Sunday, October 6, 2019
The Industrialisation of Healthcare/Therapy
Alan Rowan
http://www.thelacanianreviews.com
In June of this year many people in the UK were either shocked or bewildered to hear both the American Ambassador to the UK, and then the US President Donald Trump on his state visit there, state; that any new trade agreement between the US and the UK would require that the National Health Service (NHS) was “on the table”.
In other words, that the public health provision currently supplied by the NHS to the citizens of the UK, who pay for these services through taxes, would be opened up as a market, allowing private and for-profit American companies to bid to provide health services to the UK public in place of the direct “public provision” of healthcare (i.e. via the Government’s Department of Health).
In the UK most people consider the NHS to be one of the great political achievements of the post Second World War era whereby all UK citizens were seen to have an equal right to healthcare, that, moreover, is free at the point of delivery.
There was thus nothing short of a “public outcry” in response to this demand, with most British politicians joining-in, including the then Prime Minister, Theresa May, who stated that Britain would never agree to such a stipulation being imposed as a condition of future “trade talks”.
This then led to a retraction from President Trump who stated that future “trade talks” would not be dependent on this condition being met.
To understand why all of this happened is to appreciate, firstly, the extent to which healthcare has been “industrialised”, and thus has become of prime interest to for-profit capital investment. And secondly, to appreciate the extent to which political agendas, especially in the so-called “developed economies”, have become infused with, embody and promote capitalist ideology in the form of neo-liberalism and the so-called “free market”.
That this ideology extracts an ever-increasing cost from the citizens of those countries where it is dominant is without doubt and evident in the recent “bank bailouts” and related “austerity programmes” that have affected many Western nations.
It is also evident in healthcare.
For example, the US spends not only more of its GDP than the UK on healthcare but when private payments are added to this, the amount spent on healthcare is roughly 130% more per capita compared to the UK - while failing to deliver either universal cover or better healthcare outcomes (e.g. the percentage of Americans without health cover in 2018 was 15.5%, or around 30 million people, which is down from the 44 million figure before the Affordable Care Act was introduced – though the latter is now being rolled back under the Trump Administration).
That healthcare has become “big business” is intimately tied to the way it has, over time, become industrialised - meaning being able to be supplied in measurable and costed procedures that allow for-profit margins to be calculated and achieved.
Of course this does not cover all of healthcare and Governments and Charities thus remain the dominant providers when it comes to complex and unpredictable healthcare provision – areas where costs can spiral and measuring outcomes remains inherently difficult (e.g. treating patients with multiple and/or inter-acting conditions).
In other words “big business” typically “picks off” those areas of healthcare it can provide on a for-profit basis leaving the rest to be directly funded by the public sector.
To take some examples from the UK, where about 10% of the NHS budget is spent on private provision (approximately 13 billion per year) one sees that residential care is an area of choice for such companies who now supply most of the forensic hospital beds in the UK and also almost all care-home beds.
Discreet medical procedures are also highly desirable with over 30% of hip replacements in the UK now being supplied privately.
Turning now to the world of mental health/therapy one can take the case of a leading provider of mental health care in the US to better understand the appeal of such markets.
Universal Health Services (UHS)[1], a “Fortune 500” company, has over 250 in-patient (hospitals) and 16 outpatient “behavioural health care” facilities in the US. Like many companies in this sector its return on investment (profit) is approximately 20% per annum - this high level of profit-taking being the norm with large healthcare providers.
Here a first, and perhaps obvious point to make is that in labelling its provision as “behavioural health care”, and thus eliminating terms such as “psychiatric” or “mental health” from its lexicon, one encounters a significant linguistic swoop, one aimed at, one can surmise, avoiding the complexities of treating the subject in favour of all treatment being about “behavioural adaptation”.
Some other illustratives facts about this - not-atypical - corporation are the following:
Management is highly rewarded. For example, the CEO in 2018 received a salary of $1.6 million but a total compensation package worth $23.5 million (see: www1.salary.com) a sum of money that is beyond comparison to public service pay.
Company turnover is currently around $10 billion per year – generating $1 billion of cash profit per year. This, in Marxian terms, is surplus-value (profit) seeking surplus-value.
Given the above point company expansion follows logically, and taking here the UK as an example, has led to the following acquisitions: in 2014 Cygnet Health Care (743 beds – mostly forensic), in 2015 Alpha Hospitals Holdings (350 beds – mostly “secure rehabilitation”), and in 2018 The Darshell Group (288 beds – mostly learning difficulties and autism provision).
While the step from providing in-patient treatment to the world of therapy might seem an inherently difficult one to take, it is nevertheless actively being achieved.
Central to this, and again using the UK as an example, is the introduction of a data driven and performance management approach to therapy.
In the UK the main vehicle for this has been the “Improving Access to Psychological Therapies” (IAPT) initiative, introduced in 2008 with the aim of increasing the availability of evidenced-based therapy - based on an economic evaluation of benefit carried out by Lord Layard on behalf of the Government (i.e. in terms of decreasing sickness days and related payments to working age adults).
In practice such therapy is invariably short-term and CBT based, with standardised questionnaires used to control access to and evaluate the services provided.
At one level much of this no doubt seems reasonable (e.g. increasing access to therapy).
However it is only by going beyond this “mask of rationality” that one can grasp how a process of “industrialisation” lies at the heart of this approach.
Here the work of Dr Elizabeth Cotton, an academic at Middlesex University, who also runs a blog (www.survivingwork.org) targeted at supporting healthcare workers, provides an insightful, if somewhat tongue-in-cheek, commentary on how this is achieved, which I have adapted, as follows:
Downgrade the service provided by standardization,
manualisation and digitalization of available treatments and
marginalise those that cannot easily fit into this framework
Collect performance data that acts as a “evidence base” for a downgraded model of sub-therapy
Sell it to the public as a value-for-money service
Enforce performance management based on numerical targets (e.g. number of patients seen) and standardised measures of recovery that are difficult to challenge
Downgrade the jobs of those who provide treatment by employing more “healthcare workers” and fewer professionals
Silence any dissent from both those accessing and those delivering services via a range of sanctions and/or rules
Open the healthcare door to digital providers and platforms
Two final point can now be made.
Firstly, it is important to underline that for all this to happen the health service must already be a managed system, meaning one wherein decision-making power lies firmly in the hands of management and where professional influence has been downgraded.
Secondly, and in my opinion, the “psy professions” in the UK sleepwalked into this development in healthcare (I was working in NHS at the time) and thus, and obviously, the challenge we now face is to be more awake!
From April 2019, 'Sanders Worries Impeachment Works To Trump’s Advantage'
https://dailycaller.com/2019/04/22/sanders-impeachment-trump-advantage/
April 22, 2019
Scott Morefield
Independent Vermont Sen. Bernie Sanders cautioned Democrats that pushing for the impeachment of President Donald Trump could shift the focus from other issues and ultimately work “to Trump’s advantage.”
However, the avowed socialist and 2020 presidential candidate began his Monday night town hall on CNN by replying to Chris Cuomo’s question about impeachment by calling Trump “the most dangerous president in the modern history of this country.”
Sen. Bernie Sanders says he worries focusing on impeachment would benefit President Trump #SandersTownHall https://t.co/9KZzt9ziEc pic.twitter.com/VwikdyJSwb
— CNN Politics (@CNNPolitics) April 23, 2019
“I agree that we have the most dangerous president in the modern history of this country, somebody who’s a pathological liar,” Sanders said before stating that Congress should “explore” whether Trump obstructed justice during special counsel Robert Mueller’s investigation.
But the independent Vermont senator was cautious on the issue of pushing for impeachment, saying,
But here is my concern. At the end of the day what is most important to me is to see that Donald Trump is not re-elected president. I intend to do everything I can to make sure that doesn’t happen.
But if—and this is an if—for the next year or year-and-a-half, going right into the heart of the election, all that Congress is talking about is impeaching Trump, Trump Trump and Mueller, Mueller, Mueller, and we’re not talking about healthcare.
We’re not talking about raising the minimum wage to a living wage.
We’re not talking about combating climate change.
We’re not talking about sexism and racism, homophobia and all of the issues that concern ordinary Americans.
What I worry about is that it works to Trump’s advantage.
Of the other major candidate town halls held Monday, Massachusetts Sen. Elizabeth Warren and California Sen. Kamala Harris favored impeaching the president, while Minnesota Sen. Amy Klobuchar dodged the question.
Of the other major candidate town halls held Monday, Massachusetts Sen. Elizabeth Warren and California Sen. Kamala Harris favored impeaching the president, while Minnesota Sen. Amy Klobuchar dodged the question.
Saturday, October 5, 2019
Impeaching Trump is not a left-wing project — progressive Democrats shouldn't be fooled
This is about one individual,
and Russia. And it conveniently skims over all we know about US institutions
and what they stand for
Slavoj
Zizek New York
2 days ago
The campaign against Trump and
for his impeachment tells
a lot about our current ideological predicament. Trump is portrayed as an
individual pursuing his own private interests, not as the representative of a
state and its apparatuses. Edward Snowden immediately
got this point, commenting
that “a whistleblower's complaint, which triggered US President Donald Trump's impeachment
inquiry, is strategically ‘quite wise’ in its focus on the president versus an
institution.… Congress could be more than happy to throw an individual abusing
their office under the bus, in a way that they are not willing to do when they
themselves are implicated by the same allegations.… This whistleblower is doing
something [that's] a little bit unusual. They're alleging that an individual is
breaking the law who, of course, is the president, [who] is historically
unpopular at this moment.”
It is acceptable to criticize
an individual who breaks the law while he pursues his interests or private
pathological inclinations (revenge, lust for power and glory, and so on) — but
it is much more difficult to discern a crime in the activity of a state institution,
a criminal activity which is performed by personally honest individuals
dedicated to their job. Evil and crime are here not individualized but
inscribed into the very functioning of the institution.
Trump is undoubtedly a
repellant person lacking a basic moral compass; however, what about the
systematic violations of human rights in the continuous activities of the US
intelligence agencies? The true enemy are not idiosyncratic figures who act as
a disturbance for the establishment itself; the true enemy are honest patriotic
bureaucrats ruthlessly pursuing the goals of the United States.
To name names, the model of
such a patriotic bureaucrat is James Comey, the FBI
director deposed by Trump. Although, at the level of facts, Comey was probably
mostly truthful in his critique of Trump (see his memoir A Higher Loyalty),
one should nonetheless admit that his “higher loyalty” to the principles and
values of the US leaves untouched what one cannot but call the criminal
tendencies inscribed into the US state institutions — in other words, all that
was revealed by Assange, Snowden and Manning.
One should also not forget
that the movement to impeach Trump is mostly motivated by the desire to prove
that Russia influenced the last presidential elections, enabling Trump to win.
While there probably was Russian meddling (in the same way that the US tries to
influence elections all around the world; they just call their interventions “a
defense of democracy”), focusing on this one aspect ignores why Hillary Clinton
was actually defeated in 2016. Her ruthless struggle against Bernie Sanders and
the leftist wing of the Democratic Party should take centerstage here.
Bernie Sanders was
right to warn that “if for the next year, year-and-a-half, going right
into the heart of the election, all that the Congress is talking about is
impeaching Trump and Trump, Trump, Trump, and Mueller, Mueller, Mueller, and
we're not talking about healthcare, we're not talking about raising the minimum
wage to a living wage, we're not talking about combating climate change, we're
not talking about sexism and racism and homophobia, and all of the issues that
concern ordinary Americans. What I worry about is that works to Trump's advantage.”
Impeaching Trump is not a
leftist project. It is a centrist-liberal project whose secret aim is also to
prevent the progressive wing of the Democratic Party from taking over. We
should bear that in mind.
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