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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What to look out for in the 2017 local elections on 4 May

Your guide to the important results, through the night and into Friday evening. 

Voters in England, Scotland and Wales will elect councillors and county councillors on 4 May, in the first major indicator of party strength since the referendum contest. The snap election on 8 June gives the contest an added edge. Here's what to look out for as the night unfolds. 

22:00:  Polls close, and the New Statesman liveblog opens. Parties will start their spin operations, which will give us an idea how well or badly they think they’ve done.

Remember the historic trajectory is for the opposition parties to do better at local elections than general elections, as voters use them to send a message to the boss. That even holds true for the elections in 1983 and 1987, which occurred in May before a June election, where the Conservatives made gains, unusually for a governing party when locals are not held on the same day as general election. So both the Liberal Democrats and Labour will want to post big results in anticipation of doing worse on 8 June than they will on 4 May.

We will also be electing the new combined authority mayors. These use the instant run-off system, which means that if no candidate gets more than 50 per cent of the vote in the first round, the top two go through to a run-off. This is one reason why the Conservatives will struggle to win any of these elections other than Cambridgeshire and Peterborough.

There will, I imagine, be some on-the-whistle polls, though these should not be considered “exit polls” in the sense of the big one on general election nights.

Well, British exit polls aren’t measuring voting intention – they don’t give us much of a sense of what the percentage of the vote will be, for instance – but change. Although there are many more Labour voters in Hackney than there are in Harrogate, for instance, for the most part, if there is a five per cent increase in the Labour vote at the expense of the Conservatives in Hackney, there will be a five per cent increase in the Labour vote at the expense of the Conservatives in Harrogate – and, more importantly, in Harlow, a marginal seat.

This is very expensive however, so broadcasters will not be shelling out for an exit poll for the local elections. Instead, we’ll just get ordinary polls.

Hopefully they’ll be interesting, because we won’t have much to talk about until…

02:00: Results come in from the Isle of Wight, which, thanks to its large number of independents, won’t tell us all that much unless the Liberal Democrats are on course for a fantastic night. More interesting is Swansea, the first Welsh council due to declare.  Labour hold 49 of the seats here, but the Liberal Democrats went from 23 seats here to just 12 last time, so they will hope to make gains.

These results won’t disprove anything – Labour could hold on in Swansea and the Isle of Wight could continue to be a bit odd and the Liberal Democrat revival could be on, but it’s also possible that we will see that they are really starting to get back to their pre-coalition position.

Also keep a look out for how the Conservatives do in the wards that make up Gower, a Labour seat from 1906 until the 2015 election, where Byron Davies is defending a wafer-thin majority on 8 June.

02:30: Wrexham will declare. Wrexham has been in no overall control since ten Labour councillors, including the council leader, resigned the whip in protest at interference from regional officers. As a result, we won’t get as good an idea as we’d like what this result means for Ian Lucas’s chances of holding onto to Wrexham, which narrowly stayed Labour in 2015.

03:00:  It’s raining Welsh councils. Cardiff (Labour controlled, Liberal Democrats looking to recover lost ground in a council they ran until 2012) , Flintshire (Labour in coalition with independents facing Liberal Democrats), Merthyr Tydfil (Labour controlled having been run by a Liberal coalition with Indepedents from 2008 to 2012), and the improbably-named Neath Port Talbot  (Labour hegemony).

In terms of general election battles, look at how the Conservatives do in the wards making up Cardiff North, which they are defending, and Cardiffs West and South, which they hope to take. Look out for how the Labour-Liberal Democrat battle works out in Cardiff Central, too. In Flintshire, keep an eye out for the results in Delyn and Alyn and Deeside, where Labour’s Mark Tami and David Hanson face tough re-election bids against the Tories.

The great unknown is how well Ukip will do. Ukip have performed strongly in Wales but the last time these seats were up, in 2012, the party hadn’t enjoyed its 2013-4 surge and now it is in institutional crisis. They are standing fewer candidates though some former Kippers may do well as independents.

Then the English mainland finally gets on the act, as county councils in Dorset (narrow Conservative majority) , Essex, Gloucestershire (narrow Conservative majority) and Lincolnshire (Conservatives in coalition with Liberal Democrats and independents), Somerset (Conservative majority), Warwickshire (no overall control) declare.

In Dorset, watch out how the Liberal Democrats do, particularly in the wards of Mid Dorset and Poole,  which they held until 2015 and then lost on a massive swing. We’d expect a reversion to the mean for the Liberal Democrats on 8 June as they come off the back of their very bad losses in the 2015 general election. So look out for signs of that here. For Labour, their best hope comes within South Dorset, a seat they held until 2010, though unfavorable boundary changes since then make it a safe seat for Richard Drax.  

In Gloucestershire, the Liberal Democrats will be looking for a big performance in the wards of Cheltenham, another 2015 loss, while Labour will hope to build on their 2012 gains in the city of Gloucester itself. Seats in the Cotswolds constituency will give us a good clue as to whether or not the Liberal Democrats’ push into affluent Conservative areas that voted Remain is bearing fruit.

Meanwhile, Labour have two marginals to defend, while the Tories have three at a parliamentary level in Lincolnshire. The Tories will hope to defend LincolnBrigg and Goole and Cleethorpes in June, while Labour’s Melanie Onn and Nic Dakin are protecting narrow majorities in Great Grimsby and Scunthorpe respectively.

In Somerset, look out for the scale of the Liberal Democrat revival, particularly in Taunton Deane and Wells where Rebecca Pow and James Heappey are hoping to head off Liberal revivals. Remain-voting Bath in particular is worth keeping an eye on.

Warwickshire is all-blue at a Westminster level, though it contains the marginal seats of Nuneaton, North Warwickshire, and Rugby, which despite its 10,000 vote majority is the emblematic seat Labour would need to win to secure a parliamentary majority. As with all three of those seats, the council race should be a straightforward Tory-Labour battle.

04:00: Look for how Ukip or Ukippers-turned-independent can do in Blaenau Gwent, while the Conservatives hope to take Bridgend – held by Madeleine Moon at Westminster and crucially, Welsh Labour leader Carwyn Jones at the Assembly level – in June. A good Labour performance here would indicate that the Tories will face a harder time in Wales than the polls suggest.

In Newport, Labour regained their majority – lost in 2008 – in 2012, and the Liberal Democrats and Tories will both hope to eat into it. If the polls are to be believed, both Newport seats are at risk from the Conservatives, so look out for how they do here.

English county councils in Hampshire (Conservative) and Northumberland (no overall control) will declare. In Hampshire, the Liberal Democrats are looking for gains, particularly in Portsmouth South and Eastleigh, both lost in 2015.

04:30: Ceredigion, one of just eight Liberal Democrat defences, is up, but unfortunately, the local council is run by independents and Plaid Cymru so it's unlikely to tell us much unless the Welsh nationalists have an astonishingly good result, in which case, we won’t know much about what these means for Mark Williams’ re-election hopes.

05:00: CityMetric editor Jonn Elledge is scheduled to make his “O” face as the first ever combined authority mayoral result for the West of England comes in. (More accurately, it’s the Bristol-Bath-South Gloucestershire-and-North-East-Somerset mayoralty but that doesn’t roll off the tongue. Irritate a Bath resident and call it the “Greater Bristol” mayor. 

I am v. sceptical that this will come in at the advertised time as Bristol famously counts its results very, very slowly. But this is the only genuine three-way marginal of the mayoralties, though thanks to the form of run-off voting used, I expect there will be a lot of wasted transfers. (If you are a Green voter, it’s not at all clear whether you should put Labour or the Liberal Democrats as your second preference to stop the Tories, for instance.)  

That the Liberal Democrats are standing their still-popular former Bristol MP Stephen Williams as their candidate increases their chances here.

Monmouthshire (Conservative-Liberal coalition), will declare. Labour will hope to become the largest party and take control. Monmouth constituency has a formidable Tory majority of 10,000 despite being Labour until 2005, but is, again, in the ballpark of seats Labour must compete in if it wishes to govern alone. 

05:30: Doncaster mayoralty. Ukip used to talk a big game about taking this kind of thing. Not so much now.

07:00: Vale of Glamorgan will declare. Conservative at Westminster, but run by a minority Labour administration since 2012, Labour must take control and take control comfortably if they are to take the seat back on 8 June.

08:00:  Cumbria, where Labour runs a minority administration, to declare. Look out for how the party performs in the wards of Copeland and Barrow, both of which the party hopes to hold onto from 2015. The Welsh council of Torfaen, a Labour stronghold at both Westminster and local level, will also declare.

08:00-11:00: Sleep.

11:00: The first Scottish result comes in. Unfortunately, it’s from the Orkney Islands, where only independents stand at a local level, so we will learn….not a lot.

Scotlad elects councillors under the single transferable vote system so most of the councils are coalitions. In terms of stress-testing the polls, there are two things to look out for: the first is a general Conservative vote increase. The second is the emergence of what you might call the Unionist front: that is, people voting on constitutional lines across left-right lines. If that happens, the SNP may underperform their voteshare significantly as far as council seats go.

The nightmare for Labour: a massive increase in the Tory vote but no emergence of Unionist tactical voting. That would suggest that not only are the polls showing the Tories up to 30 per cent in Scotland are true, but that there is no electoral dividend for Labour there at all. (This would also be in contrast to the 2016 Scottish Parliament elections, where Labour lost votes but their vote became more effective thanks to tactical Unionist votes.)

The other thing to watch out for: if people, particularly Green-aligned voters, use these elections to punish the SNP government, which is sort of what we’d expect in regular times, or if they too vote tactically for pro-Yes candidates.

12:00: Stirling, the first Scottish local authority which may tell us anything at all about how the general election is going to play out, reports. The SNP are the largest party but they are in opposition, as a combined Labour-Conservative coalition run the show.

12:30: Clackmannanshire, currently run by the SNP but no overall control. Formerly held by Labour at Westminster and now represented by Tasmina Ahmed-Sheikh. Meanwhile, in Wales, Denbighshire will declare. The polls suggest that Labour’s Susan Jones will be out of a job come 9 June. If Labour are going to hold the seat at the general, they will want to take control of the council in May. (It is presently a hung council with Labour the largest party.)

13:00: The Shetland Islands, which like Orkney elect independents, will declare. More interesting for the general will be Angus, where the SNP are the largest party by a distance. If the Tories are going to make gains of the kind forecast in the polls in Scotland, they need to at least be becoming the official opposition in places like Angus.

In England, Devon and Hertfordshire will declare. Devon is a straight Tory-Liberal battle. Hertfordshire is more complex. The Liberal Democrats will want a good result in the wards of Three Rivers while Watford is a three-way marginal. If Labour are to defy the polls and form a government, they should expect to gain seats in the wards making up Stevenage.

 14:00:  In England, Buckinghamshire, Cambridgeshire, East Sussex all declare. Cambridgeshire is the one to watch – if the #LibDemfightback is a thing, we’ll feel it there, in the wards of the city itself in particular.

In Wales, Caerphilly, Conwy, Gwynedd, and Pembrokeshire all declare. Gwynedd, Pembrokeshire and Conwy have large numbers of independents so may not tell us very much about how the general election will pan out.  Caerphily is a straight party battle: it’s a Labour vs Plaid Cymru but it won’t tell us much about how things will play out in the parliamentary seats, where Labour are miles ahead and their opponent is Ukip.

And in Scotland, Dumfries & Galloway, Comhairle nan Eilean Siar, Inverclyde, Moray, Midlothian, Scottish Borders and South Ayrshire all declare. The big one to watch is the Borders – the Conservatives are the largest party but are in opposition to an SNP-Liberal Democrat-Independent coalition. Getting good results in places like this will give us an idea how much the Conservative revival in Scotland will pay dividends in terms of gaining seats.

14:30: Aberdeenshire, East Lothian, and Renfrewshire all declare. Aberdeenshire is the fun one: the SNP are the largest party by a distance at the council and they of course hold the seats at Westminster. But it voted to stay in the United Kingdom by a heavy margin and the Scottish Conservatives won the Holyrood seat last year. If the Tories can become the largest party here, they are headed for a great result in Scotland in June.

15:00: Liverpool City Region will declare. Given my dubiousness about Bristol’s counting proccesses, I reckon Steve Rotheram is in with a chance of being the first person elected to these new combined authorities.

In England, Cornwall, Oxfordshire, Suffolk, Surrey and West Sussex declare. Cornwall is run by a Liberal Democrat-Independent coalition, and if there is to be a Liberal revival in that part of the world, it will surely be felt in the council elections. 

In Scotland, Aberdeen, East Dunbartonshire, Falkirk, North Ayrshire and West Lothian declare. East Dunbartonshire may give us a hint about Jo Swinson’s chances of taking back the parliamentary seat for the Liberal Democrats.

 16:00: A little bit of history will likely be made when Labour lose control of Glasgow Council.

The combined authority of Tees Valley should be a routine Labour win. Worry about June if it’s not. Norma Redfern is running for re-election as Labour’s mayor inn North Tyneside, which she ought to win easily.

In England, Labour should consolidate their position in Derbyshire, and win a majority in Lancashire, where they are currently no overall control. If they don’t – and if they slip back in both or either – that will be further evidence that Labour’s dire polling is correct.

17:00: In England, Labour will hope to make gains in Staffordshire and Nottinghamshire. Elsewhere, it’s a Conservative-Liberal fight.

It is very, very, very unlikely that anyone but the Tories will win the Cambridgeshire & Peterborough combined mayoralty. If the Liberal Democrats do it, expect a lot of Conservative MPs to start worrying.   

In Scotland, Edinburgh will declare. Who comes out on top there will be a fascinating pointer as to where Scottish politics is going: the city returned candidates from the SNP, Labour, Conservatives and Liberal Democrats last year. At a council ward-level, it really is anyone’s game.

17:30: The Tories won seats at a clip in the Scottish Parliament last year, including Eastwood. See how they do in East Renfrewshire to see if they have a chance of doing the same to its Westminster equivalent.

18:00: Who will win the Greater Manchester mayoralty? Hint: rhymes with Andy Burnham.  More interesting is the West Midlands mayoralty, where Labour’s Sion Simon faces a strong challenge from the Conservatives’ Andy Street. 

Stephen Bush is special correspondent at the New Statesman. His daily briefing, Morning Call, provides a quick and essential guide to British politics.

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