Healthcare: another thing that the Germans just do better

Germany has rejected restrictions on doctors visits.

Recent Conservative ideas to restrict the number of GP visits in a year may be discounted as too controversial. But with the concept of universalism in health and welfare under threat we should not be so complacent. This is another area where we should follow the current trend of noting what has happened in Germany: consultation fees for visiting the doctor were abolished in Germany on 1 January 2013.

Co-payments, as they were called, of €10 if you visited the doctor in any given quarter or if you went to a specialist without a referral, were introduced by Schroder’s government in 2004. Addressing similar concerns to the NHS at present on health costs and the waste of doctors’ time on trivial conditions it was thought, at the time, to be a good idea by all the main parties in Germany. It was supposed to deter the practice in Germany’s compulsory health insurance system of patients hopping from specialist to specialist. They also thought it would bring in approximately €2bn per year.

Once in opposition the Social Democrats (SPD) and Greens turned against the idea of co-payments. As you would have predicted the charges deterred many people from going to the doctor. So it is obvious that the cost in dealing later with deteriorating conditions and in personal misery was great. Even on the projected revenue the German government did not meet its targets. When the abolition of co-payments was debated in the Bundestag last November the Financial Times Deutschland reported that medical practices spent approximately 120 hours a year collecting the fee, a total administrative cost of €360m. Once it came to a vote at the end of last year – coincidentally on the historic date of 9 November – the ruling conservative-liberal coalition (CDU/CSU and FDP) also changed their minds and the Bundestag voted unanimously to abolish the charge.

Could co-payments be introduced in Britain? The idea could be sold as a fairer method than restricting the number of GP visits per patient, it would be said "only those who can afford to pay will have to make this small contribution". But people of all income brackets have commitments to meet, whether it is a mortgage, rent or bills and any fee, no matter how small will deter people from seeking medical help. For those with long-term conditions the need to see your doctor regularly is clear. For the rest of us, also, we need to see the doctor when we have concerns. We may dismiss our niggling symptoms, but we will all get something serious eventually and it may happen sooner if, being human, we decide to spend our tenner on something other than going to the doctor for a trivial matter.

I would suggest that following recent top-down healthcare reforms it is only a matter of time before a formal proposal on GP visits is made – the Tory idea on restricting the number of visits is just to test the water. Universalism has not been defended but is a sound principle. It is more straightforward, we all contribute (even those on out-of-work benefits pay VAT) and we all benefit. The bureaucracy of means-testing is avoided. The case for the better-off benefiting is clear, we are all part of the community and the costs can be recouped by looking at the tax paid by the better-off. In terms of GP visits this is another case where we can learn from the way the Germans do things – a mistake was made but they reconsidered it and put it right.

Photograph: Getty Images
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How English identity politics will shape the 2017 general election

"English" voters are more likely to vote Conservative and Ukip. But the Tories are playing identity politics in Scotland and Wales too. 

Recent polls have challenged some widely shared assumptions about the direction of UK elections. For some time each part of the UK has seemed to be evolving quite distinctly. Different political cultures in each nation were contested by different political parties and with different parties emerging victorious in each.

This view is now being challenged. Early general election surveys that show the Tories leading in Wales and taking up to a third of the vote in Scotland. At first sight, this looks a lot more like 1997 (though less enjoyable for Labour): an increasingly hegemonic mainland party only challenged sporadically and in certain places.

Is this, then, a return to "politics as normal"? Perhaps the Tories are becoming, once again, the Conservative and Unionist Party. Maybe identity politics is getting back into its box post Brexit, the decline of Ukip, and weak support for a second independence referendum. We won’t really know until the election is over. However, I doubt that we’ve seen the back of identity politics. It may actually bite more sharply than ever before.

Although there’s talk about "identity politics" as a new phenomenon, most votes have always been cast on a sense of "who do I identify with?" or "who will stand up for someone like us?" Many voters take little notice of the ideology and policy beloved of activists, often voting against their "objective interests" to support a party they trust. The new "identity politics" simply reflects the breakdown of long-established political identities, which were in turn based on social class and collective experiences. In their place, come new identities based around people, nations and place. Brexit was never really about the technocratic calculation of profit and loss, but about what sort of country we are becoming, and what we want to be. 

Most social democratic parties in Europe are struggling with this change. Labour is no different. At the start of the general election, it faces a perfect storm of changing identities. Its relationship with working-class voters continues to decline. This is not because the working class has disappeared, but because old industries, with their large workplaces, shared communities and strong unions are no longer there to generate a labour identity. 

Labour is badly adrift in England. The English electorate has become increasingly assertive (and increasingly English). The Brexit vote was most strongly endorsed by the voters who felt most intensely English. In the previous year’s general election, it was fear of Scottish National Party influence on a Labour minority government that almost certainly gave the Tories the English seats needed for an overall majority. In that same election, Labour’s support amongst "English only" voters was half its support amongst "British only" voters. The more "English" the voters, the more likely they were to vote Ukip or Conservative. It shouldn’t be a surprise if Ukip voters now go Tory. Those who think that Ukip somehow groomed Labour voters to become Tories are missing the crucial role that identity may be playing.

So strong are these issues that, until recently, it looked as though the next election - whenever it was called - would be an English election - fought almost entirely in English battlegrounds, on English issues, and by a Tory party that was, increasingly, an English National Conservative Party in all but name. Two powerful identity issues are confounding that assumption.

Brexit has brought a distinctly British issue into play. It is enabling the Tories to consolidate support as the Brexit party in England, and at the same time reach many Leave voters in Wales, and maybe Scotland too. This serendipitous consequence of David Cameron’s referendum doesn’t mean the Tories are yet fully transformed. The Conservative Party in England is indeed increasingly focused on England. Its members believe devolution has harmed England and are remarkably sanguine about a break up of the union. But the new ability to appeal to Leave voters outside England is a further problem for Labour. The Brexit issue also cuts both ways. Without a clear appeal cutting through to Leave and Remain voters, Labour will be under pressure from both sides.

North of the border, the Tories seemed to have found - by accident or design - the way to articulate a familial relationship between the party in Scotland and the party in England. Scottish Conservative leader Ruth Davidson appears to combine conservatism, unionism and distance from English politics more successfully than Scottish Labour, which must ride the two horses of "near home rule" and committed unionism. Scottish Labour has a perfectly good call for a reformed union, but it is undermined by the failure of Labour in England to mobilise enough popular support to make the prospect credible.

Identity politics is not, of course, the be all and end all of politics. Plenty of voters do cast their ballots on the traditional tests of leadership, economic competence, and policy. Labour’s campaign will have to make big inroads here too. But, paradoxically, Labour’s best chance of a strong result lies in taking identity politics head on, and not trying to shift the conversation onto bread and butter policy, as the leaked "talking points" seem to suggest. Plenty of voters will worry what Theresa May would do with the untrammelled power she seeks. Challenging her right or ability to speak for the nation, as Keir Starmer has done, is Labour’s best bet.

 

John Denham was a Labour MP from 1992 to 2015, and a Secretary of State 2007 to 2010. He is Director of the Centre for English Identity and Politics at Winchester University

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