Can Ed Miliband reform the NHS, and not just save it?

Labour’s health policy should focus on patient empowerment and obtaining the best value for money fo

Ed Miliband's primary task today was to turn the screw on Andrew Lansley. In this, he has been largely successful, but his speech was also revealing for what it says about his future approach to public-service reform.

During the Labour leadership campaign, none of the candidates had an incentive to raise difficult reform arguments, for fear of alienating union and grass-roots votes. This might have been tolerable if Labour had renewed its pitch on public services in its last years in office. But despite repeated attempts, it only came close to a new, post-Blairite paradigm with its manifesto pledges on citizen guarantees or entitlements and public-sector takeovers of weak providers by strong ones. It is fair to say that Labour thinking on public services has not advanced much since about 2004.

The coalition government has made much running dismantling the worst elements of New Labour's statecraft: its indicators and targets, anaemic localism and a latter-day preference for stakeholder management over bold reform. But it has said very little about the big strategic choices. There is no sense in the coalition's programme of which public services best support full employment and an affordable welfare state; of the challenges that an ageing society poses for reform of the NHS and social care; or how real innovation and productivity can be secured in universal services that face enormous cost pressures.

Miliband devoted a substantial section of today's speech to outlining the main long-term challenges facing the NHS, including far higher levels of chronic disease, growing levels of mental illness and the rising social care needs of the elderly. Each of these challenges requires services that are more joined up (integrating NHS care with social care provision, for example) and at the same time more preventative, to take pressure off the acute services.

But they will also entail rising costs. This is why making public services more productive and efficient needs to be a key task for the centre left and why Miliband is right to say that he will be "a reformer of the state as well as the market". If we are to defend high-quality universal public services, at a time when voices on the right are calling for services to be cut back and targeted just at the most disadvantaged, then we need to set out how these can be afforded, given rising cost pressures and the public's reluctance to pay higher levels of tax.

Miliband emphasised that to make services responsive to their users requires strong forms of accountability. Here he needs to learn the lessons of the last Labour government, which generally favoured the use of central targets in order to hold professionals to account. These targets did lead to significant improvements – waiting times fell and the number of failing schools was radically reduced. Nevertheless, there were too many targets that made doctors and teachers the slaves of a tick-box culture. Professionals on the front line need the flexibility to do what is right for individual patients and children, rather than simply follow Whitehall guidelines.

A chance to pull ahead

But if Miliband wants to reduce central targets, how does he ensure accountability to patients and parents? In the health service, the proposed health and well-being boards need to be strengthened by giving them the power to sign off the strategic plans of GP consortiums.

In education, it is crazy for the secretary of state to be directly funding an ever-growing number of free schools and academies from Whitehall. Instead, we should look at the idea of our big cities having an appointed schools commissioner, whose role would be to raise educational standards in their area, allocate funding to each school and provide shared support services to local schools. Having a single individual to perform this role would provide for greater focus and accountability to parents.

In policing, Labour should accept the government's plans for elected police and crime commissioners, but in the long term look at shifting responsibilities for policing in the large cities to elected mayors.

Miliband is absolutely right to point to the lack of patient empowerment in the coalition's NHS reforms: the agenda is all about bureaucratic change or market disciplines. Very little is said about passing power to patients. This is a golden opportunity for Labour to get ahead of the debate, by advocating the devolution of funding to "personal budgets" for those with chronic long-term conditions.

But Miliband is relatively silent on the role of competition in public services. Oppositions always default to woolly talk of "collaboration" and partnership. But competition has its place. In the NHS Blair's 2006 reforms – which gave patients the right to choose from a list of five hospitals and which led to competition for patients between NHS trusts – successfully improved outcomes (PDF) measured by length of hospital stay and deaths from heart attacks.

Labour should oppose the government's proposal to make the promotion of competition the overriding objective of the health regulator Monitor. This is putting the cart before the horse. Instead, its objective should be ensuring the best value for money for the taxpayer: competition may or may not be the best means of achieving that.

Ed Miliband criticised the Health Bill on the grounds that it would undermine the sense of "national mission" underpinning the NHS. He should be careful that talk of the public-service ethos is not used simply to defend vested interests. But his defence of the NHS as a national institution resonates with the "Blue Labour" approach.

The NHS is a popular public institution, which embodies values of solidarity, public interestedness and fairness. It is a British tradition. Any decent society should defend institutions that are run by and large in the public interest and not simply for profit. There is a very real danger that these institutions could be lost in the government's rush to expose every public service to market competition.

Miliband may save the NHS, but can he reform it?

Nick Pearce is director of the Institute for Public Policy Research (IPPR).

Nick Pearce is Professor of Public Policy & Director of the Institute for Policy Research, University of Bath.

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Expressions of sympathy for terror's victims may seem banal, but it's better than the alternative

Angry calls for "something to be done" play into terrorists' hands.

No sooner had we heard of the dreadful Manchester Arena bombing and before either the identity of the bomber or the number of dead were known, cries of “something must be done” echoed across social media and the airwaves. Katie Hopkins, the Mail Online columnist, called for “a final solution”, a tweet that was rapidly deleted, presumably after she remembered (or somebody explained to her) its connotations. The Telegraph columnist Allison Pearson wanted “a State of Emergency as France has” and “internment of thousands of terror suspects”, apparently unaware that the Nice attack, killing 86, happened after that emergency was declared and that nobody has been interned anyway.

It cannot be said too often that such responses play into terrorists’ hands, particularly if Isis was behind the Manchester bombing. The group’s aim is to convince Muslims in the West that they and their families cannot live in peace with the in-fidel and will be safe only if they join the group in establishing a caliphate. Journalists, striving for effect, often want to go beyond ­banal expressions of sympathy for ­victims. (It’s a mistake I, too, have sometimes made.) But occasionally the banal is the appropriate response.

Pity begins at home

Mark Twain, writing about the “terror” that followed the French Revolution and brought “the horror of swift death”, observed that there was another, older and more widespread, terror that brought “lifelong death from hunger, cold, insult, cruelty and heartbreak”. The first, he wrote, we had been “diligently taught to shiver and mourn over”; the other we had never learned to see “in its vastness or pity as it deserves”.

That is true: more children across the world die each day from hunger or disease than could ever be killed in a terror attack. We should not forget them. Nor should we forget that the numbers killed in terrorist attacks in, for example, Baghdad far outnumber those killed in all European attacks of our times combined. In an age of globalisation, we should be more cosmopolitan in our sympathies but the immediacy of 24-hour news make us less so.

When all is said and done, however, pity, like charity, begins at home. We naturally grieve most over those with whom we share a country and a way of life. Most of us have been to concerts and some readers will have been to one at the Manchester Arena. We or our children could have been present.

Cheers from Highgate Cemetery

What a shame that Theresa May modified the Tory manifesto’s proposals on social care. For a few giddy days, she was proposing the most steeply progressive (or confiscatory, as the Tories would normally say) tax in history. True, it was only for those unfortunate enough to suffer conditions such as dementia, but the principle is what counts. It would have started at zero for those with assets of less than £100,000, 20 per cent for those with £120,000, 50 per cent for those worth £200,000, 99 per cent with those with £10m and so on, ad infinitum. Karl Marx would have been cheering from Highgate Cemetery.

Given that most people’s main asset – the value of their home – did not have to be sold to meet their care costs until death, this was in effect an inheritance tax. It had tantalising implications: to secure their inheritance, children of the rich would have had to care for their parents, possibly sacrificing careers and risking downward mobility, while the children of the poor could have dedicated themselves to seeking upward mobility.

The Tories historically favour, in John Major’s words, wealth cascading down the generations. In recent years they have all but abolished inheritance tax. Now they have unwittingly (or perhaps wittingly, who knows?) conceded that what they previously branded a “death tax” has some legitimacy. Labour, which proposes a National Care Service but optimistically expects “cross-party consensus” on how to finance it, should now offer the clarity about old age that many voters crave. Inheritance tax should be earmarked for the care service, which would be free at the point of use, and it should be levied on all estates worth (say) £100,000 at progressive rates (not rising above even 50 per cent, never mind 99 per cent) that yield sufficient money to fund it adequately.

Paul Dacre’s new darling

Paul Dacre, the Daily Mail editor, is in love again. “At last, a PM not afraid to be honest with you,” proclaimed the paper’s front page on Theresa May’s manifesto. Though the Mail has previously argued that to make old people use housing wealth to fund care is comparable to the slaughter of the first-born, an editorial said that her honesty was exemplified by the social care proposals.

On the morning of the very day that May U-turned, the Mail columnist Dominic Lawson offered a convoluted defence of the failure to cap what people might pay. Next day, with a cap announced, the Mail hailed “a PM who’s listening”.

Dacre was previously in love with Gordon Brown, though not to the extent of recommending a vote for him. What do Brown and May have in common? Patriotism, moral values, awkward social manners, lack of metropolitan glitz and, perhaps above all, no evident sense of humour. Those are the qualities that win Paul Dacre’s heart.

Sobering up

Much excitement in the Wilby household about opinion polls that show Labour reducing the Tories’ enormous lead to, according to YouGov, “only” 9 percentage points. I find myself babbling about ­“Labour’s lead”. “What are you talking about?” my wife asks. When I come to my senses, I realise that my pleasure at the prospect, after seven years of Tory austerity, of limiting the Tories’ majority to 46 – more than Margaret Thatcher got in 1979 – is a measure of my sadly diminished expectations. l

Peter Wilby was editor of the Independent on Sunday from 1995 to 1996 and of the New Statesman from 1998 to 2005. He writes the weekly First Thoughts column for the NS.

This article first appeared in the 25 May 2017 issue of the New Statesman, Why Islamic State targets Britain

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