Who failed Bob and Eve Tonkin?

Amongst the disturbing lapses in this case study of NHS Cornwall’s outsourced out-of-hours GP service there is an alarming report of the initial telephone conversation.

The caller, anxious to get urgent assistance to his suffering wife, recalls telephoning the out-of-hours GP service at about 7:40pm, when he is warned that “it could be a six-hour wait despite his assessment of the urgency of the problem because it was so busy”. (The call is logged by the Service Desk at 20:01)

This alone raises serious concerns about the quality of the contractual arrangements between the Primary Care Trust and Serco Healthcare. Such an excuse is not permissible. If it was an honest assessment by the agent who received the call, it flags a failure in the service and in the management of the service. But by which party to the contract: the PCT or Serco Healthcare?

Central to the delivery of an outsourcing agreement are the Service Level Agreements (SLA).  SLAs are the detailed definitions by which the quality of service to be delivered are constrained and monitored. The contract between NHS Cornwall and Serco Healthcare will (hopefully) include SLA related to response times, and these should include different response times based on the priority and impact of the telephone call.

The SLAs are there to be met, and regular service management meetings between PCT and Serco Healthcare will review Serco’s performance against the SLAs, using key indicators as measures. Such KPI might be, say, 99% of telephone calls answered within 6 rings”. If, as implied by this part of the story, SLAs were being set aside because the services were “too busy” or “undermanned” then there is clearly a problem.  The question then is, what happens when the SLAs are not being met?

Outsourcing a service successfully is a complex task; and the experience of many businesses is that no matter how thoroughly the outsourcing is done, it doesn’t bring expected benefits.  It may be that these were never properly defined or implemented:  it may be that outsourcing was done for the wrong reason, and the most common wrong reason is to outsource in a leap of faith (or desperation) that it will cut costs but leave a service intact or even improve it (the “more for less” challenge).

The tragic experience in this case was that although the NHS staff were superb,  interleaved between personal contact with NHS services is an outsourced service which failed these patients; or which could not meet their needs because healthcare professionals were spread too thinly.

Because that is the difference between an SLA for mending printers and an SLA for assigning care to patients. Best practise service level management is to avoid 100% performance indicators for SLA, because any single exception is immediately a failure. Unfortunately – tragically – a failure to provide adequate service to a patient can easily mean loss of dignity, excess suffering, or death.

Thus we return to the question: who is failing the public in Cornwall, the PCT or Serco Healthcare? Elsewhere in this report there are suggestions that Serco is not keeping or providing accurate data on the service, which would mean its performance cannot be fairly judged and improved.

Whether Serco Healthcare is not providing the service which it has been contracted to do or Serco is providing the service in the full spirit of the outsourcing contract to the SLA and performance indicators agreed, the responsibility for failure in the service must lie with the PCT. Whether the contract is not being met or it was inadequately drafted, or it was done for the wrong reasons, or it was badly implemented so that the processes cannot work, or it is inadequately resourced, or inadequately funded, or the relationship between PCT and Serco does not work effectively: the PCT is responsible and must be held accountable.  Outsourcing a service does not outsource responsibility or accountability: in fact, managing an outsourced service is a challenging management activity. It is not a hand-off that the managing business can then forget about.

The statement from the PCT is therefore dismaying: “We are confident the service is adequately resourced and meeting the required national quality standards.” This reads very like a denial of responsibility. The second half of this excuse “meeting the required national quality standards” returns us to the important point that targets make organisations witless. “This is not an abstract point: targets can kill.”

But the issues this awful experience raises move beyond whether the service is suitably resourced and whether it is being properly delivered and overseen.  The real issue is why the service was outsourced in the first place, and an important factor here is the role of cost-cutting. Cost cutting is driven from the very top of the management hierarchy: in this case, the Secretary of State for Health, Andrew Lansley MP.

Camerons Big Society explained

“What’s good for M&M enterprises is good for the country”.

In Catch-22, Milo Minderbinder uses this mantra to justify every action he takes to increase his profits, including shredding the bomber crews’ parachutes to serve up as inedible food (replacing their real food, which he has sold off) and directing US crews to bomb their own airfield. The senior officers are complicit in all his undertakings as they are shareholders.

Heller’s entrepreneur paraphrases that much-used part of the neoliberal creed; the “invisible hand” argument of Adam Smith:

“By pursuing his own interest he frequently promotes that of the society more effectually than when he really intends to promote it.”

In an unintentional homage to “The Life of Brian”, neoliberals re-interpret the text as follows, by replacing:

• “his own interest” with “his own selfish accumulation of wealth”
• “he” with “the entrepreneur, banker, hedge fund manager, tax-evader, … “
• “frequently” with “inevitably”
• “that of the society” with “your economic well-being”
• “when he really intends to promote it.” with “any Government can.”

Thus in the heaven (or haven) that is an unregulated, ungoverned, untaxed “free market”, individual acts of self-interest produce a common wealth which is unachievable in the presence of any regulation, taxation, or government.

This “free market” world where not just the best, but the only way to help your fellow human beings is to act only in your own self-interest is what Margaret Thatcher idealised when she declared that there was no such thing as society. To the neoliberal, society is a false construct, a failure.

What Heller demonstrates satirically, but what most of humanity experiences painfully, is that obedience to this text justifies any act, whether it is refusing to pay taxes, selling arms, exceeding the speed limit, expelling toxic substances from your factory, or selling your daughter into prostitution.

Or, indeed, selling your neighbour’s daughter into prostitution. It is unsurprising that in the neoliberal state people are enormously frightened of crime and violence. Government has been reduced to the role of policing the victims of insecure, low-paid employment and unemployment and preventing them from disrupting the upward flow of capital: it has no presence in the domain of securing citizens.

While western politicians envy the absence of workers’ rights in China and the vast profits to be made with such lowered costs, journalist Ed Vulliamy describes the even more perfect  (neoliberal) capitalism of the Mexican drug cartels.

It does not matter, according to the faith of the invisible hand, how we treat any other human: except that we must not have a care to their well-being, and we must avoid collaboration. In the absurd manichaeistic quasi-religion of neoliberalism (“Those who are not with us are against us”) The Muppets truly are Communists, by the argument that 1/ Anyone who is not neoliberal is a Communist 2/ The occupants of Sesame Street help each other to do simple arithmetic and even show interest for each other, therefore 3/ The Muppets are Communist.

The neoliberal trope of “individual responsibility” is in reality its opposite: we are called upon to be irresponsible; to avoid feelings for others and acting to help others. The greatest enemy of neoliberalism is perhaps empathy: it is unsurprising that neoliberal states use an omnipresent barrage of stories and “news” intended to make us see all other humans as being guilty for our own discontents and dissatisfactions. In the neoliberal state, everyone is our enemy.

Cameron’s “Big Society” is thus revealed as nothing more than a new brand name for the “natural order” of “free markets”.  Neoliberal thought is inhumane.

before neoliberalism kills us all

In September 2008, Bernard E.Harcourt of the University of Chicago (that same University of Friedman, whose Economics disciples have became known with fear and contempt throughout much of the world as the “Chicago Boys”) presented a paper at UCLA on the topic “Neoliberal Penality: The Birth of Natural Order, The Illusion of Free Markets”.

In the paper (and more recently and more comprehensively in his book “The Illusion of Free Markets”), Harcourt traces the origins and development of the “free market” and “”small government” philosophies of the Chicago School from the 18th Century Enlightenment.

But the title alone is revealing: the idea of a “natural order” underlying economics was born, not found; the notion of “free markets” creates a fiction, an illusion.

Neoliberal economics is not rocket science: not in the sense that it is simple and obvious, but in the sense that it is not science at all. The theories of Special and General Relativity are examples of science. Einstein’s theories came with proposals as to how they could be tested, and they have been tested and proven many times. If – and it’s said to be a huge if – the LHD is generating faster-than-light neutrinos then Einstein’s theories will be amended, not replaced: as Einstein’s theories supplemented Newton’s.

Some – not all – properties of gravity and light have been discovered. The “natural order” created by free markets is a man-made construct. It seems, in fact, to be anti-science: starting from a desired result (reduction in the role of government) to identify causes (the efficiency of free markets).

Whereas scientific method depends on scepticism, neoliberal economics depends on unquestioning belief. It is unsurprising that religious fundamentalism and free market fundamentalism so often drive and are driven by the same people.

Harcourt refers to “free market” thought as if it were a quasi-religion. It certainly creates the same limitations to – or deficits in – human thought and action.

Because “free markets” reveal a “natural order” they must not be interfered with. What this “natural order” is, is the best which can exist. Humans cannot improve upon it, and indeed can only make things worse by trying to regulate or replace the “free market”. This is one reason why neoliberal systems are so harsh on anyone who breaks the neoliberal logics.

The neoliberal belief system encourages hopelessness (because There Is No Alternative to neoliberal “natural order”) and it generates disillusion and despair, because no matter how bad things are,no actions or changes are permitted. Government action – human action – can only make things worse. We cannot solve the social problems neoliberal economics creates: we are not allowed to.

The fundamentalist religiosity of neoliberalism quashes scepticism and destroys critical thinking. Creationism, climate-change denial, anti-vaccination hysteria, demonisation of science, the supplanting of academic study by folk-wisdom, the transformation of education to factory production of consumers and drones: all these are manifestations of how the neoliberal hegemony is making idiots of us all.

As hopeless, constricted, uncritical consumers we cannot find or take the necessary actions to solve the problems we need to solve: putting a brake on global warming and creating sustainable, just, fair, societies to live in. We have to reject the religion of “free markets”, declare that the Emperor is not only naked but sick, take back the right to solve problems and to improve human existence. Before neoliberalism kills us all.

Individual responsibility in a neoliberal world

The third logic of neoliberalism is the cultural trope of individual responsibility. A common statement of this is its use as justification for arrest or incarceration, in the form,”Lots of people are poor, but this individual deserves punishment because everyone else chose not to steal a loaf of bread to feed their kids.”

There is an appeal to moral certitude in this logic which harks back to the idea of commandment. “Thou shalt not steal” is non-negotiable: theft of property is always wrong. The individual who steals has a clear choice to make, whether or not to break this commandment. There is no appeal to extenuating circumstances, such as the situation of the individual’s poverty or that of starving offspring. Once again, neoliberalism and moral religiosity become almost indistinguishable.

Of course what the individual has actually done is to evade or disrupt (and certainly to disrespect) “the markets.” All goods are assigned a monetary value which must be used in exchange. If the individual herself does not have sufficient wealth or credit with which to purchase food, then that is not so much her fault as her choice: it is her “individual responsibility” to have sufficient wealth to purchase food for her children, and her individual responsibility to produce no more children than she can purchase food for. None of the individual’s circumstances or history: her birth, family, health, mental ability, education, immediate society, country, or misfortune or any other factor allow her to escape even for a moment what is seen as the “natural order” of the market. Individual responsibility means that a decision to disobey the market is not permitted.

The arguments are not new: during the Putney Debates, the agitators argued for the return of the “commons” which was land held in common and used for food production. The men of property wished to protect their ongoing enclosure of the commons and its expropriation from the poor and establishment of ownership by the owners of large estates. This looks like theft, as does the expropriation of common lands from the Irish, the American Indians, and others during the period of Empire building which accelerated after 1650, but in neoliberal logic everything must be property, have an owner, and have a monetary value. The landowners (Cromwell, who drained fenland and displaced the previous occupiers, included) did not consider themselves guilty of theft but obliged to create wealth and end the ownerless state of the commons.

This in turn explains why neoliberal governments are opposed to public welfare programmes. Any form of state welfare is a criminal (from a neoliberal perspective) interruption of the “markets”. Someone who is given wealth without providing labour in exchange is clearly evading the labour market, and guilty of evading their own individual responsibility to provide for themselves. Neoliberal governments therefore remove welfare by first transforming it to “workfare”, where individuals must provide some work. This also reiterates the cultural trope of individual responsibility, repeated on so many radio “phone-ins” where individuals shout that because they are working, so must everyone else: because they are not poor or unemployed or imprisoned, everyone who is must have chosen to be in that state.

Individual responsibility is, however, limited to the responsibility to act within the “natural order” of the markets. Consequently, the idea of a natural market has to be invoked to explain and control every human action, even, seemingly ironically, denial of responsibility.

This is manifest in the Health and Social Care Bill currently being passed through the UK Parliament. The provisions of this legislation remove the accountability and responsibility of the Secretary of State for Health to provide a national healthcare service created by Aneurin Bevin (on the sophistry that these obligations never existed), while legislating for individuals to take on the role of consumer of healthcare services; to renounce their common ownership of (and shared participation in) the National Health Service. When this bill is fully enacted (extraordinarily, it is already being put in place before the legislation is passed) a competitive “market” for healthcare provision will be set up between “competing” existing hospitals, charitable health provision, and corporate healthcare providers.

The Secretary of State must therefore officially renounce accountability and responsibility for the nation’s health, because if he were accountable or responsible in any way he would be interfering with the “markets” he has just created.

This is the the neoliberal order of things and explains why a US TV audience shouted “Yes” when a presidential hopeful was asked whether someone should be allowed to die if they had not provided for their own healthcare with adequate health insurance.

The neoliberal trope of “individual responsibility” excludes our responsibility for others, or indeed for anything but our predefined role in the market. In the doublethink of neoliberal logic, liberty is the obligation not to be responsible for the consequences of our actions, but only to comply with the “natural order” of the markets.

The four logics of neoliberalism

Loic Wacquant, Professor of Sociology at UCl Berkeley, essays a sketch of “the neoliberal state” in his study of social insecurity, Punishing the Poor

Neoliberalism is a transnational project aiming to remake the nexus of market, state, and citizenship from above. This project is carried out by a new global ruling class in the making, composed of the heads and senior executives of transnational firms, high-ranking politicians,…and top officials of multinational organisations (the OECD, WTO, IMF, World Bank, and European Union), and cultural-technical experts in their employ…

Beyond “reasserting the prerogatives of capital and the promotion of the marketplace”, neoliberalism entails four “institutional logics”.

1. economic deregulation
2. devolution, retraction, and recomposition of the welfare state
3. the cultural trope of individual responsibility
4. an expansive, intrusive, and proactive penal apparatus

Wacquant’s four logics allow us to evaluate any policy proposal or decision made by a government; in effect, it provides an early warning system which allows us to see through the misdirection and obfuscation with which neoliberal policies are usually presented (what George Orwell in 1984 called “doublespeak”).

The vocabulary used by neoliberal government in the UK since 1979 can be translated into the terms of one or more of the four logics. For example, “competition” as used to refer to Education or to Health implements all of the first three, and is used synonymously with “marketplace”.

1. Economic deregulation actually means reregulation intended to promote a market-like mechanism to supply a public good.
2. A component of the welfare state is devolved from state control to the “market” and recomposed to introduce “shareholder value” in place of equality of access or treatment.
3. The individual is obliged, expected, or forced to be responsible for relinquishing the role of patient or student, and accepting the role of consumer in the new “market”.

Another example is the response of Linda Whetstone to the problems of water scarcity. Whetstone’s recommendation was to the effect that most of the shortage issues should be dealt with via the market; charging for the resource, issuing property rights, and removing government interference. (BBC Newsnight, August 2008)

The neoliberal solution is thus that water could be made less scarce if there was reregulation to assert ownership of water and to create a marketplace. The most likely outcome of course would be that millions would die of dehydration once the insufficient water they had no access to had been expropriated by corporations in order to sell it back to them (with no Government control).