got some bad press when it was revealed that the wife of your former chairman John Nash gave £21,000 to Andrew Lansley’s office before the last election, when Lansley was shadow health secretary. But let’s view it from another angle – doesn’t this serve to highlight Care UK’s excellent political connections? And look how it turned out: Lansley is in power and he has passed the Health Act. He has opened the door wide to privatisation, and Care UK is already inside redecorating the place.  We thought Lansley wasn’t going to manage it for a while, when all those thousands of patients and doctors started protesting and June Hautot shouted ‘codswallop‘ at him in the street. But he pulled through, sacrificed his future public career for private gain, and God bless him for that. Care UK now stands to make a fortune. This is something to boast about, for Bevan’s sake! And all for £21,000, less than it would cost to employ a Media Relations Executive for a year. (Please confirm.)

You should play to your strengths. Care UK is a true pioneer in this privatisation drive. You were the first private company to run a GP surgery in Dagenham back in 2006. And the first to face enforcement action from the Healthcare Commission because of slack hygiene procedures at the Sussex Orthopaedic Treatment Centre in 2008. And who’s to say you weren’t the first to forget to process 6,000 x-rays at your ‘urgent’ care centre in North-West London in 2012? As a Mediocre Relations Executive, I would advise not mentioning those last two.

If there’s just one thing that Care UK knows how to do – and there is – it’s take money from the state. I would make a bigger deal of the fact that 96 percent of Care UK’s revenue comes from the NHS. That’s the kind of solid base that any company would envy – taxpayers’ money, minimal risk, easy profits. So shout about it! It shouldn’t just be left-wing NHS obsessives who hear about this stuff.

Take the Barlborough Treatment Centre. It’s a complicated story, but in the hands of a good Media Relations Excretion it can be turned into a wonderful example of the company’s strengths. First, Care UK was paid £21.9 million over five years to do orthopaedic surgery – hip and knee replacements, that kind of thing – but you only did £15.1 million worth of work. (The local NHS Medical Director saw the trick, complaining: ‘The problem we have got is that they cherry-pick; they don’t take any patients with complicated conditions’. I guess the joke’s on him.) The NHS eventually realised it was getting a bad deal, and things weren’t looking good for Care UK. But then the NHS bought the treatment centre from you for £8.2 million, a lovely gesture. And finally the NHS signed a new 30 year contract to run the centre with… Care UK! (As an aside, it is important from a media management perspective not to spoil this tale of triumph-from-the-jaws-of-lucrative-defeat with any reference to the several lawsuits brought by local patients claiming that their surgery went wrong.)

As an example of what I could bring to the company I would like to propose a new corporate motto: ‘Care UK – Providing less, for more’. These words came to me when I was thinking about Manchester, where last year the NHS paid you £2.7 million for work that was never done at your Clinical Assessment and Treatment Services centre. According to a parliamentary report, the services you provide up there are between 7 percent and 12 percent more expensive than equivalent services in local hospitals. Providing less for more – it’s a record that really ought to be publicised.

And Care UK should be proud of its talent for cost-cutting, like the plan to use more nurses and healthcare assistants in your GP surgeries because doctors are too expensive. Your managing director, Mark Hunt, describes this as ‘workforce efficiency on skill mix’. As a Meddling Relations Executive I would advise him to ditch the jargon and tell it as it is. Patients might get a worse service, but at least the company is making more money and that’s good for the economy. We’re all in this together, as someone once said, in jest. I’m convinced that if Care UK followed my strategy it would solve the serious problem of patients accidentally opposing the private take-over of GP surgeries through confusion and surfeit knowledge, like when those blasted Keep Our NHS Public campaigners scuppered the Care UK health centre in Euston by threatening court action.

Be bold. Be proud. Be shameless. That’s the approach I would bring to the job, and I hope you like my initial ideas. Please be sure to let me know when and where the interview will take place (the formalities must be gone through, I understand). I trust that I will hear from you soon.

Yours sincerely,

Alex Nunns

For the health campaigners, unions, medical professional bodies and others who opposed the Health and Social Care Bill, at varying volume and often in staccato style, the moment when it passed into law was demoralising. Their long-drawn-out battle against the Bill had been in vain. But through their efforts they had managed to establish in the public mind the sense that the Government’s health policy was controversial and unpopular. The question facing this very loose alliance now is how to build on this foundation as the Act is implemented, for an ongoing defence of the NHS.

At the ‘Reclaiming Our NHS’ conference in London on 23 June, campaigners will try to forge an answer. In advance of the event several important organisations, including the TUC and the big unions, the National Pensioners Convention, and pressure groups like the NHS Consultants’ Association and the NHS Support Federation, have put their names to a joint statement that warns of ‘the breakup of NHS services and the undeniable process of NHS privatisation,’ and commits them to ‘reclaim a publicly provided, funded and accountable NHS that continues to deliver comprehensive care to all in our society.’

But how to do this? One issue is whether a single organisation uniting the disparate groups is needed to continue the pressure. ‘I think we should have some big umbrella organisation,’ says Jacky Davis, a consultant radiologist and a founder member of Keep Our NHS Public. ‘It’s not effective for everyone to be doing their own small thing. If we put all the little punches together we’d have a killer punch.’

But this is unlikely to happen. Aside from thorny tactical differences and the inclination of organisations to guard their own identity, many believe that the ‘swarm approach’ to campaigning can be ‘a nimble and durable model,’ in the words of David Babbs, Executive Director of online campaigners 38 degrees. ‘I know some people feel that not having an umbrella organisation was a significant problem in the campaign against the Bill, but that’s not my view and it’s certainly not top of my list of reasons why I think we lost,’ he says.

One area where collaboration is essential is the task of monitoring the effects of the Act, which campaigners expect to be myriad, from the withdrawal of some services to the encroachment of profit-making companies into vital areas of care. There are already examples of opportunistic providers taking advantage of the new climate to impose charges on NHS patients, as happened recently for podiatry in Greenwich. And the deep cuts happening as part of the so-called efficiency savings will be extended by the dynamic of the Act.

False Economy, the new anti-cuts web resource (funded largely by the TUC but not strictly a union initiative), is one option to host such a database. ‘We are certainly interested in being that place,’ says False Economy’s Clifford Singer. ‘We do have the infrastructure and we have the most comprehensive list of cuts available at the moment so it makes sense for us to do it. We have the same problem that everyone has of resources, but if the TUC or anyone else wanted to fund a specific project it could be done.’

Proper collection and presentation of information is important because the theatre of campaigning is moving away from the national stage. During the legislative process all eyes were on Westminster, but now most campaigners believe the NHS will be won or lost at the local level. Long-standing campaigns, such as Keep Our NHS Public with its network of local groups, have vital experience of these kinds of struggles. For others who came to NHS campaigning because of the Bill, such as 38 degrees, it is ‘new territory,’ as David Babbs admits. ‘The most important resource you need for local campaigning is a network of inspired local campaigners,’ he says. ‘38 Degrees has one million members all across the UK and many of them have indicated a strong commitment to continuing the NHS campaign, including at the local level.’

Paul Evans of pressure group the NHS Support Federation believes that the success of local community campaigning will depend on how well a broad range of players are able to knit together in each area. ‘There are many who want to do something to keep the NHS alive,’ he says. ‘Some have national networks, others have research expertise or information, some have funding, others are poor but have highly motivated members who will organise meetings and take to the streets. The art is in creating a framework for them to work together in communities all over the country.’

This hope of broadening the campaign is fuelled by the experience of the last two years, when new groups like 38 degrees and UK Uncut joined forces with the traditional core of health campaigners. According to Lucy of UK Uncut, their distinctive style of direct action has proved surprisingly popular, even with health professionals. ‘We’ve had a lot of conversations with senior medical practitioners who are very supportive of direct action,’ she says. ‘These are what you might think of as unlikely people for civil disobedience.’ The influence of UK Uncut could be seen in the ‘Block the Bridge,’ protest on Westminster bridge, and the attempt to form a road block outside the House of Lords by activists chaining themselves together while Peers were debating the Bill. Lucy says the biggest impediment to more people joining actions and occupations is not lack of willing, but simply that people ‘don’t know how to go about it, so skill sharing is very important.’

If the process of opposing the Bill undoubtedly entailed branching out in new directions, it did not result in the kind of universal involvement across civil society that some had hoped for. In the view of Paul Evans, ‘Saving the NHS is still not mainstream. Some of our most powerful potential allies, like some of the national charities, whose users will really suffer under a fragmented and privatised system, really must step forward much more boldly.’

But a conversation with Neil Churchill of charity Asthma UK reveals just how far campaigners have to go before their analysis is shared by such organisations. According to Churchill ‘the Act is of secondary importance. The most important game in town is the productivity challenge.’ Churchill’s voice is significant because his views are representative of the Richmond Group of ten large patient charities. Even on the fundamental matter of competition the message of campaign groups and unions has barely registered: ‘The Act is not about open competition,’ Churchill insists, ‘it’s about managed competition.’

The people best placed to explain and thwart the most dangerous aspects of the Act are NHS clinicians, the majority of whom opposed the legislation. One example of a practical measure they could take is for GPs to push their Clinical Commissioning Groups (the new bodies that will buy care for patients) to adopt a ‘Fair Commissioning Charter’, committing them to resist private encroachment and act in an open way. This idea, which originated from campaigners like Health Emergency’s John Lister, has been endorsed by the GPs Committee of the BMA. Such steps are important – doctors who want to take a stand may feel exposed without collective backing (and, in this regard, pressure from patients through patient involvement groups is significant too). But passing a resolution is one thing; ‘without doing something about it and communicating it, it’s useless,’ says Jacky Davis, who sits on the BMA Council (the Association’s central decision-making body). She is scathing about the performance of clinicians’ professional bodies: ‘I blame the medical establishment for the Bill going through. I’m so angry about it. There’s no doubt in my mind that if the medical establishment had acted together the Bill could never have passed.’

Some doctors are taking a direct approach. The newly formed National Health Action Party plans to stand candidates at the next election. Clive Peedell, a consultant oncologist who in January ran six marathons in six days in opposition to the Bill, is one of the originators of the new party. ‘The aim is to win seats if we can, but mainly to make the NHS the second issue at the next election behind the economy,’ he says. ‘This will be a really exciting political development. The NHS is an amazing brand that people support, and we can connect with that through social media to harness that energy and reach out to a wider spectrum of people than normal politics can.’

‘Part of the strategy,’ Peedell explains, ‘is to make Labour rethink its health policy.’ Campaigners hope that a Labour victory at the next election could at least undo the damage done by the Act. But they have their doubts. ‘[Labour’s shadow health secretary] Andy Burnham has said they’re going to repeal the Act,’ says Jacky Davis. ‘But Miliband has said he’s going to deal with the three worst aspects of it. So come on guys, what do you mean?’

According to Guy Collis, policy officer at Unison, ‘repeal is probably unlikely because there are things Labour will want to keep. So it will be about reinstating a public NHS.’ Collis believes ‘if any party enters the next election promising another top down reorganisation it will be suicidal. But the big thing in Labour’s favour is the Act was so unpopular the public will be on their side if they take a bold stand.’

Clive Peedell, who thinks another reorganisation is necessary, nevertheless agrees that it cannot be done all at once: ‘I think it would have to be a longer term vision to restore the NHS. There is a clear first step to reinstate the Secretary of State’s duties, powers and responsibilities. That would be easy in terms of repealing part of the Act and it would have a big impact. Then other things would be done over time.’

Until then, as David Babbs of 38 degrees puts it, ‘The new legal framework threatens the NHS, so we need to campaign for that legal framework to be changed. But it’s hard to see that happening this side of a general election, so we need to work hard in the next three years to make sure we still have an NHS worth saving.’

The ‘Reclaiming Our NHS’ conference will take place at Friends House, Euston Road, London on Saturday 23 June, 10.30am – 4.30pm. For full details and to book tickets visit http://www.nhscampaign.org/reclaiming.html

Alex Nunns is Red Pepper’s political correspondent. This article was sponsored by the NHS Support Federation and a longer version appears on their website: http://www.nhscampaign.org/reclaiming/reclaiming-the-nhs-analysis.html

Well, it’s depressing: the government got its Health Bill through. The NHS has been abolished in all but name. All the work and effort that went in to building it up, all the money that people have paid in to it, all the ties of social solidarity that it has fostered – just squandered away in a right-wing spasm.

The campaign against the Bill – brilliant as it was – failed. The campaign against the Act can’t afford to. Up to now the battle has been fought largely at the national level. The next phase will be about local action. Here are some of the early ideas that health campaigners are discussing for how to move things forward:

1) Local campaigners want to do something – fighting the Bill generated huge amounts of energy that must be sustained – but it’s difficult to know where to focus in the new system. GPs will be the group with the most power to frustrate the implementation of the Act, and they are much more likely to do so if they feel pressure from their patients. So we should have a campaign to get people to ask their new CCG (Clinical Commissioning Group) to adopt a statement that commits it to treat the NHS as its preferred provider to protect local NHS facilities, to refuse to sign contracts that involve commercial confidentiality, and to take all decisions openly in public. There is no reason for clinicians, who all opposed the Bill, to disagree with these pledges. And if the government intervenes it will give the lie to all the talk of local control and their denials of privatisation.

2) Encourage people to get involved in patient participation groups at their GP surgery, to tell their GPs to resist the market elements of the Act by favouring local NHS hospitals over private facilities. Health Watch bodies and foundation trust boards also offer some opportunities to influence how the Act is implemented, or at least to monitor what is happening.

3) We need a central point for people to report local cuts and the loss of services (when patients are told they can’t have a certain treatment), so we can keep track of the real effects of the Act after the media has moved on. Somewhere like 38 Degrees would be perfect for this – a high profile website that can store and display all the information.

4) Every time a service is cut or removed, we should contrast government statements saying that this wouldn’t happen with a quote from a patient who is suffering. This should be disseminated in every way, via the internet, mailings, billboards.

5) ‘Occupy Healthcare’ – physically occupy facilities that are threatened with closure, in a way that doesn’t obstruct patient care. Hold local anti-cuts protests, always making the link back to the Act.

6) Expose which facilities are run for profit, and make local patients aware of it. Where a choice is available (which may not be the norm once the legislation is fully implemented), encourage patients to choose NHS-provided care.

7) Labour has pledged to repeal the legislation once it is power. This is possibly meaningless, since by the time of the next election the realities on the ground could mean it is impossible to simply repeal it. But it’s a symbolic commitment and we should hold them to it. While the NHS is a big political issue there’s an opportunity to pressure Labour to re-adopt its 1997 manifesto pledge, when it stood for a publicly funded, publicly provided health service. That did a fat lot of good last time, but right now it could have the beneficial effect of making the private sector – upon whose involvement the real purposes of the Act rest – more cautious and risk-averse, stalling the Act in practice.

More ideas will be needed and new strategies will emerge as the Act becomes reality. One thing is guaranteed: there will be chaos in the health service. This will not be one of those battles that fade into memory once the legislation is implemented; it will remain urgent and visible. Things were going to be bad in the health service anyway, with the NHS being required to make £20 billion of cuts. Combine this with a messy transition to a new system that hasn’t even been fully invented yet and the outcome will be manifested in many individual disasters. As Richard Horton, the editor of the internationally respected Lancet medical magazine writes in the April/May edition of Red Pepper, “People will die thanks to the government’s decision to focus on competition rather than quality in healthcare.” Those are the stakes.

But this cosy arrangement has now gone catastrophically wrong with the arrest of four A4e employees over claims of fraud. It has emerged that, among other allegations, A4e has had to pay back public funds on five occasions after government investigations found irregularities, and that the company made job seekers work in its offices for at least a month for no pay.

Margaret Hodge for Labour has called for all of A4e’s contracts to be suspended until the allegations of fraud have been investigated, but the government has so far resisted, and for good reason – under New Labour and the Coalition, A4e has practically made itself into an arm of the State. In five regions of the UK it is in charge of the government’s Work Programme, responsible for selecting providers to do the work of job placement and channelling public money to them, taking a huge fee along the way. Some third sector providers (charities, non-profits, community initiatives etc) that work under A4e in these regions have complained that job seekers have not been sent their way by the company and that they were merely window-dressing for A4e’s contract bid. In other areas of the country A4e wears a different hat, working as a provider itself.

This is what the patchwork privatisation of the welfare system looks like. A dominant player gets itself into an indispensible position and (allegedly) abuses the system, so that even when it is being investigated for fraud and is under so much public pressure that its celebrity chairman has to resign, the State appears powerless to act.

This is all the more shocking because the activities of A4e should come as no surprise – exactly the same scenario played out in Australia under the Howard government when it implemented the original scheme which the Tories have explicitly copied.

The problem, common also to other faux-market reforms of public services, is that there is (and can be) no functional market because there are no proper customers (the unemployed) and only one source of money – the tax payer. What emerges instead is a form of contractual clientelism.

In 2008 Red Pepper published an article called 2014: A Tory dystopia. The piece was written from an imaginary future but was based on the policy papers developed and published by the Tories in opposition – no one can say they weren’t warned. We are still two years from the imagined date of the article, but the piece bears re-reading (even if I did write it myself) because so much of it has already come true. (This speaks volumes about the Lib Dem’s “moderating” influence on the Tories.)

And what do you know, the piece contained a section on the Tories’ plans for job placement privatisation and the likelihood that it would end in fraud. The article predicts the emergence of dominant players with huge power to abuse the system, the sidelining of third sector organisation, and points to New Labours culpability. Here is the section, written back in 2008, but as if it was 2014:

As well as squeezing the benefits system, the Conservatives have privatised its job placement function. Jobcentres now grade potential benefit claimants according to their capability for different kinds of work and refer them to a private company to find a job. This fundamental reshaping of the welfare system built on New Labour’s reforms – Tory ministers defend their policies by saying they are only continuing James Purnell’s work.

The ‘payment-by-results’ system, under which companies’ funding depends on getting people into jobs and keeping them there, is meant to provide the state with the levers it needs to control the process. But it doesn’t work like that. The Tory plans were largely based on the Australian system introduced by the Howard government, but in that country the profit motive produced perverse outcomes and fraudulent behaviour. There was no real market, because the ‘customers’ (unemployed people) didn’t pay for the service and couldn’t choose to switch between companies. Although private providers were paid by results in Australia as in the Tory scheme, there was minimal competition once a few companies became dominant. To compensate for the failure of the market, the Australian government was forced to tighten regulation and central control – undermining the original aim of cutting bureaucracy and costs.

The Conservatives chose to ignore this evidence, and promptly repeated the Australian experience. They also faced an outcry from the voluntary sector, which had been promised a key role delivering job placement services but didn’t have the capital necessary to win many contracts. The sector belatedly realised that its involvement had been used as PR cover for privatisation.
When the current scandal could be seen from as far back as 2008, we should say ‘I told you so’ as loudly as possible.

In the UK Al Jazeera is channel 514 on Sky or 89 on Freeview. It’s also streamed live online here: http://www.aljazeera.com/watch_now/

The film doesn’t just cover the 18 days but the year since (I did some extra research work for Al Jazeera). It has been masterfully put together by Adib Nessim.

Watch!