Liquid healthcare

Gavino Maciocco

Both in the UK and in Italy, as the political seasons turned, we have gone from fair and reassuring health systems to increasingly unjust and uncertain ones. We have moved on from a “solid” healthcare, to a “liquid” one, to mirror Zygmunt Bauman’s concept of liquid modernity. Today, hardships and suffering are fragmented, dispersed, and widespread, and such is the dissent they produce, too. The fragmentation of dissent, the difficulty in concentrating it and anchoring it to a common cause – to then direct it towards a common foe – makes suffering that much harsher.

The day in which – in July 1948 – the NHS act took force, the government circulated a leaflet that explained in a few lines the healthcare reform and its aims:

Your new National Health Service begins on 5th July. What is it? How do you get it?

It will provide you with all medical, dental and nursing care. Everyone – rich or poor, man, woman or child-can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a “charity”. You are all paying for it, mainly as tax payers, and it will relieve your money worries in time of illness.

The entire philosophy of the NHS is summarized, extremely efficiently, in these few lines:

  1. Universal and fair access
  2. All-encompassing, free healthcare interventions
  3. Financing through general taxation, and the final reassurance
  4. No one will go broke because of an illness, no one will have to forego treatment because of its cost.

The birth of the NHS was part of a package of reforms, all with a flavor of universal coverage that went beyond healthcare into the realms of welfare and education, which were first brainstormed and proposed in 1942 by economist William Beveridge, on the initiative of a bipartisan government whose prime minister was conservative Winston Churchill. Its core aim was to reinforce social cohesion, showing its citizens that the government’s care was to protect them against turns of bad luck, to increase social security, and to eliminate class differences within the realms of healthcare and education. Whilst it is true that all of this happened at the height of World War II, and that in those harrowing days social cohesion was as crucial for the nation’s survival as was its bread (which was being rationed), but it is also true that these reforms remained in place for decades – whether under Labour or Tory governments – and that they became a solid and effective model for a welfare state, a paragon that Italy among others largely emulated.

Since the 1980s, however, libertarian politics have been launching an onslaught against this solid and effective welfare state model, beginning with Margaret Thatcher and ever thereafter. Here, too, this U-turn was bipartisan: After Thatcher came Labour’s Blair, and then Conservatives Cameron and May.

Libertarian politics have destroyed the NHS, grinding it down to its current state that we described in the newsletter article. To the list of horrors we must add one more dreadful entry: In a Third of the UK, the smokers and the obese are denied elective surgery, according to the Royal College of Surgeons’ exposé. The reasons are different, but the fundamental motive is of an economic nature: savings. (Our worry is that smokers and overweight patients are becoming soft targets for NHS saving). And since smokers and obese people come predominantly from the most disadvantaged population groups, this will cause a further ballooning of health inequality.

In Italy things aren’t going better (see L’anno che verrá). Here, no one has had the political courage to stick their neck out (see La Parabola della rana bollita), to overtly enact libertarian healthcare reforms like in the UK, but the substance does not change much because the ingredients are ultimately the same: underfinancing of the public healthcare system, staff haemorrhage, privatizations, and the monetization of health. Indeed, the effects are very similar too: infinitely long waiting lists, millions of people who forsake treatment, hundreds of thousands of people who are denied access to a lifesaving drug (our readers know we are talking about Hepatitis C).

Both in the UK and in Italy, as the political seasons turned, we have gone from fair and reassuring health systems to increasingly unjust and uncertain ones. We have moved on from a “solid” healthcare, to a “liquid” one, to mirror Zygmunt Bauman’s concept of liquid society.

Liquid, because afflicted by Unsicherheit, the poisonous fruit of globalization, where international financial capital – with its speed – has imposed its hegemony, and against which states and political institutions are impotent.

In the other Newsletter post we talk about Lombardy’s new healthcare. Among the newly introduced changes we note the new method for managing chronic illness. This blog has repeatedly touched on this theme, and we recently published an update on what happens in Tuscany as regards the Chronic Care Model, the most widespread and tested model worldwide, which is based on primary care treatment and multidisciplinary teams wherein the GP is the guarantor of treatment continuity.

Lombardy has chosen an entirely different path: management of chronic disease will be entrusted to many organizations (public and private), in competition amongst themselves, who ought to guarantee the entirety of healthcare cover. Cooperatives of GPs, too, will be able to participate in the competition, but on equal footing with other providers.

Alea iacta est: primary care (already extremely weak in Lombardy) is eliminated, the General Practitioners’ role is totally marginalized – perhaps a prelude to their future annihilation (and for this, the GPs themselves carry an enormous amount of blame).

Meanwhile, while the UK’s healthcare crisis is at its direst peak, Prime Minister Theresa May has no better solution than to blame GPs for hospitals’ black alerts, threatening them what had been afforded them by Cameron’s latest libertarian reform: distribution of NHS resources. Is that BMJ cover that shows Theresa May’s high heel trampling GPs an omen of their future doom?

It wouldn’t be surprising. Universal healthcare systems that entrust the GP with the role of gatekeeper to secondary care, combined with doctor-patient trust are fundamentally incompatible with a consumerist model of healthcare, which is based on consumption and profit, and who does not tolerate any middleman between consumer patients and service providers. (Already, in the UK, there is a move towards referring to patients as “service users” in increasingly more settings, translator’s note). 

In a consumerist healthcare system GPs can continue to exist, like they do in the USA, where they indeed act as gatekeepers, but do so in the interest of insurance companies.

Liquid healthcare demands this.

English translation edited by Salvatore Cognetti



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