Cameron's EU stance is unsustainable and the sceptics know it

The EU-lite deal he imagines to keep the best of both worlds can't be done.

David Cameron would not campaign for a “No” vote if the British people were asked in a referendum if they wanted to stay in the European Union. That is one of the main news items to come out of a wide-ranging interview the PM has given to the Daily Telegraph at the start of the long summer recess.

At one level, it isn’t that much of a surprise. In a long parliamentary debate after the last European Council summit, Cameron expressed, albeit in fairly delicate terms, the very same point. He indicated that he doesn’t want to hold a referendum now, because the nature of the EU is changing rapidly in response to the single currency crisis. He would rather wait to see what institutional adjustments and treaty changes emerge, use those amendments to negotiate a different, looser relationship with Brussels and then perhaps consult the nation on whether his preferred EU terms are acceptable.

It stands to reason that he expects his negotiations to be successful, or at least that he would only dare hold a referendum if he thought he had wangled a decent package, including “repatriation” of powers. So, by extension, he would be selling a deal with his name on it. Naturally he would then campaign for a “yes” vote.

The curious thing is that he has chosen to spell it out again now in black and white. Anyone familiar with or who cares about the way EU diplomacy actually works knows it would be an affront for an incumbent British PM to go around advertising in advance that he might campaign for complete exit. And those who think exit is the only serious and desirable option already suspect Cameron of being a bit of a Brussels quisling. So the only thing this interview line can achieve is rubbing the sceptics’ noses in the fact that they don’t have a friend in Number 10. An odd choice, given the difficulties Cameron already has with party management.

But the real problem Cameron has with all this stuff is the complacency (or naivete?) in thinking he will get a renegotiation deal that will satisfy the Tories. The argument usually deployed is that Britain is a desirable market for our European neighbours and a purchaser of their goods and services. Ergo, they will want to keep us on side and will acquiesce to our demands.

There are two problems. First, diplomacy can trump economics in Europe. Cameron has persistently underestimated how fed up the rest of the continent is with the UK’s half-hearted engagement – the in/out “hokey-cokey” approach. This goes back way further than the current government. The Germans in particular are said to be impatient and their appetite to meet London’s needs is diminished further by conspicuous Schadenfreude among Tories over the failings in the single currency project. The British message in Brussels at the moment boils down to: “We’re sorry that you’ve made a right hash of everything. We did warn you. It’s not really our problem, except when it impacts on our growth. So could you please sort it out. Follow policies of deeper integration, which we despise and would never pursue ourselves and then, when you’ve finished, could we please have a whole bunch of social policies back plus other yet-to-be named dispensations? Oh, and by the way, we’ll veto your treaties unless you give us what we want. And did we add that we won’t surrender any control over the terms of the single market. We must stay at the top table at all times. Is that ok?”

A Whitehall source, who has discussed these things with senior figures in Angela Merkel’s office, recently ran this proposition past German counterparts and reports that: “The answer is ‘no’”. Of course it is.
 
Second, even if Cameron negotiates some nominal repatriation of powers – a looser arrangement on paper – and even if he secures formal guarantees that our status in the single market is preserved, he can’t deliver that protection in practice. He can do nothing about “caucusing”. This is the process by which members of a new, ultra-integrated, consolidated Eurozone turn up at wider EU summits with pre-agreed positions that can be voted through, whether Britain likes it or not. In other words, Cameron could have a piece of paper saying the UK will not be disadvantaged in the single market and wave it around like crazy when he steps off the Eurostar, but it won’t matter because we’ll be marginalised when it comes to the detail of all subsequent rule changes. The sceptics understand this perfectly well and so won’t be fooled by any “renegotiation”. They will still want out.

So really Cameron’s message is that he can’t give his party what it really wants on Europe and he won’t pretend that he can. That is a brave line to take given the current mood of the Conservative benches.

PS. For further reading on UK relations with the EU, by far the best thing published recently is this excellent Centre for European Reform pamphlet by David Rennie of the Economist.

David Cameron said he would not campaign for a "no" vote in an EU referendum. Photograph: Getty Images.

Rafael Behr is political columnist at the Guardian and former political editor of the New Statesman

Photo: Getty Images
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British mental health is in crisis

The headlines about "parity of esteem" between mental and physical health remain just that, warns Benedict Cooper. 

I don’t need to look very far to find the little black marks on this government’s mental health record. Just down the road, in fact. A short bus journey away from my flat in Nottingham is the Queens Medical Centre, once the largest hospital in Europe, now an embattled giant.

Not only has the QMC’s formerly world-renowned dermatology service been reduced to a nub since private provider Circle took over – but that’s for another day – it has lost two whole mental health wards in the past year. Add this to the closure of two more wards on the other side of town at the City Hospital, the closure of the Enright Close rehabilitation centre in Newark, plus two more centres proposed for closure in the imminent future, and you’re left with a city already with half as many inpatient mental health beds as it had a year ago and some very concerned citizens.

Not that Nottingham is alone - anything but. Over 2,100 mental health beds had been closed in England between April 2011 and last summer. Everywhere you go there are wards being shuttered; patients are being forced to travel hundreds of miles to get treatment in wards often well over-capacity, incidents of violence against mental health workers is increasing, police officers are becoming de facto frontline mental health crisis teams, and cuts to community services’ budgets are piling the pressure on sufferers and staff alike.

It’s particularly twisted when you think back to solemn promises from on high to work towards “parity of esteem” for mental health – i.e. that it should be held in equal regard as, say, cancer in terms of seriousness and resources. But that’s becoming one of those useful hollow axioms somehow totally disconnected from reality.

NHS England boss Simon Stevens hails the plan of “injecting purchasing power into mental health services to support the move to parity of esteem”; Jeremy Hunt believes “nothing less than true parity of esteem must be our goal”; and in the House of Commons nearly 18 months ago David Cameron went as far as to say “In terms of whether mental health should have parity of esteem with other forms of health care, yes it should, and we have legislated to make that the case”. 

Odd then, that the president of the British Association of Counselling & Psychotherapy (BACP), Dr Michael Shooter, unveiling a major report, “Psychological therapies and parity of esteem: from commitment to reality” nine months later, should say that the gulf between mental and physical health treatment “must be urgently addressed”.  Could there be some disparity at work, between medical reality and government healthtalk?

One of the rhetorical justifications for closures is the fact that surveys show patients preferring to be treated at home, and that with proper early intervention pressure can be reduced on hospital beds. But with overall bed occupancy rates at their highest ever level and the average occupancy in acute admissions wards at 104 per cent - the RCP’s recommended rate is 85 per cent - somehow these ideas don’t seem as important as straight funding and capacity arguments.

Not to say the home-treatment, early-intervention arguments aren’t valid. Integrated community and hospital care has long been the goal, not least in mental health with its multifarious fragments. Indeed, former senior policy advisor at the Department of Health and founder of the Centre for Applied Research and Evaluation International Foundation (Careif) Dr Albert Persaud tells me as early as 2000 there were policies in place for bringing together the various crisis, home, hospital and community services, but much of that work is now unravelling.

“We were on the right path,” he says. “These are people with complex problems who need complex treatment and there were policies for what this should look like. We were creating a movement in mental health which was going to become as powerful as in cancer. We should be building on that now, not looking at what’s been cut”.

But looking at cuts is an unavoidable fact of life in 2015. After a peak of funding for Child and Adolescent Mental Health Service (CAMHS) in 2010, spending fell in real terms by £50 million in the first three years of the Coalition. And in July this year ITV News and children’s mental health charity YoungMinds revealed a total funding cut of £85 million from trusts’ and local authorities’ mental health budgets for children and teenagers since 2010 - a drop of £35 million last year alone. Is it just me, or given all this, and with 75 per cent of the trusts surveyed revealing they had frozen or cut their mental health budgets between 2013-14 and 2014-15, does Stevens’ talk of purchasing “power” sound like a bit of a sick joke?

Not least when you look at figures uncovered by Labour over the weekend, which show the trend is continuing in all areas of mental health. Responses from 130 CCGs revealed a fall in the average proportion of total budgets allocated to mental health, from 11 per cent last year to 10 per cent in 2015/16. Which might not sound a lot in austerity era Britain, but Dr Persaud says this is a major blow after five years of squeezed budgets. “A change of 1 per cent in mental health is big money,” he says. “We’re into the realms of having less staff and having whole services removed. The more you cut and the longer you cut for, the impact is that it will cost more to reinstate these services”.

Mohsin Khan, trainee psychiatrist and founding member of pressure group NHS Survival, says the disparity in funding is now of critical importance. He says: “As a psychiatrist, I've seen the pressures we face, for instance bed pressures or longer waits for children to be seen in clinic. 92 per cent of people with physical health problems receive the care they need - compared to only 36 per cent of those with mental health problems. Yet there are more people with mental health problems than with heart problems”.

The funding picture in NHS trusts is alarming enough. But it sits in yet a wider context: the drastic belt-tightening local authorities and by extension, community mental health services have endured and will continue to endure. And this certainly cannot be ignored: in its interim report this July, the Commission on acute adult psychiatric care in England cited cuts to community services and discharge delays as the number one debilitating factor in finding beds for mental health patients.

And last but not least, there’s the role of the DWP. First there’s what the Wellcome Trust describes as “humiliating and pointless” - and I’ll add, draconian - psychological conditioning on jobseekers, championed by Iain Duncan Smith, which Wellcome Trusts says far from helping people back to work in fact perpetuate “notions of psychological failure”. Not only have vulnerable people been humiliated into proving their mental health conditions in order to draw benefits, figures released earlier in the year, featured in a Radio 4 File on Four special, show that in the first quarter of 2014 out of 15,955 people sanctioned by the DWP, 9,851 had mental health problems – more than 100 a day. And the mental distress attached to the latest proposals - for a woman who has been raped to then potentially have to prove it at a Jobcentre - is almost too sinister to contemplate.

Precarious times to be mentally ill. I found a post on care feedback site Patient Opinion when I was researching this article, by the daughter of a man being moved on from a Mental Health Services for Older People (MHSOP) centre set for closure, who had no idea what was happening next. Under the ‘Initial feelings’ section she had clicked ‘angry, anxious, disappointed, isolated, let down and worried’. The usual reasons were given for the confusion. “Patients and carers tell us that they would prefer to stay at home rather than come into hospital”, the responder said at one point. After four months of this it fizzled out and the daughter, presumably, gave up. But her final post said it all.

“There is no future for my dad just a slow decline before our eyes. We are without doubt powerless – there is no closure just grief”.

Benedict Cooper is a freelance journalist who covers medical politics and the NHS. He tweets @Ben_JS_Cooper.