We are in danger of loving the NHS to death

Universal healthcare is the least citizens should expect. To make the NHS better for patients, politicians, press and public alike need to cultivate a healthly scepticism towards it, not give it unlimited adulation.

When Gary Walker broke the terms of a non-disclosure agreement to reveal the impact on patients of excessive target-setting at the United Lincolnshire Health Trust over which he used to preside, he revealed a great deal more. Most obviously, he lifted the lid on a culture of fear of that still pervades much of the NHS, a culture in which whistle-blowers stand to lose reputations and careers, in which silence is commonly bought through the use of legal gagging clauses that break the spirit and perhaps the letter of the Public Interest Disclosure Act. It's significant that when the BBC put Walker's allegations to the NHS, the response of the trust's lawyers was to write to the former manager threatening him with the loss of his £500,000 severance package, rather than to deal with the substance of his allegations.

But what's equally striking is that the story was presented as one about whistle-blowing, about the morality and legality of non-disclosure agreements, rather than about the horrendous overcrowding and patient neglect that caused Walker to blow his whistle. The fact that United Lincolnshire is one of fourteen NHS trusts currently under investigation for hundreds of excess deaths seemed of less significance than a debate about management practices. And of course it is important. A corporate culture that discourages and punishes whistle-blowing is one in which failures and abuses go unchallenged, one that breeds complacency and in which those responsible are rarely held to account. What is truly shocking, however, is that vulnerable people in our hospitals are spending their last days in squalor and dying needless deaths through dehydration and neglect.

At least it should be shocking. But perhaps, following years of revelations about dirt, mistreatment and neglect in hospitals - elderly patients left wallowing in their own waste, deprived of food and water while staff are sitting in offices filling in forms, beds parked in corridors while their occupants are treated with contempt - such tales have ceased to shock.

It's now two weeks since the release of the second report by Robert Francis into Mid Staffordshire hospital trust, where almost 1,200 excess deaths occurred between 1996 and 2008, years when the Labour government was pumping unprecedented amounts of cash into the NHS and boasting loudly about having transformed standards of treatment. By any standards, this is one of the biggest scandals of recent years - bigger than Savile, bigger than MPs' expenses, certainly bigger than the horsemeat saga that has largely relegated Mid Staffs to the inside pages. Bankers can steal your money, the press can invade your privacy, but only the NHS can kill you. Yet no-one has been forced to resign, and at this stage criminal charges seem an unlikely prospect. Yes, there have been ritual expressions of regret. But where is the outrage, where is the raw anger?

The Labour party, which was in government in the period covered by the Francis reports, prefers to talk about the Coalition's forthcoming reforms (or about horsemeat). The Conservatives, for whom Mid Staffs ought to represent an open goal, if only as evidence that their radical measures are needed, have been if anything even more reticent. David Cameron has contented himself with expressing his full confidence in Sir David Nicholson, the bureaucrat who presided over the Mid Staffs debacle and who now runs the entire NHS, dismissing calls for his resignation as "scapegoating."

For both main parties, where the NHS is concerned there's a fear of treading on sacred ground. It's especially acute for the Tories, fearful of detoxifying the brand by saying anything that might be construed as critical of the NHS. For Labour, meanwhile, the NHS is the great shibboleth. The Labour attitude is an unfortunate combination of sentimentality and a defensive sense of ownership. Its problems can be acknowledged only as unrepresentative and untypical; the only possible cure, more funding.

As for the public? The picture here, I suspect, is rather more mixed than often assumed by politicians or the press. The NHS regularly tops surveys of the things that make people proud to be British. At the same time, whenever the topic of hospital treatment features on a radio phone-in there's a huge response from people with bad experiences to share.  A talk by Christina Patterson on Radio 4 about the poor quality of nursing care she experienced while in hospital resonated hugely with audiences. Last summer, even as Danny Boyle brought a patriotic tear to many an eye with his vision of dancing nurses a survey recorded the biggest ever drop in public satisfaction with the NHS.

Few, though, are yet willing to contemplate any alternative. The former chancellor Nigel Lawson once said that the NHS was the closest thing this country has to a national religion. And indeed, the reverence with which the NHS continues to be treated is not entirely rational. Its devotees believe in the NHS despite all the evidence to the contrary, because to do so is an act of faith. The idea of state provision, "free at the point of need" (even while, much of the time, it isn't) is a powerful sustaining myth, a moral ideal whose purity negates the inconvenient fact that the provision itself is frequently worse than it is in countries with mixed systems. Belief in the goodness and inevitability NHS persists alongside the grumbling, alongside the equally widely held belief that the NHS is "failing", underfunded and fraying at the seams.

Universal healthcare isn't just a noble ideal, it is the least that citizens of an advanced society should expect. But there are many ways of providing it. When it was first established after the Second World War, the NHS one of the world's first experiments in nationalised medical care. It's still often said that the NHS is "the envy of the world"; but few other countries have copied it, and while it compares well with other systems in terms of cost efficiency it does much less well in terms of outcomes. Cancer survival rates, for example, are among the worst in the developed world.

What other countries took from the pioneering British example was the idea that universal health coverage was possible, and desirable; and they proceeded to build their systems in their own way, usually by mixing private insurance with public provision, ensuring that the most vulnerable didn't slip through the net.

All systems have their drawbacks. With the NHS, the main problem is lack of transparency, which allows abuses such as those in Mid Staffordshire and United Lincolnshire to fester. I see a direct connection between the lack of transparency and the NHS's sacrosanct place national life, certainly in political debate. Other countries may provide more of the people, more of the time, with better healthcare; they may protect the vulnerable more effectively, and be less unequal; they may keep more patients alive. But they will never be loved, as the NHS is loved. People who can see a connection between their financial contribution and the care they receive don't have this same superstitious reverence for their healthcare system, so in other countries it has been easier to introduce reforms.

"Each man kills the thing he loves," as Oscar Wilde once wrote. The NHS is in danger of being loved to death, by politicians, press and public alike. We should not love the NHS, any more than we should hate the NHS. We should, rather, cultivate a healthy scepticism about the NHS. We should appreciate that, however great the NHS's achievements in the past, it was built for a different age, an age of far greater social conformity and far less sophisticated (and thus expensive) medical care, when "one size fits all" represented a liberation not a straightjacket. We should try to separate the institutions and bureaucracy from the many tremendous people who work in it - who would, after all, continue to care for the sick and injured under whatever system happened to exist. And we should remember that, in the end, the patients are the only people who matter.

 

Danny Boyle's Olympics opening ceremony coincided with a survey recording the biggest ever drop in public satisfaction with the NHS. Photograph: Getty Images
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After the defeat of Hillary Clinton, what should the US left do next?

For disappointed Bernie Sanders supporters and others on the left, the big question is now: should they work within the Democratic party?

For the majority of the US left, Hillary Clinton’s electoral defeat came as a surprise. Sure, they’d had doubts about her candidacy from the start. They’d expressed disgust at her platform, history, priorities and dubious associations – not least, at her campaign’s focus on cosying up to wealthy elites, courting the support of billionaires such as slum landlord Warren Buffett, at the expense of trying on to hold on to the party’s core working-class vote – but the general belief was that, however undeservedly, she’d still manage to pull it off.

After all, polling suggested she maintained a fairly consistent lead in key swing states even as Trump somewhat narrowed the gap, and there was reason to think that demographic trends would work against her competitor, who openly courted white supremacist votes.

Hindsight is 20/20, but many now feel they took their eye off the ball.  Leslie Lee III, a writer from Louisiana currently residing just outside Washington DC, argues that people “got so worn down by the polls that we forgot our message, that Clinton was the worst possible candidate to put against Trump”. For him, identifying what went wrong is simple:  “Trump promised people something, the establishment candidate was telling people America was already great. It doesn’t matter if he was doing it in a dishonest, con-artist, racist, xenophobic, sexist way – he said he’d fix people’s problems, while Clinton said they didn’t have problems”.

Leslie isn’t alone in believing that a wonkish focus on polls and data distracted from what was really going on. Everyone I speak to feels that the supposed ‘experts’ from the liberal mainstream aren’t equipped to understand the current political landscape. “We are witnessing a global phenomenon,” suggests writer Amber A’Lee Frost, who first got involved with the Democrats to support the Sanders campaign but voted Obama in 2008. “The UK offers the most clear parallel to the US. Nationalism, racism and xenophobia are festering.” Student and Democratic Socialists of America activist Emily Robinson agrees: “All across the world we’ve seen massive right-wing upswells, from Trump, LePen and May in the West to Modi and Erdogan in the East.” Whatever differences exist between these respective politicians, it’s hard to argue with the contention there’s been a widespread shift to the right.

US left-wingers argue that liberals fail to understand their own role in the current situation. From a British perspective, it’s hard to disagree. Repeatedly, I’ve seen discussions shut down with the claim that even acknowledging economy policy may have contributed to the resurgence of ethno-nationalist ideology amounts to apologism. Nor can faulty data be held entirely responsible for any complacency. In the run-up to the Brexit vote, polls suggested that the result would be too close to call; nonetheless, within the liberal bubble almost everyone assumed we’d vote to remain. The fact the value of the pound rose on the eve of the referendum was seen as evidence for this belief, as if currency traders have some sort of special insight into the mind of the average UK voter. Looking back, the whole thing is laughable.

Over in the US, the disconnect seems to be much the same. “People in the street weren’t following that stuff,” Leslie says of the finer details of both the Trump and Clinton campaigns. “Trump said he would fix their problems, Clinton said they didn’t have any. If we’d stayed focused on that it would have been obvious.” Instead, many of her supporters believed that it was Hillary’s turn and consequently dismissed substantive criticisms, sometimes claiming the vast majority of opposition was simply latent sexism. Even the campaign slogan “I’m With Her” seemed to be about what voters could should for Clinton, not what Clinton would do for them. As polls narrowed, party insiders continued to insist that Clinton was the rightful heir to Obama’s voting coalition, however little she actually did to earn it. 

A lack of message simplicity definitely seems to have been part of the problem. When I speak to Christian, who currently works in outreach and recruitment for the Democratic Socialists of America’s national office, he admits he was barely aware of the platform Clinton was campaigning on. “I’d ask my friends, and sometimes she’d talk about stuff, but it’s so vague,” he explains. “The average working-class person shouldn’t have to go to a website and read a 30 page policy document. It feels like it’s written that way for a reason, it’s muddled, neoliberal bullshit that lobbyists have written.” It’s true that media coverage probably didn’t help, with reporting frequently focuses on gossip and overblown scandal over substantive policy issues, but an effective political communicator must ensure their core messages cut through. Obama managed it in 2008, and however abhorrent we might find it, pretty much everyone heard about Trump’s wall.

It’s also hard to ignite excitement for the continuity candidate when many people don’t believe that the status quo actually benefits them. “I think neoliberalism no longer works as an electoral incentive to voters, especially working-class voters,” argues Amber. Emily tells me that prior to this election she’d worked on two Democratic campaigns, but before Sanders she’d been ready to give up on the party. “When they had the power to, the Democrats failed to implement policies that helped the working class, Hispanic, Black and Muslim communities, and women.”

She explains her disappointment during the early part of Obama’s first term, when the Democrats held the House, Senate and Oval Office. “They jumped away from the single payer option for healthcare, which would have helped the entire American population. The implementation of the DREAM act would have helped immigrant communities. There’s also a lot they could have done on policing and carceral reform, repealing federal use of private prisons, for example, and labour rights, by introducing federal protections for trade unions and effectively repealing so-called ‘right to work’ laws in many states. They did not mandate free, universal pre-kindergarten nor did they even attempt to work forwards free collect – or, at the bare minimum free community college.”

For Douglas Williams, a graduate student at Wayne State University, it was Obama’s relationship with labour unions that caused him to drift away from the party. “In 2013, Barack Obama appointed a union buster to a federal judgeship in the District of Columbia. I started to think, labour gave $1.1 billion to national Democrat party politics between 2005 and 2011, and labour got literally nothing from it.”

One left-leaning activist, who prefers to be identified by his blogging pseudonym Cato of Utica, campaigned door-to-door for Clinton. He explains in visceral detail his disillusionment with the party he’d worked within for roughly a decade: “I was heavily involved in North Carolina in places where the recovery never even touched. These were working poor people, and the doorbells didn’t work. If the doorbells are broken, what else is broken inside the house? What else isn’t the landlord taking care of? I looked at our candidates and none of the people I was pushing were going to address the problems in these people’s lives.”

Much ink has been spilled trying to pin down exactly what motivated people to vote Trump, whose campaign rhetoric was more explicitly xenophobic, racist and sexist than any other recent presidential candidate. Most of his supporters also voted Republican in previous elections, but two other groups are more interesting from a left-wing perspective: those who previously voted Obama but opted for Trump this time round, and non-voters who were inspired to make it to the polling booth for the first time. Overwhelmingly, both groups are concentrated in lower income categories.

“I think people voted for Trump because he acknowledged that there is something very wrong with America,” suggests Amber. “I obviously disagree with Trump voters on what is wrong with this country, and the fact that his campaign was fuelled by nationalism and racism certainly gave it a terrifying edge, but I know why they voted for him, even though he will ultimately betray his most vulnerable supporters.”

It would be absurd to discount racism as a factor in an election where the winning candidate was endorsed by the official newspaper of the Ku Klux Klan and its former leader David Duke, but Leslie disagrees with those who claim it was the primary motivation for the most Trump voters. His earliest political memory is from around 4th or 5th grade, when David Duke was running for Governor of Louisiana. “As one of the few Black kids in your class,” he recalls, “it really makes you realise how important politics is early on”. One of his closest friends was a previous Obama voter who opted for Trump this election, and the common factor seems to have been a message of optimism.

“Obama offered something more important than these people’s prejudices: hope and change, basically. He didn’t deliver it but he offered it. Romney was seen as the establishment. Obama said, ‘I’m an outsider and I’ll bring something new to the table’. There’s a line between Trump and Obama in that vein – and my friend will tell you the same.”

At a time when many people have a strong desire to kick out at the political establishment, Clinton was the ultimate establishment candidate. Leslie is scathing about the extent to which she actively highlighted this in her campaign: “She talked about being experienced – what does that mean? It means you’ve been part of the establishment. She attacked Obama with her experience in 2008 so I don’t know why she thought it would work. It’s not like being the local dog catcher, you don’t turn in your resume and if you have the most experience you get it. You need to have a message and get people inspired, and she didn’t have it.”

Most of the people I speak to believe that Sanders would have had a better chance of beating Trump, and many poured significant time, effort and money into his campaign. They note that polling showing Sanders had consistently higher approval ratings amongst the general public than Clinton throughout the primaries, and argue that people citing recently released unused opposition research as evidence he’d have lost don’t understand voter motivations. The idea that Sanders’ experience of being poor and unemployed would have worked against him is seen as particularly mockable. Whatever the truth, the more relevant question now is what the left does next.

Opinion is split between those who think working within the Democratic Party is the best approach and those who believe its unaccountable, bureaucratic structures make it a lost cause. Emily is in the first category. “I think leftists should, in a limited capacity, be running within what is now the desiccated carcass of the Democratic Party, rather than naively attempting to build a party from the ground up and risking splitting the left-liberal vote,” she tells me. “They should be prepared to run for elections with a (D) next to their name, even if they refuse to bend at the knee to the neoliberal, imperial tendencies of the Democratic elite.”

Particularly exciting right now is the work of the Democratic Socialists of America, an organisation which aims to shape the future of the party in a leftwards direction. Membership had increased by a third since the election – aided partly by support from celebrities such as Killer Mike and Rob Delaney. “We’re planning on Trump being a one-term president,” DSA representative Christian tells me. “We have a 50 state strategy, but right now we only have chapters in 31 states. It’s not just about elections, it’s threefold: electoral, workplace and community organising to win on all counts.”

Douglas is sceptical about whether it’s possible to restructure the Democratic Party in the way he considers necessary, but he agrees with the DSA’s focus on community organising: “Why can’t an organisation be like ‘we’re going to sponsor a little league team’? Why can’t we open a soup kitchen? We’re making noise, we’re out here, but we heard your aunt is having trouble with her roof. We’ve got guys who can fix that, and then we’ll leave a little sign saying it was us.” Cato of Utica references something similar that happened in Flint, where the Plumbers and Pipefitters Union visited people’s homes to make sure their water filters were properly fitted.

“We need to rebuild the labour movement,” agrees Emily. “Not only to carry out all the normal functions of unions, but also to provide a community, and spaces for education, child care and other forms of support. If we don’t build solidarity among the working class – not just the white working class, but the Hispanic working class, the Black working class and so on – we risk allowing another reactionary movement caused by cleavages promoted by the ruling classes.”

Left-wing organisations traditionally target places like New York, Los Angeles and Chicago, where it’s easier to build support. Christian argues that the Democratic Party, and the DSA specifically, need to “focus on the Rust Belt, where the Democrats lost, and the South, where Bernie lost”. There’s a widespread belief that Southern states which have been Republican for decades now could be winnable in future presidential elections, partly because of demographic trends pointing towards increasingly ethnically diverse voting populations. As for the Rust Belt, it’s hard to argue with the claim that a different candidate could do better than Clinton – who didn’t even bother to visit Wisconsin, which swung Republican, in the months preceding the vote.

The DSA’s 50 state strategy involves creating a national framework, but with devolved power allowing local chapters to focus on the issues most relevant in their area. “In Texas our chapter is really strong and we do a lot of work on immigration reform, working with undocumented communities, whereas Boston obviously doesn’t have to deal with that so much,” Christian explains to me. “In places like Kentucky and West Virginia, coal country, Republicans like Trump will say coal is coming back. We say we actually need to transition to a new economy and create green jobs, and places where people live where they don’t get cancer from coal.”

Christian believes that the unexpected success of the Sanders campaign indicates there’s an appetite for the kind of politics the DSA is offering, and that a similar candidate could gain the Democratic nomination in four years time. “Having a candidate announce earlier than Bernie did, and with a good ground game in place, we could have 50,000 volunteers ready to go. We wouldn’t be scrambling around this time, we’d be ready to go to war with [Trump]”. Like many on the left, he thinks that Keith Ellison’s selection as DNC chair is a crucial part of the puzzle. Ellison was the first Muslim elected to Congress and is chair of the Progressive Caucus. “He’s a way better politician than Bernie,” Christian contends. “He understands the intricacy of talking about labour, poverty and unions very well.”

Others I speak to argue that focus should be on working from the ground up. “I’m not even talking about state legislatures,” explains Douglas. “I mean city councillors, school boards, things like that. This is going to be a long-term project and has to start at the absolute lowest level and work its way up. People don’t even realise, in some of these cities you can get elected to the city council on 500 votes. We want to start on the big stuff but it has to be an independent, left local movement. We can run all the candidates we want, but unless we’re out here informing people ‘it’s not actually about Mexicans or Muslims, it’s your boss, it’s his fault you can’t afford to save the money to send your kids to college,’ what’s the point?”

Whatever disagreements about strategy exist, the US left seems to be united by two things: fear of Trump’s presidency and a determination to succeed. Many members of the DSA are worried about their involvement with the organisation being publicly known. Unsurprisingly, this is more acute for members of groups attacked in Trump’s rhetoric. “We see apprehensiveness with some of our Latino membership,” Christian tells me. “People don’t want to out themselves because that's risking your own livelihood. We’re a working class organisation and most people have other jobs.”

With Trump associates making noises about recreating the House Un-American Activities Committee, some fear left-wingers could be targeted as dissidents as in previous decades. However realistic the threat of government persecution, there’s already a far-right website, KeyWiki, that keeps tabs on members of socialist organisations. Everyone I speak to agrees that groups particularly vulnerable to being targeted by Trump and his supporters – including Muslim, Latino and African American communities – must be defended at all cost. “The aim of the left should be to make it impossible for Trump to govern,” says Cato of Utica. “Establishment Democrats are already making conciliatory noises. If the Democrats aren’t going to do it in the Senate, the people have to do it in the streets through direct action.”

When I ask Amber what happens next, her response seems to sum up the mood amongst the US left: “To be honest, I have no idea. I’m terrified but I am ready to fight.”