In the latest issue:

Real Men Go to Tehran

Adam Shatz

What Trump doesn’t know about Iran

Patrick Cockburn

Kaiser Karl V

Thomas Penn

The Hostile Environment

Catherine Hall

Social Mobilities

Adam Swift

Short Cuts: So much for England

Tariq Ali

What the jihadis left behind

Nelly Lahoud

Ray Strachey

Francesca Wade

C.J. Sansom

Malcolm Gaskill

At the British Museum: ‘Troy: Myth and Reality’

James Davidson

Poem: ‘The Lion Tree’

Jamie McKendrick

SurrogacyTM

Jenny Turner

Boys in Motion

Nicholas Penny

Jia Tolentino

Lauren Oyler

Diary: What really happened in Yancheng?

Long Ling

Is that it for the NHS?Peter Roderick
Close

Terms and Conditions

These terms and conditions of use refer to the London Review of Books and the London Review Bookshop website (www.lrb.co.uk — hereafter ‘LRB Website’). These terms and conditions apply to all users of the LRB Website ("you"), including individual subscribers to the print edition of the LRB who wish to take advantage of our free 'subscriber only' access to archived material ("individual users") and users who are authorised to access the LRB Website by subscribing institutions ("institutional users").

Each time you use the LRB Website you signify your acceptance of these terms and conditions. If you do not agree, or are not comfortable with any part of this document, your only remedy is not to use the LRB Website.


  1. By registering for access to the LRB Website and/or entering the LRB Website by whatever route of access, you agree to be bound by the terms and conditions currently prevailing.
  2. The London Review of Books ("LRB") reserves the right to change these terms and conditions at any time and you should check for any alterations regularly. Continued usage of the LRB Website subsequent to a change in the terms and conditions constitutes acceptance of the current terms and conditions.
  3. The terms and conditions of any subscription agreements which educational and other institutions have entered into with the LRB apply in addition to these terms and conditions.
  4. You undertake to indemnify the LRB fully for all losses damages and costs incurred as a result of your breaching these terms and conditions.
  5. The information you supply on registration to the LRB Website shall be accurate and complete. You will notify the LRB promptly of any changes of relevant details by emailing the registrar. You will not assist a non-registered person to gain access to the LRB Website by supplying them with your password. In the event that the LRB considers that you have breached the requirements governing registration, that you are in breach of these terms and conditions or that your or your institution's subscription to the LRB lapses, your registration to the LRB Website will be terminated.
  6. Each individual subscriber to the LRB (whether a person or organisation) is entitled to the registration of one person to use the 'subscriber only' content on the web site. This user is an 'individual user'.
  7. The London Review of Books operates a ‘no questions asked’ cancellation policy in accordance with UK legislation. Please contact us to cancel your subscription and receive a full refund for the cost of all unposted issues.
  8. Use of the 'subscriber only' content on the LRB Website is strictly for the personal use of each individual user who may read the content on the screen, download, store or print single copies for their own personal private non-commercial use only, and is not to be made available to or used by any other person for any purpose.
  9. Each institution which subscribes to the LRB is entitled to grant access to persons to register on and use the 'subscriber only' content on the web site under the terms and conditions of its subscription agreement with the LRB. These users are 'institutional users'.
  10. Each institutional user of the LRB may access and search the LRB database and view its entire contents, and may also reproduce insubstantial extracts from individual articles or other works in the database to which their institution's subscription provides access, including in academic assignments and theses, online and/or in print. All quotations must be credited to the author and the LRB. Institutional users are not permitted to reproduce any entire article or other work, or to make any commercial use of any LRB material (including sale, licensing or publication) without the LRB's prior written permission. Institutions may notify institutional users of any additional or different conditions of use which they have agreed with the LRB.
  11. Users may use any one computer to access the LRB web site 'subscriber only' content at any time, so long as that connection does not allow any other computer, networked or otherwise connected, to access 'subscriber only' content.
  12. The LRB Website and its contents are protected by copyright and other intellectual property rights. You acknowledge that all intellectual property rights including copyright in the LRB Website and its contents belong to or have been licensed to the LRB or are otherwise used by the LRB as permitted by applicable law.
  13. All intellectual property rights in articles, reviews and essays originally published in the print edition of the LRB and subsequently included on the LRB Website belong to or have been licensed to the LRB. This material is made available to you for use as set out in paragraph 8 (if you are an individual user) or paragraph 10 (if you are an institutional user) only. Save for such permitted use, you may not download, store, disseminate, republish, post, reproduce, translate or adapt such material in whole or in part in any form without the prior written permission of the LRB. To obtain such permission and the terms and conditions applying, contact the Rights and Permissions department.
  14. All intellectual property rights in images on the LRB Website are owned by the LRB except where another copyright holder is specifically attributed or credited. Save for such material taken for permitted use set out above, you may not download, store, disseminate, republish, post, reproduce, translate or adapt LRB’s images in whole or in part in any form without the prior written permission of the LRB. To obtain such permission and the terms and conditions applying, contact the Rights and Permissions department. Where another copyright holder is specifically attributed or credited you may not download, store, disseminate, republish, reproduce or translate such images in whole or in part in any form without the prior written permission of the copyright holder. The LRB will not undertake to supply contact details of any attributed or credited copyright holder.
  15. The LRB Website is provided on an 'as is' basis and the LRB gives no warranty that the LRB Website will be accessible by any particular browser, operating system or device.
  16. The LRB makes no express or implied representation and gives no warranty of any kind in relation to any content available on the LRB Website including as to the accuracy or reliability of any information either in its articles, essays and reviews or in the letters printed in its letter page or material supplied by third parties. The LRB excludes to the fullest extent permitted by law all liability of any kind (including liability for any losses, damages or costs) arising from the publication of any materials on the LRB Website or incurred as a consequence of using or relying on such materials.
  17. The LRB excludes to the fullest extent permitted by law all liability of any kind (including liability for any losses, damages or costs) for any legal or other consequences (including infringement of third party rights) of any links made to the LRB Website.
  18. The LRB is not responsible for the content of any material you encounter after leaving the LRB Website site via a link in it or otherwise. The LRB gives no warranty as to the accuracy or reliability of any such material and to the fullest extent permitted by law excludes all liability that may arise in respect of or as a consequence of using or relying on such material.
  19. This site may be used only for lawful purposes and in a manner which does not infringe the rights of, or restrict the use and enjoyment of the site by, any third party. In the event of a chat room, message board, forum and/or news group being set up on the LRB Website, the LRB will not undertake to monitor any material supplied and will give no warranty as to its accuracy, reliability, originality or decency. By posting any material you agree that you are solely responsible for ensuring that it is accurate and not obscene, defamatory, plagiarised or in breach of copyright, confidentiality or any other right of any person, and you undertake to indemnify the LRB against all claims, losses, damages and costs incurred in consequence of your posting of such material. The LRB will reserve the right to remove any such material posted at any time and without notice or explanation. The LRB will reserve the right to disclose the provenance of such material, republish it in any form it deems fit or edit or censor it. The LRB will reserve the right to terminate the registration of any person it considers to abuse access to any chat room, message board, forum or news group provided by the LRB.
  20. Any e-mail services supplied via the LRB Website are subject to these terms and conditions.
  21. You will not knowingly transmit any virus, malware, trojan or other harmful matter to the LRB Website. The LRB gives no warranty that the LRB Website is free from contaminating matter, viruses or other malicious software and to the fullest extent permitted by law disclaims all liability of any kind including liability for any damages, losses or costs resulting from damage to your computer or other property arising from access to the LRB Website, use of it or downloading material from it.
  22. The LRB does not warrant that the use of the LRB Website will be uninterrupted, and disclaims all liability to the fullest extent permitted by law for any damages, losses or costs incurred as a result of access to the LRB Website being interrupted, modified or discontinued.
  23. The LRB Website contains advertisements and promotional links to websites and other resources operated by third parties. While we would never knowingly link to a site which we believed to be trading in bad faith, the LRB makes no express or implied representations or warranties of any kind in respect of any third party websites or resources or their contents, and we take no responsibility for the content, privacy practices, goods or services offered by these websites and resources. The LRB excludes to the fullest extent permitted by law all liability for any damages or losses arising from access to such websites and resources. Any transaction effected with such a third party contacted via the LRB Website are subject to the terms and conditions imposed by the third party involved and the LRB accepts no responsibility or liability resulting from such transactions.
  24. The LRB disclaims liability to the fullest extent permitted by law for any damages, losses or costs incurred for unauthorised access or alterations of transmissions or data by third parties as consequence of visit to the LRB Website.
  25. While 'subscriber only' content on the LRB Website is currently provided free to subscribers to the print edition of the LRB, the LRB reserves the right to impose a charge for access to some or all areas of the LRB Website without notice.
  26. These terms and conditions are governed by and will be interpreted in accordance with English law and any disputes relating to these terms and conditions will be subject to the non-exclusive jurisdiction of the courts of England and Wales.
  27. The various provisions of these terms and conditions are severable and if any provision is held to be invalid or unenforceable by any court of competent jurisdiction then such invalidity or unenforceability shall not affect the remaining provisions.
  28. If these terms and conditions are not accepted in full, use of the LRB Website must be terminated immediately.
Close

The​ National Health Service in England is being dismantled. But you wouldn’t know it from listening to the radio or reading the newspapers. As so often, you have to look beyond the headlines about pressures on funding and the junior doctors’ dispute to find out what’s really going on. In 1990, Kenneth Clarke introduced an internal market into the NHS, following on from the ‘options for radical reform’ set out by Oliver Letwin and John Redwood in 1988. It had three pillars: GP fund-holding (delegating budgets to individual GP practices); the replacement of health authorities by ‘NHS trusts’ (self-governing accounting centres with borrowing powers, and their own finance, human resources and PR departments) and the splitting of purchasers from providers (the planning and delivery of services was to be undertaken by separate bodies, with the money flowing between them). In its 1997 manifesto, New Labour promised to ‘end the Tory internal market’. It did get rid of GP fund-holding (only to reintroduce it later as Practice Based Commissioning), but otherwise took the Tories’ ideology even further by introducing, in 2003, the market-oriented ‘NHS foundation trusts’ and their regulator, Monitor, as well as scaling up the Private Finance Initiative. Clarke was able to say on the sixtieth birthday of the NHS in 2008 that ‘in the late 1980s I would have said it is politically impossible to do what we are now doing.’

Then came Andrew Lansley’s Health and Social Care Act 2012. No longer does the government – or anybody else – have a legal duty to provide hospital services throughout England. The hundred or so NHS trusts were all prospectively abolished, and a plan set out to transform them (if not to close them down or sell them off) into foundation trusts. The 150 or so foundation trusts had their private patient income cap abolished and were permitted to receive 49 per cent of their income from non-NHS sources. About 113 private providers have since been licensed by Monitor, and tendering for services has been made virtually compulsory. ‘Public health’ has been carved out of the NHS, and shared between local and central government. Meanwhile, Lansley, having stood down as an MP before the election in May, has been given a peerage and hired as a consultant to Bain & Company, which, according to its website, ‘helps leading healthcare companies work on the full spectrum of strategy, operations, organisation and mergers and acquisitions’. The appointment at Bain was signed off in July 2015 by Baroness Browning, who chairs the Advisory Committee on Business Appointments – herself a consultant to Cumberlege, Eden and Partners, ‘a specialist consultancy to the health sector’ led by Baroness Cumberlege. You couldn’t make it up.

We are now at a crucial time in the wrecking process. Under the 2012 Act, clinical commissioning groups (CCGs) buy services from providers, especially from NHS foundation trusts. But the trusts are no longer obliged to provide particular services. Since April 2013, their services have fallen essentially into two categories: Commissioner Requested Services (CRS), and the rest. Services designated as CRS are subject to ‘continuity of service’ restrictions on the trust’s ability to cut or alter them. Monitor has the power to make the trust provide CRS services for a specified period, but cannot stop them being cut once that period expires. Trusts also need to have Monitor’s consent before they sell off buildings and equipment used to provide CRS. Services that are not CRS are not subject to these restrictions. So the more services that are not designated as CRS, the more freedom an NHS foundation trust has to do what it likes – so long as 51 per cent of its income comes from NHS services.

When the 2012 Act was implemented, the services that foundation trusts had to provide under the previous rules were automatically designated CRS for three years, until April 2016, in their new licences. But Monitor said then that the planning and purchasing responsibilities of CCGs include ‘designating a range of services that local commissioners believe should continue to be provided locally if any individual provider is at risk of failing financially. We call these Commissioner Requested Services.’ CCGs are supposed to imagine that the foundation trusts they contract with could financially fail and to use a four-stage Designation Framework to come up with a new list of CRS by April 2016 on the basis of that imagining. ‘We expect the number of services that are designated as Commissioner Requested Services to decrease as a result’ of CCGs doing that, Monitor says, because if a trust goes bust it is expected to provide fewer services than it would otherwise. In other words, services that were mandatory until April 2013, and which for three years afterwards will have had some protection from ‘continuity of service’ conditions, are expected to decrease. This is an instance of applying powers supposed to ensure continuity in order to bring about discontinuity.

Halting the demise of the NHS in England won’t happen without a new law. The National Health Service Bill, scheduled to have its second reading in the House of Commons on 11 March next year, would prevent the specific sleight of hand I have described from going ahead, as well as reversing 25 years of marketisation. It was tabled in June by the Green MP Caroline Lucas, and is supported by Labour (including Jeremy Corbyn and John McDonnell), as well as by Lib Dem, SNP and Plaid Cymru MPs and the British Medical Association.

The question now is whether Labour under Corbyn will end its support for the market in the NHS and get behind the bill. The shadow health minister, Heidi Alexander, is still finding her feet, but the signs are not good. Unlike McDonnell, she has not brought in new political advisers. She is being advised by those who advised Andy Burnham, and judging from a meeting I had with her very recently New Labour thinking on the NHS is for now still very much in place. Ross McKibbin, writing in the LRB of 8 October, expected Corbyn’s leadership to end in tears. If that turns out to be the case, one reason may well be that Corbyn just wasn’t able to translate the support he has in the party into parliamentary backing.

Send Letters To:

The Editor
London Review of Books,
28 Little Russell Street
London, WC1A 2HN

letters@lrb.co.uk

Please include name, address, and a telephone number.

Letters

Vol. 38 No. 1 · 7 January 2016

Peter Roderick is right to trace the ills of the NHS to the Thatcher-Clarke ‘reforms’ of 1990 (LRB, 3 December 2015). Having worked as a hospital physician in the NHS between 1968 and 2007, I see the Lansley Act of 2012 as the latest stage in a long process of fragmentation, marketisation and erosion of professionalism. There are two effects of this process that I think should be more widely understood. The first is that before 1990 the NHS ran on goodwill, which has now largely been dissipated. The extra, usually uncounted, unpaid hours that people are willing to put in when they are public servants tend to disappear under a commercial or quasi-commercial regime. I suspect that politicians who thought that commercial pressures and competition would improve efficiency had no idea what they stood to lose, and probably thought that staff were, on average, taking what they could get away with rather than giving more than they were paid for.

Second, when providers are private or, like foundation trusts, quasi-commercial there is an incentive to increase activity. The more patients seen, the more investigations or operations performed, the better the bottom line (as long as the accountants and contract lawyers have done their work well). This makes for overdiagnosis, overinvestigation, overtreatment, iatrogenic disease and quackery. It is almost an invitation to profit from public gullibility.

Nicholas Dennis
Winchester

send letters to

The Editor
London Review of Books
28 Little Russell Street
London, WC1A 2HN

letters@lrb.co.uk

Please include name, address and a telephone number

Read anywhere with the London Review of Books app, available now from the App Store for Apple devices, Google Play for Android devices and Amazon for your Kindle Fire.

Sign up to our newsletter

For highlights from the latest issue, our archive and the blog, as well as news, events and exclusive promotions.