Richard Horton, editor of the Lancet: Cowards, betrayers and appeasers have destroyed the NHS

All three parties have colluded in the creation of ideal conditions for an unprecedented colonisation of the NHS by an aggressive, profit-seeking private sector. NHS SOS, a new book edited by Jacky Davis and Raymond Tallis, explains how it was done.

NHS SOS: How the NHS Was Betrayed and How We Can Save It
Edited by Jacky Davis and Raymond Tallis
Oneworld, 288pp, £8.99

Andy Burnham, the shadow secretary of state for health, tells a revealing story about his last days in the Department of Health, back in May 2010. As Burnham was saying his goodbyes to civil servants in Richmond House, David Nicholson, the fierce chief executive of the National Health Service, warned that if he returned after the election, his priority would have to be efficiency – achieving a better NHS with less money. A financially fragile health service could tolerate no more reorganisations.

When, just two months after the election, Burnham read Andrew Lansley’s extra - ordinary white paper Equity and Excellence: Liberating the NHS, he was dumbstruck. A huge top-down reorganisation was being proposed, despite what he knew to be the department’s view that such changes were unwanted and unsustainable. Something seemed to have gone very wrong at the heart of government.

What we now know – and what Jacky Davis’s and Raymond Tallis’s new book, NHS SOS, so lucidly describes – is that a very British coup had taken place. During the run-up to the election, the Conservative Party had claimed that there would be “no more top-down reorganisations of the NHS”. Despite this, Lansley soon infiltrated the Department of Health, ignored the advice of his most senior civil servants and implanted his carefully constructed plan to end more than 60 years of consensus that it was the duty of the secretary of state to provide a comprehensive, continuous and equitable health service that was free at the point of use.

Lansley set about a major – indeed, revolutionary – reversal. Like many coups, this did not result in immediate victory but it started a civil war within the NHS that today threatens to create further crises, providing justi - fication for even more destructive reforms in the future.

Conservatives have an honourable philosophy that unites them and that seems to make some intuitive sense. They argue that competition is by far the best way to solve society’s ailments. Competition certainly works in sorting out the best football teams from the worst. In business, competitive instincts can sharpen minds to create new products that transform important aspects of our lives. It would be entirely natural to think that competition among health providers would enhance the quality of our NHS. The problem for the Conservatives is that there is not one shred of reliable evidence to prove that competition improves health. On the contrary, we know only too well that creating competitive markets in health is extremely harmful.

The US has the most advanced marketbased health system in the world. There, competition has driven up costs, created enormous variations in the quality of services available and fuelled distortions and disparities that make the idea of equity a pipe dream. Despite this, Conservatives, ably and surprisingly supported by their Liberal Democrat partners, have succeeded in creating conditions for the unprecedented colonisation of the NHS by an aggressive, profitseeking private sector. For these reasons, it is a simple, although appalling, truth that the Health and Social Care Act 2012 marked the end of the NHS.

NHS SOS explains how it was lost. It is a painful story and one that we must confront if we are to have any hope of reclaiming what was once ours. There were three catastrophic failures. The first great error was made by the Labour Party. As Tallis argues, “Labour was most culpable.” It was a suc - cession of Labour ministers, led by Alan Milburn and Patricia Hewitt, who prepared the NHS for privatisation. Having betrayed their visionary Labour forebears, many of them went on to line their pockets with well-paid consultancies in the private sector that they had done so much to foster.

The second failure lay with the media and especially with the BBC. Journalists consistently failed to ask questions about who would profit from Lansley’s reforms. They failed to explain the conflicts of interest staining so many of those designing his plans (from management consultants such as McKinsey to “think tanks” such as the King’s Fund). And they failed to point out that Lansley’s bill would dissolve the vital link between the secretary of state and his duty to provide care.

Perhaps the most atrocious betrayal of all came from an unexpected quarter – the medical profession. The British Medical Association pursued a policy of appeasement, which rendered it guilty of a crime of quite astonishing proportions: the death of a health system that had led the world in proving that a universal right to health could also be a universal symbol of our respect – and responsibility – for one another.

The Royal Colleges preferred to fight their own internecine wars rather than unite in opposition to a government that they each privately detested. The most senior medical leaders within government – notably the chief medical officer – chose to remain silent. The authors of NHS SOS use words such as “feeble” and “dismal” to describe their medical colleagues. They are too kind.

Tallis writes, “There is room for hope.” Maybe. Labour must unequivocally commit to repealing the Health and Social Care Act 2012. Campaigns must be launched, political pressure applied, evidence of harm gathered, so-called leaders held to account. Most of all, we need “an urgent inquest into the abysmal failure of professional leadership” within medicine.

What we have learned from the past decade is this: Labour, yes Labour, initiated a process that eventually erased an institution that had become a beacon of advanced democracy. The Conservatives happily used Labour’s perversions to accelerate this destruction. And the Liberal Democrats? They colluded and connived. If there is a hell, I look forward to the day when I meet these cowards, betrayers and appeasers – burning in obloquy.

Andrew Lansley, upon arrival at the Department of Health, ended "more than 60 years of consensus" that secretary of state should keep the NHS "free at the point of use". Photograph: Getty Images.

This article first appeared in the 15 July 2013 issue of the New Statesman, The New Machiavelli

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Britain's diversity crisis starts with its writers. Here's why

What happens on the casting couch draws the headline, but the problem starts on the page, says James Graham. 

I’m a playwright and screenwriter, which – pertinent to the issues we’ll be discussing in this enquiry – still feels weird to say. I get embarrassed, still, saying that, in a taxi or hairdressers. I don’t know why I still carry that insecurity about saying I’m a writer, but I do, because it sounds like I’m lying, even in my own head.

Obviously I’m completely biased, and probably overstating the influence and importance of my own profession, but I think so many of the problems surrounding lack of representation in the performing arts start with writers.

If we aren’t encouraging and generating writers from certain communities, classes or backgrounds to tell their stories, to write those roles, then there’s not going to be a demand for actors from those communities to play them. For casting agents or drama schools to prioritise getting diverse actors on stage. We need to create those plays and TV dramas –like the ones that I grew up with. I didn’t have any access to much theatre until I was fifteen, but I did have Boys From the Black Stuff, and I did have Cracker, and I did have Band of Gold. I think the loss of those regional producing bodies – Central, Granada – now all completely centralised into London, means that we just tell less of those stories. I remember a TV show called Boon – anyone? – which was set in Nottingham, and I would see on the TV streets I’d walked down, and think, Oh my God, that actor is walking down a street I’ve walked down. That sounds like it’s insignificant. If you’re from a town that is deprived, that feels ignored, it isn’t.

I was very lucky that at my school (which was, at the time, the largest comprehensive school in the country), from the headmaster down to the drama teachers, everyone just believed that working class kids should do plays. Be in plays, read plays, perform plays to the community. Both inside the curriculum of the school day, and outside it – drama teachers dedicating their time to staying behind. Our head of drama identified a group of us who clearly had a passion for it. We weren’t likely thesps. One lad’s entire family were made unemployed when the pit closed. Many lived on the big council estate. My parents and step-parents worked respectively in warehouses, the local council, or as the local window cleaner (incidentally, my first real job. Which I was terrible at).

Our drama teacher was encouraged and determined enough to launch the first ever Drama A-Level in our school. Based on that, about 10 or 12 of us got the confidence – or arrogance – to take our own show to the Edinburgh Festival. We were 16 or 17, and the first people in our community to ever go to visit the festival. We did a play up there, and after that, a psychological unlocking happened, where I thought: maybe I could do a degree in drama (it was the first time I had ever thought to do so) at university (the first in my family to go. Well, joint-first. My twin sister went on the same day, but I walked into my digs first).

I enrolled in drama at Hull University. A high proportion of my peers were middle class. A higher proportion from London or the South East. They talked often about institutions I had never heard of. They were talking about the National Theatre: I didn’t know we had a national theatre that my parents had been paying tax for that I had never been to. Many had performed with the (again, apparently) ‘National’ Youth Theatre, also in London. Paul Roseby, also on this panel, has made such leaps forward in getting the NYT producing in regional venues, and making auditions possible for people across the UK, but unfortunately, at the time, that wasn’t the case for me – and I was the ideal candidate to be in the National Youth Theatre.

I started writing because I had the confidence after I read texts by people like Jim Cartwright, Alan Bennett, John Godber, Alan Ayckbourn: Northern writers, working class writers that made me think it wasn’t just something that other people do.

After returning home, and working at local theatres, I moved down to London. I had to. The major new writing producers are there. All the TV companies are there. The agents are there. I was lucky to find support in a pub fringe theatre – though the economics meant there was no money to commission, so I wrote plays for free for about four years, that would get produced, and reviewed in the national press, while I worked various jobs in the day and slept for a time on a mate's floor. The first person to ever pay to commission me to write a play was Paul Roseby of the National Youth Theatre. I’m now very lucky to be earning a living doing something I love. In a way, compared to actors, or directors, it’s easier for writers who don’t come from a background that can sustain them, financially, in those early years. Your hours can be more flexible. Yes, it was annoying to miss rehearsals because I had a shift in a call centre, but it was still possible to do it. If you’re an actor or director, you’re fully committed. And if you’re doing that for nothing, there starts to be cut-off point for those from backgrounds who can’t.

I’m sure that local and regional theatres are the key to drawing in talent from less privileged backgrounds. But the range of national arts journalism that cover work outside London has been so significantly reduced. In our little echo chamber a few weeks ago, we theatre types talked about Lyn Gardner at the Guardian. Her coverage has been cut, which is very directly going to affect her ability to cover theatre shows outside of London – and so the self-fulfilling cycle of artists leaving their communities to work exclusively in London takes another, inevitable, turn.

I am culpable in this cycle. I have never done a play at the Nottingham Playhouse, my local producing house growing up – why? Because I’ve never submitted one, because I know that it will get less national press attention. So I just open it in London instead. That’s terrible of me. And I should just bite the bullet and say it doesn’t matter about the attention it gets, I should just go and do a story for my community. And if I, and others, started doing that more, maybe they will come.

I also want to blame myself for not contributing back to the state schools that I come from. I really really enjoy going to do writing workshops with kids in schools, but I would say 90 per cent of those that I get invited to are private schools, or boarding schools, or in the South of England. Either because they’re the ones that ask me, because they’re the ones who come and see my shows in London and see me afterwards backstage, or because they have the confidence to email my agent, or they have the budget to pay for my train ticket. Either way, I should do more. It would have helped the younger me so much to meet a real person, from my background, doing what I wanted to do.

I don’t know how to facilitate that. I take inspiration from Act for Change, creating a grassroots organisation. I know that there is a wealth of industry professionals like me who would, if there was a joined-up structure in place that got us out there into less privileged communities, we would on a regular basis go to schools who don’t get to meet industry professionals and don’t unlock that cultural and psychological block that working class kids have that says, that is not for me, that is something that other people do, I would dedicate so much of my time to it. That’s just one idea of hopefully better ones from other people that might come out of this enquiry.

James Graham is a playwright and screenwriter. This piece is adapted from evidence given by James Graham at an inquiry, Acting Up – Breaking the Class Ceiling in the Performing Arts, looking into the problem of a lack of diversity and a class divide in acting in the UK, led by MPs Gloria De Piero and Tracy Brabin.