NHS reform is a never-ending nightmare for Cameron

The Prime Minister could end up with a reputation as the man who broke the NHS.

The NHS bill cleared a legislative hurdle in the Lords this week . But that doesn't really solve any of the political problems facing the government's reforms. Of those problems, one of the biggest is that the coalition doesn't seem to have a clear grasp of why Andrew Lansley's plans are causing so much difficulty.

The one thing everyone can agree on is that the plans have been appallingly presented. Lansley cooked them up in the Department of Health without much input or scrutiny from Downing Street. (So blindsided was the prime minister that the episode triggered a whole re-organisation of the Number 10 policy operation earlier this year.) According to one senior civil servant at the heart of the operation, when Cameron was first presented with Lansley's plan he skimmed the introduction and then turned to his aides in shock and disbelief and said "have you read this stuff?!" He had, until then, had no idea of the scale of what was being planned.

There was a moment, towards the end of January, when a u-turn was still an option. But Cameron feared looking weak by abandoning such a huge public sector policy drive - and, reasonably enough, worried that dropping the reforms would implicitly confirm voters' suspicions that the Tories had some hidden agenda on health. A u-turn would make it look as if they had been rumbled. The way senior figures in government tell the story, Cameron's foot hovered between the brake and the accelerator, finally choosing the latter. That now looks like a huge mistake.

The essential miscalculation was the PM's assumption that if he personally threw some weight behind the cause - deploying the powers of persuasion in which he has considerable confidence - the public mood might shift. Of course, the Conservatives did not count on a Lib Dem backlash, sanctioned from the top of the party as a device to "differentiate" the junior coalition partner (fearful of losing its identity) over an issue of famous toxicity to the Tories. Some of the Lib Dem turbulence around the NHS earlier this year was principled objection to the reforms but some is retaliation for the Tories' personal attacks on Nick Clegg during the referendum campaign on the alternative vote. The compromise package that ended up before the Lords this week was therefore a mangled monster consisting of the original Lansley plan with heaps of ad hoc Lib Dem caveats, brakes, disruptions and supposed safeguards.

And there lies the government's problem. The reform it is now trying to sell is the expression of Westminster political choreography and not a coherent response to the needs of the health service. Everyone in the NHS knows it and voters can sense it.

Cameron and Lansley have tried to sell the need for reform on the grounds that the health service cannot cope with rising levels of demand without major structural change (especially when there is no more money to fund the existing system). My own impression is that they haven't got that message across too well. One thing, however, is certain and that is their failure to persuade people of the follow-up assertion that the only solution lies in much more private sector involvement using much more vigorous competition to provide services. The Lib Dems and Labour are just as queasy about bald expressions of that view - it is, essentially, the Blairite model of public sector reform and has advocates in all three main Westminster parties.

But opponents of Lansley's plans don't need to rebut the theoretical premise on which it rests because (a) they can just accuse the government of unleashing needless revolutionary chaos in the NHS, which is plainly true and (b) they can accuse the prime minister of reneging on a pledge not to do (a), which is also true. Plus, (c) voters' mistrust of the Tories over the health service is visceral. Whatever it is the Tories are doing will raise suspicions of an ulterior motive; Cameron and Lansley have done everything possible to confirm that view by failing to sell the reforms on their own terms. You can't credibly insist that there will be no privatization of the health service when the core concept of the reforms is to promote more competition and more private sector involvement. OK, so it's not privatization in way that BT and BA were sold off in the Eighties, but it's hardly reinforcing the "national" in National Health Service.

The only way to actually persuade people that the Lansley plan is any good would be to sell the first principle of increased marketisation in health care but, implicitly, the Tories have accepted that such an approach is toxic to their political reputation. Besides, changes demanded by the Lib Dems have corrupted Lansley's vision enough that - even if it were the best way forward (which I doubt) - it can't be implemented as the health secretary envisaged. Meanwhile, there are £20bn of "efficiency savings" to be found, which will feel like cuts and inflation at around 5 per cent, which will have an impact on health budgets that will also feel like cuts. Every doctor and nurse in the country will have motive and cause to blame the government for every refused treatment and every bad outcome.

David Cameron needs to wake up to the fact that he has allowed a process to get underway whose long term outcome could easily be an historic reputation for him as the man who broke the NHS.

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

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Is our obsession with class propping up the powerful?

Lynsey Hanley’s memoir Respectable: the Experience of Class attacks the sharp-elbowed bourgeoisie – but society will only be transformed by building coalitions between the middle and working classes.

Class is no longer banished from mainstream discussion, but it remains an uncomfortable topic for most mainstream media. The background to this is straightforward. The media all too often discriminate on the basis of parental wealth rather than talent: from unpaid internships to expensive postgraduate journalism qualifications, the routes into the industry are difficult to traverse without parents able to offer financial support. But most of us want to believe that our successes are personal achievements: that if we do well, it is because of our own ability, intelligence and determination. To realise that actually, you have queue-jumped, in effect, because of your parents’ bank balance: well, that would provoke insecurity and defensiveness. And so journalists and columnists are often disinclined to understand why society is stacked in the interests of some, but not others. Even raising the issue of class is felt as a personal attack.

That is one reason Lynsey Hanley is such a crucial voice. When she writes about class, she is writing about lived experience. Her new book, Respectable – the belated follow-up to her seminal Estates, published in 2007 – is a powerful investigation into the psychological impact, and cost, of shifting from class to class. She compares it to “emigrating from one side of the world, where you have to rescind your old passport, learn a new language and make gargantuan efforts if you are not to lose touch completely with the people and habits of your old life”. The case study? Hanley herself. The Personal Is Political would be as appropriate a subtitle for this book as any other.

Respectable compellingly (if sometimes erratically) weaves autobiography with academic research. Hanley grew up on a council estate in Chelmsley Wood, a 1960s ­new-build area of Solihull, in the West Midlands, a few miles from Birmingham. Her childhood, she says, would once have been labelled “respectable working class”: far removed from middle class but not “quite classically working class either” – rather, “foreman class” or “skilled tradesman class”. It feels wrong to infringe on Hanley’s right to self-define, but she does seem to have a very restrictive view of what being working class entails, so much so, that she isn’t entirely convinced she belongs. There has long been a clash between those who define class as a cultural identity and those who believe it has more to do with economic relationships (and those who think it is a combination of the two).

At Hanley’s school, “people didn’t do A-levels”. The high achievers ended up at the gas board or the Rover works and the word “university” evoked “something as distant as Mars”. Her school had 600 unfilled places, “effectively . . . abandoned by the community as much as by the local authority and by central government”. Hanley has always felt like an outsider: she struggled to make friends, found the limits of what was expected of someone from her background suffocating, and when – against the odds – she made it to sixth form, it seemed “one minute I was struggling for air, the next I felt as though I’d entered a large bubble of pure oxygen”. She looks to academics to help explain experiences she found difficult to navigate at the time. Her sense of isolation, for instance, can be illuminated by the sociologist Angela McRobbie’s exploration of “the ‘hermetically sealed’ nature of working-class culture in Birmingham”. The Uses of Literacy, Richard Hoggart’s 1957 classic, is her Bible; she feels he “could have been writing about my own childhood”.

Aged 17, Hanley was juggling five ­A-levels with four jobs: working at Greggs, selling Avon products, delivering newspapers and “making cakes and chocolates and selling them door to door”. But she became a professional journalist. When she was a teenager she visited Aldi to buy margarine and glacé cherries; now she comes back with “cold-pressed rapeseed oil and Pinot Noir”. She says “lunch” where she used to say “dinner”.

This is a well-crafted book full of insights. Hanley is determined to challenge the assumptions of left and right. She refers to socio-linguists such as Basil Bernstein, who examined how middle-class forms of communication were given preference over working-class expression but not because they were innately superior. Those who made the leap from working class to middle class found themselves assimilated by the new world. Many found it increasingly difficult to relate to the world they grew up in, and the people they grew up with.

Hanley thinks the approaches of both left and right to social mobility are problematic. Whereas the right uncritically worships the idea of “social mobility” – of parachuting the “lucky few” into the middle class without challenging the structure of society – the left, she says, believes that “social justice and social mobility are mutually exclusive”. In other words, she is questioning that old socialist maxim: “Rise with your class, not above it.”

Hanley assails those – including me – who place support for populist anti-immigration movements in a broader social context. She believes that we are downplaying the extent of racism in working-class communities, reducing it to fears over housing and jobs. We are robbing people of agency by letting individuals off the hook for their prejudices, she argues, stressing the casual racism she encountered on a daily basis. Disturbingly, she found that racism was often seen as a “sign of respectability”. She remembers sentiments along the lines of “Only common people hang out with darkies” and so on. My parents met through the Trotskyist movement; my father eventually became a white-collar local authority worker, my mother an IT lecturer at Salford University, and I was always by far the most middle-class of my friends. I’m not going to wish away the casual racism I encountered growing up in Stockport (and I’m white), but I’m not sure I’m entirely convinced by Hanley’s argument. Why is there an anti-immigration party with mass support now, yet there wasn’t one in the 1950s, when bigotry was far more open and widespread? Surely something has changed, and rising job, housing and general economic insecurity have had a role to play? And will a strategy of criticising people for voting Ukip – or even for the far right – win them over?

My main problem with Hanley’s book is this. Those of us who want to transform society so that it is not run as a racket for a tiny elite need to build a broad coalition. I’m a political activist who writes; Hanley is someone writing about reality as she has lived it. But her book surely challenges attempts to build unity between the working and middle classes. She writes of how middle-class people both hog and deny their “social and cultural capital”, and believes that those who argue in favour of a “99 Per Cent” under attack by an elite help entrench middle-class privilege. The middle classes pretend they have the same interests as the working class, while using their sharp elbows to keep them down.

I wonder if there is a third way. Abolish unpaid internships; introduce scholarships; invest in education at an early age; automatically enrol the brightest working-class young people into top universities; deal with social crises, such as the lack of affordable housing, which help destroy opportunity for the less privileged; have a proper living wage. And so on. But if those who believe in social justice fail to build a coalition of supermarket worker and schoolteacher, cleaner and junior doctor, factory worker and university lecturer . . . well, we will fail. From the low-paid against the unemployed, to private-sector against public-sector worker, to indigene against immigrant, there are enough divisions exploited by the powerful as it is.

Nonetheless, Respectable is of vital importance: a searing indictment of a chronically unjust society in which our opportunities are granted or denied from the earliest of ages. The book may not offer clear prescriptions, but it is incumbent on all of us to fight for a just and equal society – one that currently does not exist. 

Owen Jones’s Chavs: the Demonisation of the Working Class is newly republished in paperback by Verso

Respectable: The Experience of Class by Lynsey Hanley is published by Allen Lane (240pp, £16.99)

Owen Jones is a left-wing columnist, author and commentator. He is a contributing writer to the New Statesman and writes a weekly column for the Guardian. He has published two books, Chavs: the Demonisation of the Working Class and The Establishment and How They Get Away With It.

This article first appeared in the 28 April 2016 issue of the New Statesman, The new fascism