privatisation
Liberalism Against Itself: Cold War Intellectuals and the Making of Our Times – review
In Liberalism Against Itself: Cold War Intellectuals and the Making of Our Times, Samuel Moyn dissects intellectual battles within Cold War liberalism through six key figures: Judith Shklar, Isaiah Berlin, Karl Popper, Gertrude Himmelfarb, Hannah Arendt and Lionel Trilling. Teasing out their complex relationships with Enlightenment ideals, historicism, Freudianism and decolonisation, Moyn’s masterful group biography sheds light on the evolution of liberalism and the cause of the Red Scare, writes Atreyee Majumder.
In his most recent book, Samuel Moyn provides a set of intertwined intellectual profiles of six scholars of the Cold War, especially post-WWII era: Judith Shklar, Isaiah Berlin, Karl Popper, Gertrude Himmelfarb, Hannah Arendt and Lionel Trilling. Before I read Liberalism Against Itself: Cold War Intellectuals and the Making of Our Times, I had never come across the term Cold War liberalism. As Moyn clarifies, the term was coined in the 1960s by enemies of liberal ideas (presumably from within the Free World) emerging at the time, blaming “domestic compromises and foreign policy mistakes”. Moyn offers an intriguing argument that liberalism arrived at its current iteration through its defenders in the Anglo-American region during the Cold War.
Moyn offers an intriguing argument that liberalism arrived at its current iteration through its defenders in the Anglo-American region during the Cold War.
Interestingly, all the scholars in Moyn’s study except for Karl Popper are Jewish intellectuals of the post-Holocaust era or are children of American Jewish immigrants. An Austrian émigré in England, Popper was born Jewish but later converted to Lutheranism. Moyn takes great care not to reduce their loyalty to a certain iteration of liberalism to their religious identity (111). He employs an interesting writing strategy whereby he establishes a grapevine of conversations among these six figures and their various compatriot liberals. For instance, Shklar appears as a sharp critic of Hannah Arendt in Chapter five, while Berlin provides a corrective to Shklar’s rejection and blaming of Rousseau for sowing the roots of the red spectre with which the free world was confronted with in the twentieth century.
The first two chapters elaborate on Shklar and Berlin who have divergent attitudes towards the Enlightenment, Romanticism and Rousseau. Both are critical of the Enlightenment to the extent that they find themselves amplifying liberalism’s state-limiting function over its dimension of emphasising creative agency of the individual. They differ on the extent to which the Enlightenment could be held responsible for the rise of the Red Scare. It is in the Karl Popper chapter (Chapter Three) that the plot thickens, as Popper rejects “historicism” by way of rejecting Hegel and his infusion of the idea of progress with Christian “inevitabilism” (77, 80). As Moyn narrates, Popper held that history, if embraced, would mean the inevitable progress as argued for Hegel and later, in Marx’s terms, would lead to a communist version of progress that would usurp liberalism’s dominance. This anxiety made Popper reject the category of history itself. In fact, Jacob Talmon, the “slavish follower” of Popper, described “the idolization of history” as a “nineteenth century novelty” (80).
It is through Hannah Arendt that we see the uncomfortable relationship the Cold War liberals had with the decolonisation movements outside the west
The book reaches a crescendo in the last two chapters on Hannah Arendt and Lionel Trilling, respectively. It is through Hannah Arendt that we see the uncomfortable relationship the Cold War liberals had with the decolonisation movements outside the west; those that claimed the word ”freedom” for colonised populations. As a reader from the postcolony, I found it instructive to read Moyn’s discussion of Arendt’s ambivalence about reconciling her liberalism with the growing liberalisms of the former colonies. In an insightful section at the end of the Arendt chapter (137-8), Moyn discusses how nationalisms of these fledgling nations were objects of suspicion for Arendt and the Cold War liberals while they were eager to embrace the cause of Israel’s nationalism. In the final chapter we witness Lionel Trilling’s strange embrace of Freud’s psychoanalysis, especially Freud’s late work Civilization and its Discontents (1930). Trilling wanted to render a reformed liberalism – one that wasn’t so naïve and shocked at crisis or evil in the world. Moyn writes of Trilling’s use of Freud in working out his own theory of liberty and liberalism (152):
“…..Freudianism affected the theory of liberty. It turns out that people are constrained in the control they can win from the passions, and therefore in the freedom they should have in their self-making. They must use what autonomy they can gain in pitiless struggle with their own proclivities in the service of self-control.”
Trilling’s own treatment of Cold War liberalism […] could have arisen from his repeated attempts to process what he witnessed in Europe in the 1930s as fascism took hold
Trilling’s own treatment of Cold War liberalism, Moyn speculates, could have arisen from his repeated attempts to process what he witnessed in Europe in the 1930s as fascism took hold; Moyn writes that “he rationalized out of it a new liberalism” (153) – a kind of “survivalist” one. Trilling’s move for a reformed and less idealistic liberalism marked liberalism’s slow shift towards the right.
Moyn has written a masterful interconnected intellectual biography of Cold War liberals, unpacking arguments within the liberal establishment about what actually brought about the Red Scare.
Moyn has written a masterful interconnected intellectual biography of Cold War liberals, unpacking arguments within the liberal establishment about what actually brought about the Red Scare. Moyn also makes clear that these figures are not particularly worried about the institutional arrangement that will bring about such actualisation of freedoms and hence, their version of liberalism. Moyn often uses the term neoliberal and I understand that his usage is quite different from the commonplace social science use of that word – which is a political form accompanying the condition of late capitalism. Hence, I would have liked Moyn to delineate his specific use of the term. Moyn does discuss, especially, in the chapter on Hannah Arendt (Chapter Five), the discomfiture of the Cold War liberals with the rise of new nations across the globe, claiming for themselves the political and social goods of liberalism through their own interpretation of what these might entail. He especially mentions, David Scott’s indictment of Arendt for her erasure of Haiti (138). A blind spot about the rest of the world seems to have existed among the Cold War liberals, which Moyn could have explored further. Finally, I was curious about whether Western Marxism – of the Althusser variety (I believe many of them are writing at the same time as Althusser in the 1960s) – were at all in the conversations that the Cold War liberals engaged in. If so, how would they respond to the Althusserian idea that “freedom” as ideology that hides actual class relations in the name of a pleasurable political ideal which thereafter encodes their worlds of desire? Nonetheless, Liberalism Against Itself is an illuminating and, at times, counterintuitive account of the intellectual wars internal to liberal establishment while it was under attack during the Cold War.
Note: This post gives the views of the author, and not the position of the LSE Review of Books blog, or of the London School of Economics and Political Science.
Image credit: DidemA on Shutterstock.
Leading medics publicly accuse RCP of misleading docs about non-doctor ‘associates’
Open letter to Royal College of Physicians officers cites false claims, failure to declare conflicts of interest and disregard for patient safety
Twenty-nine Fellows of the Royal College of Physicians (RCP) have accused the RCP’s leading officers of misleading doctors and hiding conflicts of interest in an attempt to persuade them and other RCP Fellows into voting down a key motion, tabled at last week’s RCP Extraordinary General Meeting (EGM), calling for a slow-down in the expansion of ‘physician associate’ (PA) roles pushed by the government, which ninety percent of doctors believe are endangering patients.
Last week, Skwawkbox covered the extraordinary scenes at, and outraged reaction to, the EGM and the conduct of the RCP panel as it refused to engage with doctors’ questions and misleadingly presented statistics to inflate support for the way in which the government is (ab)using PA roles, which do not have a medical degree, to replace fully-trained doctors – and to excuse the RCP’s continued support for the government’s programme. The RCP was exposed as having a huge financial interest in the programme.
The Fellows, senior doctors and medical professors, sent their letter to the RCP expressing concern at the ‘terrible harm’ the RCP leadership has done to the College’s reputation and detailing the issues with the way the EGM was run and data were presented by the RCP panel in the debate – and the way in which the College mishandled the need to come clean after the issues were exposed, failing to let doctors know before the close of the vote on the five motions that they had been misled. The motions, including the fifth one that the RCP board had urged doctors to reject, passed overwhelmingly:
STATEMENT OF CONCERN
The events of the last week have done terrible harm to the reputation of the College and the trust that its members and the wider public have in the leadership of the organisation.
Prior to the extraordinary general meeting (EGM) on 13th March 2024 to discuss issues around Physician Associates (PAs), members of the College who are not eligible to vote on the motions were surveyed. Their views were important to inform Fellows voting on the EGM motions about the impact of PAs on patient care and doctors’ training. It has become apparent that the Senior Officers of the College presented selected survey data at the EGM on 13th March, that in our opinion was manipulated in a way that can only have been intended to mislead fellows of the college.
Of note, the Deputy Registrar who presented the survey data, but who we understand did not prepare the slides, resigned from their post immediately after the EGM.
Following the EGM, multiple formal written requests were made to the CEO and Senior Officers to release the survey data. The CEO and Senior Officers refused for 5 days to release the survey results, only doing so after sustained public and direct pressure and multiple written requests. PRCP also cited the same misleading, manipulated survey data in an email to Members and Fellows of the College after the EGM.
The survey results were published on the RCP website at 9am on Monday 18th March, but no attempts were made during the voting period which ended on 20th March, to directly inform members or Fellows of the College that the data presented at the EGM were misleading, although PRCP emailed members on related matters.
During this time, Fellows voted on the 5 motions presented at the EGM, and they were doing so informed in part by the misleading information presented to them at that meeting.
The 5 motions presented at the EGM have been approved by a substantial majority of the Fellows of the College including Motion 5, which the Senior Officers had advised Fellows to vote against, despite the patient safety concerns raised in relation to PA scope and practice.
Discussions at the EGM and events leading up to and following the meeting raise serious concerns about the conduct, governance, and performance of the RCP, especially in relation to patient safety.
These concerns include but are not limited to a number of issues over several years:
- Apparent failure of the RCP to adequately monitor the role and scope of PAs since the College agreed to house the Faculty of PAs (FPA) in 2015
- Apparent failure to communicate clear parameters and scope for PAs from 2015 to March 2024, including failure to clearly communicate that PAs are not doctors and PAs must not replace doctors.
- Apparent failure to respond to the concerns of the RCP Training Committee in relation to PAs raised in 2015 and subsequently with regard to loss of training opportunities for doctors and patient safety.
- Apparent failure to respond to patient safety concerns raised by Fellows of the RCP with Senior Officers during 2023.
- Providing false assurance from 2015 onwards to Members and Fellows of RCP and the wider public that PAs were safely working in their intended scope of practice.
- Apparent failure to acknowledge that PAs in substantial numbers are and were working outside the intended scope despite being provided with evidence that this was the case.
- Apparent failure to acknowledge that PAs are and were working in place of doctors in General Practice, and that PA locum agencies were facilitating this using NHS ARSS funding despite being provided with evidence that this was the case.
- Apparent failure to acknowledge that PAs in substantial numbers are and were working in place of doctors on medical rotas in hospitals.
- Apparent failure to act on evidence ]Provided by DAUK and the BMA that PAs are and were systematically replacing doctors in General Practice and hospitals.
- Apparent failure to work collaboratively with NHS England, the FPA and GMC to ensure that PA Schools educate and communicate with PAs in line with their agreed scope, including but not limited to the principle that PAs are not doctors and must not replace doctors.
- Apparent failure to adequately monitor and analyse the performance of PAs in clinical practice to determine patient safety, performance, clinical outcomes and cost effectiveness.
- Apparent failure of Senior Officers to act on patient safety concerns raised by Members and Fellows and the wideir public because of the potential financial impact on the College.
- Apparent failure of the Senior Officers to fully declare their Conflicts of Interest.
- Apparent failure of the Senior Officers to adequately determine the Conflicts of Interest of the FPA leadership team.
- Apparent failure of the Senior Officers and CEO to act in accordance with the RCP Code of Conduct.
- Apparent failure of the Senior Officers to act in accordance with GMC Good Medical Practice.
This non-exhaustive list highlights that the Senior Officers and CEO have failed on multiple accounts to adhere to the RCP Code of Conduct.
Whilst, given the time pressures, there must be an immediate action plan to ensure that PAs are working within their scope of practice and not in place of doctors, there is a parallel urgent need for an independent review of the Senior Officers with a particular focus on governance and probity.
Dr Asif Qasim FRCP
Professor Alexander Ford FRCP
Professor Charlotte Bolton FRCP
Professor Trisha Greenhalgh OBE FRCP
Professor Martin McKee CBE FRCP
Dr Dagan Lonsdale FRCP
Professor Shah Ebrahim FRCP
Dr Taryn Youngstein FRCP
Professor Nick Hopkinson FRCP
Dr Vinoda Sharma FRCP
Dr Barry Monk FRCP
Dr John Stephens FRCP
Dr Arjun Ghosh FRCP
Dr Scot Garg FRCP
Dr Shrilla Banerjee FRCP
Professor Liz Lightstone FRCP
Professor Mamas Mamas FRCP
Professor Raanan Gillon FRCP
Dr David Nicholl FRCP
Dr Animesh Singh FRCP
Professor Jim Nolan FRCP
Dr Philip Pearson FRCP
Dr David Cohen FRCP
Professor Shahrad Taheri FRCP
Dr Rajiv Sankaranarayanan FRCP
Dr Nasser Khan FRCP
Dr Kevin O’Kane FRCP
Dr Zoe Wyrko FRCP
Dr Muhammad Ahsan FRCP23rd March 2024
The use of PAs, which is considered by nine out of ten doctors to be dangerous to patients and confuses many patients, who do not realise that they have not been seen and treated by a fully-qualified medic, is being pushed by the government as a way of ‘downskilling’ the NHS, reducing costs and allowing increased profits for private providers, under the guise of the so-called ‘NHS Workforce Plan’ as part of the ‘Integrated Care Systems’ (ICS) project.
ICS, formerly called ‘Accountable Care Organisations’ (ACOs) after the US system it copied, were renamed after awareness began to spread that ACOs were a system for withholding care from patients and that care providers were incentivised to cut care because they receive a share of the ‘savings’. The system remained the same, but the rebranding disguised the reality.
The government used a ‘statutory instrument’ (SI) to pass these changes, avoiding proper parliamentary scrutiny, but both the Tories and Keir Starmer’s Labour support these and other measures to cheapen the NHS for private involvement and only independent MP Claudia Webbe spoke against them during the brief SI debate. Green peer Natalie Bennett’s motion in the House of Lords to attempt to kill the instrument was defeated by the Tories with the help of Labour peers.
Some of the signatories, such as Keele University Professor Mamas A Mamas, have added a demand for a full investigation into the actions of the RCP leadership – and ‘urgent action’ to prevent the government’s push for physician associates to operate beyond safe boundaries:
Despite the government’s attempt to keep this cost-cutting, care-degrading manoeuvre below the radar, it is rapidly becoming a major public issue – yet both Labour and the Tories are committed to continuing it, despite the avoidable deaths among patients that it has already caused.
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Industrial Policy in Turkey: Rise, Retreat and Return – review
In Industrial Policy in Turkey: Rise, Retreat and Return, Mina Toksoz, Mustafa Kutlay and William Hale analyse Turkey’s industrial policy over the past century, highlighting the interplay of global paradigms, macroeconomic stability and domestic institutional contexts. The book offers a timely analyses of industrial policy’s past and possible future trajectories, though it stops short of interrogating exactly how cultural, social, political and economic factors shape state-business relations and bureaucracy, writes M Kerem Coban.
Industrial Policy in Turkey: Rise, Retreat and Return. Edinburgh University Press. 2023.
Is industrial policy back? The Biden administration’s Inflation Reduction Act and the CHIPS and Science Act, or the 2016 UK industrial policy are only two contemporary examples. These policies seek to address value chain bottlenecks, as well as the question of how to “take back control” in manufacturing and key sectors, along with concerns about gaining or sustaining economic edge and autonomy
In this context, the Turkish experience is illustrative for making sense of the trajectory of industrial policy in a major developing country. Mina Toksoz, Mustafa Kutlay and William Hale examine the evolution of industrial policy in Turkey. They present an accessible, detailed account of the trajectory and evolution of the policy since the establishment of the Republic, which argues that we had better study “the conditions under which state intervention works, rather than whether the state should intervene in the economy” (26, emphasis in original).
[The authors] suggest that effective industrial policy is the outcome of the interaction between global development policy paradigms, macroeconomic (in)stability, and the domestic institutional context.
The book is divided into five chapters. Chapter One discusses the political economy of industrial policy and sets out an analytical framework. The authors assert that analyses should go beyond dichotomies (eg, horizontal vs. vertical policies; export-led vs. import-substituting industrialisation) and that a broader understanding requires identifying the factors and conditions of effective industrial policy. They suggest that effective industrial policy is the outcome of the interaction between global development policy paradigms, macroeconomic (in)stability, and the domestic institutional context. Global development policy paradigms evolved from étatism of the 1930s, import-substituting industrialisation in the 1960s and the 1970s, neoliberalism of the 1980s, and the return of industrial policy after the 2008 Financial Crisis. Macroeconomic (in)stability drives (un)certainty regarding economic policies and instruments and the trajectory of economy, which, in turn, regulates investment decisions. Finally, the domestic institutional context concerns how state-society, or state-business, relations are structured, whether the state capacity is sufficient to resolve conflicts, discipline and coordinate actor behaviour, and whether bureaucracy has capabilities to formulate and implement policies. Figure 1 seeks to summarise the main argument of the book.
Figure 1: Flow chart summarising the book’s main argument. Source: M Kerem Coban.
Chapter Two focuses on the longue durée between 1923 and 1980. From the ashes of incessant wars that ruined the already unsophisticated infrastructure and demographic challenge, the new Republic had to build a new nation. Yet the rise of the state interventionist era in the 1930s drove policymakers towards the first industrialisation plan and the opening of many industrial sites across the country. When the Democrat Party assumed power, the interventionist, planning-based industrial policy was scrutinised for liberalisation that even included state-owned enterprises to be released to set up their own prices (73).
At the same time, business was encouraged to invest. For example, the fruits of these included Otosan or BOSSA (75). Between 1960 and 1980, the authors underline the second planning period with the establishment of the State Planning Organisation (SPO). SPO boosted bureaucratic and planning capacity and capabilities for disciplined, systematic industrial policy during the era of import-substitution.
Between 1980 and 2000 […] Turkey shifted to export-led growth and liberalised trade and financial flows. These shifts had profound implications for bureaucracy
The third chapter examines demoted industrial policy between 1980 and 2000 when Turkey shifted to export-led growth and liberalised trade and financial flows. These shifts had profound implications for bureaucracy: SPO was sidelined, parallel bureaucratic networks of Ozal were implanted with the opening of new offices or agencies. Consequently, the role of state became less coherent, as political uncertainty driven by unstable coalitions eroded the market-shaping role of the state. The financial sector did not help industrial policy, since banks were dominantly financing chronic budget deficits during a period of high inflation (111). What is more, business, including Islamic conservative SMEs in Anatolia, reduced or ignored investments in manufacturing given the clientelist state-business relations that incentivised construction, real-estate development (115), emphasis in original). Finally, the external conditions were not disciplinary: accession to the Customs Union with the European Union and the World Trade Organization ruled out export support and import restricting measures, among other trade regulatory instruments.
The fourth chapter claims that industrial policy retreated between 2001 and 2009. The first years of this period was marked by political instability and a local systemic banking crisis and its resolution, and Justice and Development Party (AKP in Turkish) assumed power. During this period, industrial policy was dominated by institutionalisation of the regulatory state and the privatisation of state-owned enterprises, the establishment of autonomous regulatory agencies and are structured banking sector. While the regulatory capacity of the state increased, privatisation and the regulation of the market were highly politicised. For example, “a major cycle of gas privatisation saw ‘politically connected persons’ winning fifteen out of nineteen metropolitan centres and serving 76 percent of the population” (161). In such a politically compromised setting, which was accompanied by the institutionalisation of the capital inflow-dependent credit-led growth model that prioritised “rent-thick” sectors, industrial policy could not flourish.
While the regulatory capacity of the state increased, privatisation and the regulation of the market were highly politicised.
The fifth chapter locates the policy within the global ideational and political economic context that marks the return of industrial policy in various forms. In line with policy documents such as the 11th Development Plan, horizontal measures, private and public R&D spending on high-tech initiatives, electric vehicle manufacturing attempt, and most notably the advancements in defence sector have constituted the revival of industrial policy. At the same time, the authors point to several challenges such as eroded academic research and quality and a lack of investment in ICT skills. Additionally, R&D subsidies or other industrial policy measures require thorough performance criteria and measurement to discipline actor behaviour and regulate the incentive structures.
Industrial Policy in Turkey is a timely contribution to the current debate. Its historical account and analysis of current policies, instruments, and the potential trajectory of industrial policy are its main strengths. Still, there are several caveats. First, the book’s framework is not systematic, which causes some confusion. For example, the book does not demonstrate a convincing link between the role and impact of autonomous agencies on industrial policy. Second, the book leaves the reader with more questions than answers, one of which relates to the effect of bureaucratic fragmentation in shaping industrial policy. Another is around the implications of state-business for bureaucracy, and consequently, industrial policy.
The book leaves the reader with more questions than answers, one of which relates to the effect of bureaucratic fragmentation in shaping industrial policy.
Third, the trajectory of industrial policy cannot be considered independently from the shifts in growth models. Yet the fact these shifts occur because the country depends on hard currency earnings for capital accumulation and to finance consumption and investments: Turkey either relies on capital flows or export earnings, in addition to tourism and (un)recorded (illicit) flows. Pendulums between these channels imply that the country cannot design and implement disciplined, systematic industrial policy. Put differently, there are macroeconomic and financial structural impediments against generating hard currency earnings. Industrial policy is one of the remedies, however, the macroeconomic and structural transformative consequences of the latest episode of emphasis on industrial policy and the export-driven growth experiment in Turkey are yet to be seen.
Finally, and perhaps most importantly, the book tends to relegate a core problem of coordination, long-term policy design and implementation to “governance issues”. Deeper cultural, social, political and economic factors determine the clientelist state-business relations and their effect on bureaucracy and bureaucratic autonomy. Such deeper ties have been masked by instrumentalised “democratisation reforms” or higher economic growth rates in the previous years. In this context, is the more critical problem the purposefully immobilised or challenged infrastructural power to coordinate societal actors? If that is true, then should we make interdisciplinary attempts to identify this problem’s core determinants?
Note: This interview gives the views of the author, and not the position of the LSE Review of Books blog, or of the London School of Economics and Political Science.
Image credit: Chongsiri Chaitongngam on Shutterstock.
Video: EGM leak reveals RCP ‘refusing to answer patient safety questions’ and more
Clips from 2-hour leaked extraordinary general meeting appear to show Royal College of Physicians avoiding scrutiny – but making damning admission of financial conflict of interests in government’s expansion of ‘non-doctor-doctor’ roles
A leaked video of the entire ‘extraordinary general meeting’ (EGM) of the Royal College of Physicians (RCP), called by doctors to try to force a slow-down in the roll-out of the government’s expansion of the use of non-medically-trained staff in ‘doctor’ roles, has revealed comments and obfuscation that have led medical professionals to call for the resignation of senior RCP officers. One has already resigned.
A number of patients have already died avoidably because of errors by ‘physician associates’ (PA), who have only two years’ training compared the seven-plus years completed by doctors. A Doctors’ Association UK survey has found ‘deeply disturbing’ abuse of the PA role in NHS trusts.
Keele University cardiology Professor Mamas A Mamas wrote of the leaked video:
The ‘PlatinumPizza’ Twitter/X account has posted a number of excerpts from the EGM video highlighting what it feels are the most noteworthy evasions and obfuscations. The first two reveal that, while the RCP claims that PAs must complete national exams, a freedom of information request revealed that this can be bypassed – and that the RCP, which criticised a far more comprehensive survey by the British Medical Association (BMA) as biased, in fact skews the results of its own small survey to present a falsely positive outlook:
Next, Dr Read tries to present the results of the survey. It's important to remember that Dr Read has since resigned from his post following the EGM.
Somehow, they've managed to mess-up even a basic Likert scale survey and clustered the neutrals with the positives! pic.twitter.com/G2DRpdegBx— platinumpizza
(@Xeon4f145d96s1) March 17, 2024
Doctors participating in the EGM also raised the issue of the fact that PAs are paid more than the junior doctors who often have to supervise them (and can be held to blame if a PA screws up) – but the RCP said it was ‘not a union’ and not interested in getting involved in pay issues:
Next, slightly sped-up, @DrOKaneAgain eviscerates the survey and its results. An insinuation about the BMA survey being "biased" and "leading" is raised. This comes after the RCP tries to pawn off its results by aggregating positive with neutral, as @doctor_oxford shared with us. pic.twitter.com/MefdfOmxT4
— platinumpizza
Next, the first of two posts about the RCP’s prioritisation of its finances above what nine out of ten doctors feels is a grave threat to patient safety:
Back to it, this clip talks about the fiscal and fiduciary responsibilities the RCP have. Although not shown in this particular clip (I'll include it in the thread later), mentions of millions in reparations/ law-suits/ class actions is made. pic.twitter.com/OYLBQtN5VO
— platinumpizza
And then the second, which shows the RCP’s treasurer admitting/warning that the RCP could stand to lose millions if the PA expansion is halted or even slowed down – and the RCP apparently disagreeing with the RCP of a short while below about being a ‘union’, at least when it comes to ensuring PAs have jobs:
I know you are all waiting to hear the millions the RCP might be forced to pay up…so this clip is just that!
Will someone think about the pensions?! pic.twitter.com/s8JD70ooXs— platinumpizza
And, adding farce to the ‘contempt’ of which doctors accused the RCP after the meeting, the panel refuses to say what additional benefit a PA brings to a ‘multi-disciplinary team’ that is not already present in the mix – rounded off by a clip of a doctor warning of the dangers of pressing ahead with the whole damaging system:
And lastly, in what can only be described as an epic season finale, @DrAsifQasim drops an absolute banger.
"i am deeply concerned we will take a patient safety hit if we do not act" pic.twitter.com/LaqIozrAEV— platinumpizza
And in a clip not included in the thread but created by Skwawkbox, one of the movers of the motion for the expansion to be slowed down until it can be shown to be safe for patients explains why it is so important for voting members of the RCP to support it, despite the RCP management’s recommendation to reject it and plough on:
Other discussions during the meeting included the panel failing to explain how it was going to ‘hold the government to account’ for the safe functioning of the system, as it had claimed it would – and treating the mere inclusion of any extra doctors in the government’s ‘long-term workforce plan’ as an achievement by the RCP.
The use of PAs, which is considered by nine out of ten doctors to be dangerous to patients and confuses many patients, who do not realise that they have not been seen and treated by a fully-qualified medic, is being pushed by the government as a way of ‘downskilling’ the NHS, reducing costs and allowing increased profits for private providers, under the guise of the so-called ‘NHS Workforce Plan’ as part of the ‘Integrated Care Systems’ (ICS) project.
ICS, formerly called ‘Accountable Care Organisations’ (ACOs) after the US system it copied, were renamed after awareness began to spread that ACOs were a system for withholding care from patients and that care providers were incentivised to cut care because they receive a share of the ‘savings’. The system remained the same, but the rebranding disguised the reality.
The government used a ‘statutory instrument’ (SI) to pass these changes, avoiding proper parliamentary scrutiny, but both the Tories and Keir Starmer’s Labour support these and other measures to cheapen the NHS for private involvement and only independent MP Claudia Webbe spoke against them during the brief SI debate. Green peer Natalie Bennett’s motion in the House of Lords to attempt to kill the instrument was defeated by the Tories with the help of Labour peers.
Watch the full RCP meeting here.
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Doctors’ Association survey finds ‘deeply disturbing’ misuse of govt’s non-doctor roles
Danger to patients and conflicts of interest as government continues to push for expanded use of ‘associate’ roles – with help from the Royal College of Physicians
A survey by the Doctors’ Association UK (DAUK) has revealed ‘deeply disturbing’ ‘scope creep’ in which – as warned by the British Medical Association (BMA) and others – ‘physician associates’ (PAs), who are not qualified as physicians, are being used and acting as doctors.
A statement by the group warns that PA are not only overstepping the boundaries in which they are meant to operate, but also being used by NHS trusts and health companies to fill positions that require fully-qualified doctors:
PAs are overstepping boundaries, putting patient safety at risk, and impacting doctors’ training. This is shocking in itself, but made far worse by recent events at the Royal College of Physicians… Doctors at Torbay report PAs being used as “middle grades” – clear scope creep.
According to a doctor recruitment agency:
Doctors in speciality training programmes are known as Middle Grade doctors. Junior Middle Grade doctors are trainees who have completed their foundation training and are now in the early years of their speciality training. They are: ST1/ST2: ST stands for Specialty Training.
According to survey responses from doctors at Torbay and South Devon NHS Trust, as well as being used as ‘middle grade’ doctors and putting patients at risk by acting outside their competencies, PAs:
- work without adequate supervision
- consent inappropriately
- participate in unsafe clinical activity
- treated severe infective colitis with antibiotics and steroids simultaneously
According to NHS Scotland, steroids “shouldn’t be used if you have an ongoing widespread infection. This is because they could make it more severe.”
The DAUK also linked the survey results to this week’s fiasco at the Royal College of Physicians (RCP), where attendees of an extraordinary general meeting (EGM) regarding concerns about PAs linked the behaviour of the RCP’s panel, which was accused of ‘contempt’, shutting down discussion and even filibustering, to the RCP’s financial conflict of interest in the millions of pounds it reportedly makes from administering PA examinations.
The RCP is hiding their full survey data from FRCP and Council until after the EGM vote. This lack of transparency is unacceptable…
The RCP Registrar, who sets RCP professional standards, works at this Trust. (Important note: there is no indication she was involved in this case [of steroid/antibiotic administration].)
Doctors at Torbay report PAs being used as “middle grades” – clear scope creep. Yet the Registrar, whose job is to “create consensus” & uphold standards, has been involved in withholding critical data that potentially sways the EGM vote. This is not leadership.
The Registrar’s own job description emphasises “accountability for clinical and professional affairs” and “…setting and maintaining professional standards.” How can the Registrar fulfil these duties, ensuring patient safety and upholding standards, when those very standards are being violated in their own Trust? This is an untenable conflict of interest.
In our view, the Registrar has failed in their core responsibility for transparency and integrity of RCP decision-making. We call for their resignation to restore trust in the RCP. The RCP’s position on PAs is currently compromised.
The statement concludes with a call on all voting members of the RCP to vote to support all the motions tabled at the EGM calling for a rethink on the issue of PAs:
Lastly, we are asking that Fellows vote in favour of all five motions as presented, to ensure that a safe revaluation of the PA role can be conducted to ensure patient safety and to ensure continued viable training of the medical profession moving forward.
The use of PAs, which is considered by nine out of ten doctors to be dangerous to patients and confuses many patients, who do not realise that they have not been seen and treated by a fully-qualified medic, is being pushed by the government as a way of ‘downskilling’ the NHS, reducing costs and allowing increased profits for private providers, under the guise of the so-called ‘NHS Workforce Plan’ as part of the ‘Integrated Care Systems’ (ICS) project.
ICS, formerly called ‘Accountable Care Organisations’ (ACOs) after the US system it copied, were renamed after awareness began to spread that ACOs were a system for withholding care from patients and that care providers were incentivised to cut care because they receive a share of the ‘savings’. The system remained the same, but the rebranding disguised the reality.
The government used a ‘statutory instrument’ (SI) to pass these changes, avoiding proper parliamentary scrutiny, but both the Tories and Keir Starmer’s Labour support these and other measures to cheapen the NHS for private involvement and only independent MP Claudia Webbe spoke against them during the brief SI debate. Green peer Natalie Bennett’s motion in the House of Lords to attempt to kill the instrument was defeated by the Tories with the help of Labour peers.
At least two people have already died avoidably because of misdiagnosis by PAs. Emily Chesterton, 30, who didn’t realise she wasn’t seeing a doctor, was treated for a calf strain when she had a deep vein thrombosis that led to a lethal embolism. Ben Peters, 25, was sent home from A&E with a ‘panic attack’ that was really a serious heart condition. A doctor’s Twitter/X thread includes details of others said to have died because of issues around PAs.
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Doctors’ fury at RCP ‘contempt’ and financial conflict of interest in non-doctor ‘associates’
Royal College of Physicians’ extraordinary general meeting turns to farce as doctors accuse panel of filibustering and lecturing them after concerns raised about dangers of untrained ‘physician associates’ carrying out doctor roles
The Royal College of Physicians (RCP) has provoked fury among doctors for its handling of an extraordinary general meeting (EGM) called by members to discuss motions against the College’s support for the government’s moves to both expand the use and roles of ‘physician associates’ (PAs) and to have them regulated by the General Medical Council (GMC).
PAs, who do not have medical degrees and receive only two years’ training compared to the seven years and more required to be a doctor, are increasingly being presented in healthcare settings as medical professionals and are even performing unsupervised heart surgery in some hospitals, as well as diagnosing, prescribing and seeing more patients in many general practices than GPs. Privately-owned GP companies are even making GPs redundant in order to replace them with cheaper PAs. Several patients have died, including at least two confirmed by coroner’s inquests, after misdiagnosis and inappropriate treatment by PAs.
The meeting, called to debate several motions around patient safety by enough members to trigger an EGM under the RCP’s rules, quickly descended into anger and farce. Doctor and professor Trisha Greenhalgh summed up in a series of her own and reposted Twitter/X posts indicating that the RCP panel was attacking those who raised concerns as irresponsible and damaging and were shutting down debate, even to the extent of ‘filibustering’, or talking at length to run out time:
More “headlines” without any actual RESULTS from the six questions. pic.twitter.com/SB5H6uAnW2
— Trisha Greenhalgh (@trishgreenhalgh) March 14, 2024
Here’s more. The category “neutral or positive” allows them to over-egg what they are spinning as a positive finding. Assumes that lack of experience with PAs *causes* a negative view. This would be a FAIL in any undergraduate essay on survey analysis. Correlation ≠ causation. pic.twitter.com/ZNPniLRLNM
— Trisha Greenhalgh (@trishgreenhalgh) March 14, 2024
Members attending online reported being unable to connect or losing their connection partway through:
This is fun pic.twitter.com/B4DKbbXgw7
— Trisha Greenhalgh (@trishgreenhalgh) March 13, 2024
Although opportunity to ask about financial conflicts of interest were not addressed, according to attendees, information emerging subsequently seems to indicate that the RCP does indeed have a financial interest extending to ‘millions of pounds’ in at least one aspect of the continuation and expanded use of PAs, as one disgusted doctor and NHS campaigner, Dr Rachel Clarke, pointed out:
Greenhalgh commented on the financial conflict of interest – and pointed out that the RCP’s president had just written an article about there being a role for PAs in healthcare for the British Medical Journal (BMJ) in which she did not point out the conflict, despite each BMJ article ending with a statement of potential conflicts of interest:
Even as of the time of writing, the end of the BMJ article still states that RCP president Sarah Clarke has not declared any competing interests:
So disgusted was Dr Rachel Clarke with the ‘lack of respect’ she witnessed at the meeting that, having originally been thrilled to be scheduled to appear as a keynote speaker at the RCP’s annual conference later this year, she has now withdrawn and has published an open letter about her reasons:
The use of PAs, which is considered by nine out of ten doctors to be dangerous to patients and confuses many patients, who do not realise that they have not been seen and treated by a fully-qualified medic, is being pushed by the government as a way of ‘downskilling’ the NHS, reducing costs and allowing increased profits for private providers, under the guise of the so-called ‘NHS Workforce Plan’ as part of the ‘Integrated Care Systems’ (ICS) project.
ICS, formerly called ‘Accountable Care Organisations’ (ACOs) after the US system it copied, were renamed after awareness began to spread that ACOs were a system for withholding care from patients and that care providers were incentivised to cut care because they receive a share of the ‘savings’. The system remained the same, but the rebranding disguised the reality.
Labour and Tories combine in Lords to defeat attempt to protect your right to see a doctor
The government used a ‘statutory instrument’ (SI) to pass these changes, avoiding proper parliamentary scrutiny, but both the Tories and Keir Starmer’s Labour support these and other measures to cheapen the NHS for private involvement and only independent MP Claudia Webbe spoke against them during the brief SI debate. Green peer Natalie Bennett’s motion in the House of Lords to attempt to kill the instrument was defeated by the Tories with the help of Labour peers.
At least two people have already died avoidably because of misdiagnosis by PAs. Emily Chesterton, 30, who didn’t realise she wasn’t seeing a doctor, was treated for a calf strain when she had a deep vein thrombosis that led to a lethal embolism. Ben Peters, 25, was sent home from A&E with a ‘panic attack’ that was really a serious heart condition. A doctor’s Twitter/X thread includes details of others said to have died because of issues around PAs.
The RCP was contacted for comment.
Update: the RCP has now said:
In organising the EGM, we wanted to ensure that a broad spectrum of views could be heard and addressed. There was a high volume of questions and we made clear it would be unlikely that all could be answered. However, every effort was made to facilitate an inclusive and constructive discussion where fellows, whether they were in the room, watching remotely, or contributing through randomly selected pre-submitted questions and comments, had the opportunity to express their view.
While as host to the Faculty of PAs (FPA) there will be a range of issues for the RCP to consider once the EGM ballot results are known, our core mission is excellent patient care. We agreed to host the FPA exactly because we wanted doctors to have oversight of the development of the profession. There is a workforce crisis in the NHS and when employed appropriately we believe PAs can be useful supplementary members of the multidisciplinary team. As a valued member of the RCP community we are saddened that Dr Clarke has made the decision to withdraw from the upcoming conference. However, we understand and recognise her strength of feeling on this issue and will be writing to her directly to respond to the concerns raised in her open letter.
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The Big Con: How the Consulting Industry Weakens Our Businesses, Infantilizes Our Governments, and Warps Our Economies – review
In The Big Con, Mariana Mazzucato and Rosie Collington claim that our overreliance on the consulting industry has negative consequences for society, inhibiting knowledge transfer and corporate and political accountability. The authors expose how consultancies’ goal of “creating value” may not align with addressing major issues such as climate change, arguing convincingly for greater transparency and a revitalised public sector, writes Ivan Radanović.
In their book The Big Con, Mariana Mazzucato and Rosie Collington warn that relying on consultancies harms the public interest. Asking what happens to the brain of an organisation when it is not learning by doing because someone else is doing the doing, they conclude that societies must return public purpose in centre of attention.
The authors’ thesis is that overreliance on consultancies harms public interest, disables governments, and threatens democracy.
In 2021, the consulting industry was valued at over 900 billion dollars. Its ninefold rise since 1999 is the result of rising reliance of states on consulting agencies. The authors’ thesis is that overreliance on consultancies harms public interest, disables governments, and threatens democracy. They investigate this trend and how to reverse it.
The “Big Con” is the term Mazzucato and Collington use to mark the biggest auditing, accounting, and consulting agencies such as Ernst & Young (EY), KPMG, PwC, Deloitte, McKinsey, Boston Consulting Group (BCG), Accenture and others. The consulting market emerged during early industrialisation, when engineers, periodically recruited by major industrial firms, formalised their work. In the 1920s many consultants, among them James McKinsey, cooperated with American businesses. The popularity of management consultancy rose in 1970 when BCG introduced the matrix for mapping the profitability of business portfolio. After two years, this tool was used (and paid for) by more than 100 enterprises. American firms, on the wings of the Marshall plan and later IT management projects, have spread throughout Europe.
Golden years
The election of the right-wing populists Margaret Thatcher in the UK (1979) and Ronald Reagan in the US (1981) occurred after a decade of economic turmoil, led by the end of the Bretton Woods system and two major oil crises. The opinion that the responsibility for the turmoil lay in how states were run mushroomed. The neoliberal credo was that the only value creators in society are markets, and with Thatcher and Reagan, favour was refocused from the worker to the citizen-taxpayer.
The neoliberal credo was that the only value creators in society are markets, and with Thatcher and Reagan, favour was refocused from the worker to the citizen-taxpayer.
Contrary to the belief that the essence of neoliberalism is to slash public spending, Mazzucato and Collington suggest “it is more precise to describe it as public spending redirection towards the stronger role of the market” (49). In Thatcher’s era (1979-1990) government expenditure rose in real terms by 7.7 percent (43). In Reagan’s (1981-1989) federal spending rose by almost nine percent annually (43). From the US to Australia, thousands of neoliberal reforms such as privatisation, deregulation or outsourcing states had to be implemented, and advised. The authors show us that the annual public spending for consulting in the UK from 1979 to 1990 rose fortyfold – from 7.1 million to 290 million dollars. The 1980s saw the advent of a new management doctrine. In place of earlier stable forms of organisational life emerged the model of flexible “learning organisations” which view instability as an opportunity. The main goal becomes maximising value for shareholders. In the 1990s, that led to the popularisation of storytelling in politics and business. It is no longer a product or brand that is sold, but the story about value, challenges and business success through positive change, peddled by elite consultants or management gurus.
Creating the impression of value
Today, consultants are seen as experts who transfer know-how and utilise advanced management techniques to improve clients’ businesses. The enormous rise of consulting in the last four decades is explained by the “value” they create for states and companies. However, according to the authors, consultants do not always meet expectations and they seldom transfer knowledge. Created “value” is often unclear and depends on the perception of the client. Consultants hustle to create the impression of value.
Created “value” is often unclear and depends on the perception of the client. Consultants hustle to create the impression of value.
There are many examples where engaging consultancies has backfired for states. In developing countries such as Nigeria, Mexico and Angola, hiring consultancies was a condition of their IMF loan agreements (50). The authors focus on wealthy countries, arguing that even if contracting consultants experienced in the implementation of complex macroeconomic programmes could be justified in developing countries, it is less justifiable in developed countries, which should ostensibly have high competency in these areas.
Unmet deadlines, spiralling costs
Consultancies often fail to deliver on their promises. In 2010, Sweden started the construction project for a new university hospital in Stockholm which would be the most advanced in Europe. Its operations were to be grounded in “value-based healthcare”, a concept designed by management guru Michael Porter. Costs were initially valued at 1.4 billion euro, with the project set to be completed in 2015. City authorities opted for a public-private partnership which contracted consultants from PwC and EY who claimed they would ”maximise the value and keep the costs under control” (145). Representatives from the construction company Skanska stated that this model would “transfer the risk from the state and taxpayers to the private sector” (145). However, the costs immediately surpassed the projections because vital equipment had not been included in the budget The project, beset by problems, was passed to BCG, who had nine consultants working on its implementation while earning a monthly salary of almost 70,000 euros over six years. Another consultancy, Nordic Interim AB was then contracted for an additional 12 million euro, and when the hospital was eventually finished in 2018, costs a billion euros higher than the original estimate.
Absence of accountability
It is not all about money. Consultancies contribute to many undemocratic practices, maintaining what Acemoglu and Robinson named as extractive institutions. Often, they act as a mechanism for public wealth extraction, whereby states recruit consultants when they want to “hedge” the political risk of unpopular economic measures. The states maintain legitimacy, and consultants get their share of political influence. Authors emphasise the example of Puerto Rico, which faced bankruptcy in 2016. Then-President Obama initiated the creation of an Oversight Board to supervise the bankruptcy process. Keeping reputational risk low, Washington ensured that the majority of members of the Board were of Puerto Rican heritage. The Board did not hire a large staff, to avoid looking like it was setting up a parallel government. Instead, it brought in consultants. Instead of the state, McKinsey engaged in the privatisation of public enterprises, healthcare reforms “based on value”, slashing public spending and restructuring debt. Moreover, McKinsey owned $20 million of Puerto Rico’s bonds: consultants were set to profit from the very same debt they were helping to restructure.
Regaining control
Even though consultancies did not cause the maladies of neoliberal capitalism, they have profited from them. Without transparency and democratic permission, they erode the capabilities of states and enterprises. Because knowledge is not cultivated within state workforces and institutions, a dependency on the “expertise” of consultancies spirals.
[Consultancies] erode the capabilities of states and enterprises. Because knowledge is not cultivated within state workforces and institutions, a dependency on the “expertise” of consultancies spirals.
The last section of the book is about “climate consulting”. Omnipresent and long-term, climate change is ideal ground for consultants. Competition is fierce; consultancies’ “websites are replete with beautifully designed free reports on sustainability issues for every sector, from oil and gas to healthcare” (190). They promise solutions, pitching themselves as an avant-garde of change.
The key takeaway, according to Mazzucato and Collington, is that we must challenge the predominance of consultancies. With their ultimate goal of “creating value”, they advise both the fossil polluters and the governments mandated to reduce emissions. Moreover, states are catalysts of technological change for public good, while the private sector only invests in fundamental research when it becomes enticingly profitable.
Putting aside the authors’ techno-optimistic view – which holds that climate change mitigation is mostly a technical issue regarding innovations for green transition, which is being debunked – their final suggestions are valid. A new narrative and vision for the role of the state, recovering public capacities, embedding knowledge transfer into consulting contracts’ evaluation and mandating transparency are, undoubtedly, desirable. The book’s importance lies in how it reveals the political implications of the consulting industry. Whether we choose “green growth” or abandon the growth imperative, one thing is certain: democratically elected governments are key actors. Only they can mobilise the resources required for achieving “moonshot” missions, the most urgent of which is climate change.
Note: This interview gives the views of the author, and not the position of the LSE Review of Books blog, or of the London School of Economics and Political Science.
Image credit: Alena Veasey on Shutterstock.
Locked Out of Development: Insiders and Outsiders in Arab Capitalism – review
In Locked Out of Development: Insiders and Outsiders in Arab Capitalism, Steffen Hertog critiques mainstream development models in the Middle East, focusing on state intervention and segmented market economies. Although Yusuf Murteza suggests the book under-examines neoliberalism’s prevalence, he finds its analysis on the state’s role in establishing the insider-outsider division in the economy nuanced and valuable.
Clusters of economic and political theorists have long been discussing how different actors prioritise and frame their understanding of “development”. Post-development and degrowth scholars such as Arturo Escobar, Gustavo Escobar, Wolfgang Sachs, and Jason Hickel announced the death of the mainstream development model as a project. They argued “the project of development” may not be equally beneficial to all societies, since the project carries ethnocentric and universalist dimensions which contribute to the hegemony of the West.
The ‘one size fits all’ idea of neoliberal development, which utilises finance and corporate capital, has gradually been replaced by alternative forms of development
The “one size fits all” idea of neoliberal development, which utilises finance and corporate capital, has gradually been replaced by alternative forms of development. Growing disillusionment with the Anglo-Saxon economic model increased the importance of examining alternative political and economic configurations both inside and beyond developed Western states. Varieties of Capitalism (VoC) theory’s significance can be grasped with its emphasis on existing similarities and differences within the institutions of developed economies. Recently, scholars have taken these insights seriously and benefited from the VoC framework to explain the reasons why political and economic institutions differ across societies. Discourse on the MENA region in terms of democracy and development may suffer from orientalist explanations that directly link religion and culture to the region’s political and economic stagnation. Steffen Hertog’s Locked Out of Development takes issue with what mainstream development scholars consider the political and economic inability of societies in the Middle East to take the Western route and realise neoliberal reforms in order to ensure economic development, productivity and innovation.
Neoliberal narratives suffer from a partial outlook. They trace the failures of development attempts by focusing on policymakers’ level of adherence to marketisation and privatisation.
Hertog’s main arguments throughout the book are threefold. First, neoliberal narratives suffer from a partial outlook. They trace the failures of development attempts by focusing on policymakers’ level of adherence to marketisation and privatisation. They consider ensuring faith in the market mechanisms of production and distribution systems as paramount. However, non-economic, country-specific problems matter. In the case of the Arab world, the deep dividing line of insider-outsider segmentation across societies has more explanatory power than classical narratives of having too much or too little market (81). Second, Hertog believes a comparative perspective situated within a global context carries crucial insights. The selected countries cannot be examined solely by focusing on within-region differences but should be considered within the global development trajectory and compared with developed countries (7). Third, the role of the state has a somewhat ambiguous position in development theory. The concept of a “developmental state” has added a further twist. The characteristics of the state and its symbiotic relationship with labour and the private sector need to be addressed when explaining factors contributing to the persistence of the Arab world’s development problem (8).
The role of the state has a somewhat ambiguous position in development theory
Hertog begins with a detailed examination of academic literature on the political economy of the Middle East, the varieties of capitalism approaches, and his conceptualisation of segmented market economies (SEME). The second chapter adopts a historical perspective and presents the case selected countries’ political and economic transformations after World War II. In the third chapter, Hertog reveals his argumentation of the SEME framework by bringing the state, labour market, business sector and skill composition to light. Detailed analysis of the country case studies follows, accompanied by SEME and future research directions. Lastly, Hertog sums up the reasons for the political and economic inability of the region to take the Western route.
Hertog argues that the VoC approach, with its emphasis on the heterogeneity of existing capitalisms, is useful to explain the unique characteristics of Arab capitalism. Different compositions of firms, the finance sector, networks, and the skill system create ideal-type interactions (those which typify certain characteristics of a phenomena) and lead to diversification within capitalism. The original VoC approach analysed several OECD countries from the developed world. In time, scholars used the explanatory power of VoC to explain the development performances of non-Western countries with specific modifications. Taking insights from recent accounts of VoC literature, Hertog believes the approach fits the Arab world well (8).
In broad terms, the state [in the Arab world] functions as the voice of insiders’ interests to quash any outsider’s attempt to reconfigure access to key resources.
There are two key dynamics in the region. As the second chapter discusses, the state has been a key actor in structuring the playing field between different interests to operate in the region (9). The interventionist and distributive characteristics of the state go hand in hand with the other dynamic, namely the persistence of insider-outsider division in the economy. In broad terms, the state functions as the voice of insiders’ interests to quash any outsider’s attempt to reconfigure access to key resources. Hertog warns that the nuanced structure of the SEME model applies only to the core members of the region, such as Algeria, Egypt, Jordan, Morocco, Tunisia, Syria, and Yemen. The key filter behind this selection of countries is their state-building projects between 1950 and 1970 (4-5).
Strategies of keeping public sector employment high with military jobs, large redistribution policies, food subsidies, and price controls are still prevalent in the region, demonstrating its nationalist and statist legacy.
Hertog finds the roots of his SEME model in Arab nationalism in the post-independence era. The state-building projects of the selected countries fused with nationalist and statist ideologies at the time. Discussion on the region’s long history brings up the question of path-dependence, which is used to describe the limiting power of past decisions over later trajectories. Hertog avoids engaging with these long-term theories, believing them unsuitable for a short book, and the key characteristics of the SEME model originated recently. Nationalisation policies and active intervention in the economy were characteristics of Arab nationalism (15). In state-building projects, Egypt and Syria set the parameters, which were later copied by other states. Strategies of keeping public sector employment high with military jobs, large redistribution policies, food subsidies, and price controls are still prevalent in the region, demonstrating its nationalist and statist legacy (28).
The detailed empirical discussion of the SEME is at the heart of the book. The framework is constituted by the state, labour market, business sector and skill system (9). The distributive character of a state can be located by examining the share of public employment, which remains high from a global perspective. Also, the state extensively regulates labour markets, holding key strongholds to access land and credit (29-30). Hertog argues these factors lead to segmented labour and private sectors, while keeping the skill level low. The presence of the state in the labour market ensures insider-outside division. Since there is little mobility, insiders rarely lose their position. Outsiders cannot reach to the welfare protection schemes by the state. This leads to social exclusion and an unproductive environment (32-48).
Hertog claims state intervention in the private sector creates unique opportunities for crony networks, whereby politically connected companies benefit from credits and licences.
Similar dynamics take place in the business sector, where large firms and clusters of small firms coexist (55). Hertog claims state intervention in the private sector creates unique opportunities for crony networks, whereby politically connected companies benefit from credits and licences. Business actors with outsider status engage in unproductive small-scale activities (58-60). The skill system needs to be thought of in relation to the segmented labour and business sectors. Low skill levels prevent mobility and limit innovation and technological development (69).
Overall, Hertog argues that state intervention in the region establishes the insider-outsider division in the economy. Hertog’s emphasis on bringing the state back into the analysis is beneficial. In the field of comparative politics, the idea of the state as an autonomous actor remained on the margins until the 1980s. The book’s limitations come in two forms. First, it doesn’t mention how global capitalist relations fit into the SEME. Hertog’s defence with the limitation of economic globalisation in the region may not offer a solution, since the dynamics of global capitalist accumulation depend on drawing materials from peripheral countries without contributing to them. Second, Hertog’s claim of neoliberalism’s low presence in the Arab world is dubious. Several scholars (Jason Hickel, Philip Mirowski) argue that states with strong capacity can implement the necessary reforms for deregulation and privatisation. Thus, the presence of neoliberalism and strong state capacity is not mutually exclusive. In the Middle East, we see a unique mixture of neoliberal policy reforms with strong state capacity. Even though Hertog constructs his own case, adapting earlier approaches to VoC and development topics and to explain the MENA region, policymakers, development specialists, and academics will find dry economic analysis alone is not enough. More nuanced analyses that consider the symbiotic interactions between the state, the business sector, and labour force are necessary. Only by doing this is it possible to acknowledge how politics mingle with economics, and to design alternative development programmes in response.
This post gives the views of the author, and not the position of the LSE Review of Books blog, or of the London School of Economics and Political Science.
Image Credit: AlexAnton on Shutterstock.
Royal College of GPs deletes article exposing lack of supervision of ‘PA’ not-doctors
RCGP has been equivocal about government’s changes to use of ‘associates’ without medical training to treat patients
The Royal College of GPs has deleted an article that detailed the extent of the lack of supervision by fully-qualified doctors over the actions and decisions of the ‘physician associate’ (PA) roles – who have only two years’ training – whose use the government is expanding.
The use of PAs, which is considered by ninety percent of doctors to be dangerous to patients and confuses many patients, who do not realise that they have not been seen and treated by a fully-qualified medic, is being pushed by the government as a way of ‘downskilling’ the NHS, reducing costs and allowing increased profits for private providers, under the guise of the so-called ‘NHS Workforce Plan’ as part of the ‘Integrated Care Systems’ (ICS) project.
ICS, formerly called ‘Accountable Care Organisations’ (ACOs) after the US system it copied, were renamed after awareness began to spread that ACOs were a system for withholding care from patients and that care providers were incentivised to cut care because they receive a share of the ‘savings’. The system remained the same, but the rebranding disguised the reality.
Now, as Pulse magazine has revealed, the RCGP has deleted a case study that revealed a shocking lack and laxity in the supervision of a PA:
According to the now-deleted case study, held a ‘minimum’ of 27 10-minute appointments each day and asked the on-call doctor to review patients for an ‘urgent opinion’ only ‘once every two to three months’…
…After screenshots circulated on social media, the RCGP removed the case study at the PA’s request…
…The case study previously said: ‘[The PA] has three, ten-minute appointment slots in a row, and at the end of those slots has a ten-minute break for administration and including having prescriptions signed by a GP.’
It said supervision is ‘shared’ between GPs working at the practice, and that for ‘non-urgent concerns’ there is a ‘ten minute debrief with an on-call doctor’ which takes place every two to three weeks.
Matt Kneale, co-chair of the Doctors’ Association UK which along with the British Medical Association is opposing the changes, said:
Much of the concern from doctors in recent months has built up from a lack of transparency from Royal Colleges about where they stand on physician associates.
While we are grateful that the RCGP has removed what can, at best, be described as unprofessional practice, we maintain that the College needs to sit down with wider stakeholders on the concerns around PA roles and scope more generally.
The RCGP has voiced ‘concerns’ about the new system, but has not formally opposed it, despite the outrage of doctors and the increasing examples of companies hiring PAs instead of doctors and even making doctors redundant to switch to PAs.
The government’s expansion and renaming of these roles, along with backdoor to regulate them via the General Medical Council (GMC), which regulates doctors – is part of what experts call ‘scope creep’: physician’s assistants and anaesthetist’s assistants, as they were originally called, are valuable roles in carefully limited settings, but NHS England, the government body appointed to run (and run down) the NHS has been using them way beyond their original scope, for example even to perform some types of brain surgery and expecting them to ‘learn on the job’.
The government used a ‘statutory instrument’ to pass these changes, avoiding proper parliamentary scrutiny, but both the Tories and Keir Starmer’s Labour support these and other measures to cheapen the NHS for private involvement and only independent MP Claudia Webbe spoke against them during the brief debate. Green peer Natalie Bennett has tabled a motion in the House of Lords in an attempt to kill the instrument, but without support from the notional ‘opposition’, it is unlikely to succeed.
During the Statutory Instrument debate, Tory former Health Secretary Therese Coffey gushed about the potential for using three associates to anaesthetise patients during operations, with just a single consultant anaesthetist monitoring remotely as an ‘efficiency’.
At least two people have already died avoidably because of misdiagnosis by PAs. Emily Chesterton, 30, who didn’t realise she wasn’t seeing a doctor, was treated for a calf strain when she had a deep vein thrombosis that led to a lethal embolism. Ben Peters, 25, was sent home from A&E with a ‘panic attack’ that was really a serious heart condition.
SKWAWKBOX needs your help. The site is provided free of charge but depends on the support of its readers to be viable. If you’d like to help it keep revealing the news as it is and not what the Establishment wants you to hear – and can afford to without hardship – please click here to arrange a one-off or modest monthly donation via PayPal or here to set up a monthly donation via GoCardless (SKWAWKBOX will contact you to confirm the GoCardless amount). Thanks for your solidarity so SKWAWKBOX can keep doing its job.
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Labour front bench takes £650k from health privateers – more than Tories
Starmer and co rake in cash from private health donors – twenty-five percent more than the Tories
Keir Starmer and his front bench MPs have taken almost £650,000 from private health companies, according to a compilation of their declarations of MPs’ interests.
The totals accepted by MPs in Starmer’s Shadow Cabinet between 2020 and 2023 are:
- Keir Starmer £157,500
- Shadow Health Secretary Wes Streeting £193,225
- Shadow Home Secretary Yvette Cooper £231,817
- Shadow Chancellor Rachel Reeves £14,840
- Deputy Labour leader Angela Rayner £50,000
- Shadow Foreign Secretary David Lammy £1,640
- Total £649,022
Figures compiled by David Powell
The total accepted by Labour beats similar donations to the Tories by around twenty-five percent. Starmer and his health spokesman Streeting have vowed to extend the use of private companies for NHS services if Labour gets into government, while promising further austerity and refusing to say they will increase NHS funding to meet need, or increase wages for NHS staff, instead saying – just like Tories – that the NHS must ‘reform’ to be ‘sustainable’.
Both are also fully committed to the ‘Integrated Care’ programme of health rationing and incentivised cuts through withholding care – a direct import from disastrous US healthcare – that is wrecking the NHS even more thoroughly that previous Tory ‘reforms’.
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