Will more choice help us through the maze?

Patients will want to take the path that leads them to the healthcare that they want, at a time when

Choice is often touted as a panacea. If you give people the power to choose you make them responsible for their own destiny rather than treating them like commodities on a conveyor belt.

But what use is having an array of options if you don't understand the consequences of your selection? Healthcare, and the bureaucracy that shapes it, changes swiftly and it takes an astute, almost abnormally interested individual to keep track of the various bodies operating in one's local NHS, let alone at national level. There are primary care trusts, hospital trusts, community trusts, foundation trusts - and most recently, "super surgeries", or polyclinics, which are being built in certain areas to give patients far greater access to healthcare services.

Alongside all of these alternatives, pharmacies are being recommended as places for patients to go to seek medical help for what they perceive are minor problems. The press that surrounds the promotion of pharmacies is mixed: some say the advice given is inadequate, others concur that another avenue for people to obtain healthcare guidance can only be a good thing.

Of course, it's a no-brainer that greater access to healthcare is beneficial, especially in overcrowded or remote areas. But how are members of the public meant to know which source of medical advice is most appropriate for them? Joe and Jane Public may have an inkling as to what constitutes "primary" care, but as the boundaries change and services that used to be hospital-based are offered in new settings, confusion is likely to result in them resorting to visiting the most familiar setting: the GP surgery - if they can get an appointment - or, at the weekend and evenings, A&E. The NHS Direct helpline earns praise and criticism, with negative comments along the lines of, "They just told me to see my GP", to positive accounts of lives being saved thanks to timely advice being dispensed.

Seeing a door marked “consulting area” in a pharmacy helps to embed the idea that asking advice is expected, is welcome

There is no obvious consistency when it comes to the healthcare facilities in area A or B. Why should patients know that a pharmacy is linked to the local GP practice, which in turn falls under the aegis of the primary care trust (PCT)? They may view the pharmacy solely as somewhere to pick up some paracetamol and toiletries, failing to appreciate that the pharmacist can offer far more than a swift exchange of prescription docket for packets of pills and ointments.

Indeed, if patients have only ever used their pharmacist as a post-GP stop-off to collect new medication, they need to be made aware that the professionals behind the counter can provide a range of guidance. Some pharmacies - the major chains - have installed quiet booths within which consultations can take place away from the other shoppers. Seeing a door marked "consulting area" in a pharmacy helps to embed the idea that asking advice is expected, is welcome, and is not an added extra that interrupts the flow of pharmacy life.

However, while some patients will feel confident enough to seek advice from their pharmacist, either because they trust them or are aware that dispensing advice is the done thing, others prefer the continuity afforded them through their GP. The same principle applies when considering the move to polyclinics. People value the connections they cultivate with various health professionals. These relationships are intimate and are not to be underestimated, as they can drive individuals towards, or away from, particular sources of healthcare.

That said, the problem remains that, when someone approaches a pharmacist for advice, they are perhaps relying on diagnostic skills being better than the profession demands. This is not to denigrate the pharmacist in any way, but pharmacists lack the medical training and records that GPs have at their fingertips, so is it not imperative that the two professions work closely to deal with patients in a mutually accepted, consistent manner, referring to each other when necessary?

Where there are numerous healthcare options available, all parties must collaborate, not compete. This will help make it obvious to the layman or woman that these seemingly disparate parts of NHS healthcare fall under one umbrella, that they communicate, access common information (that is safely and accurately maintained) and are working together to drive up health standards by putting patients at the centre of all decisions. Only when all the potential participants in a person's quest to achieve good health are integrated can people be successfully guided through the maze of options available to them. Who does what, where, why, and how, will become obvious through good practice.

It doesn’t matter to patients that a procedure once carried out in a hospital outpatients department is now taken care of at their local GP practice

The NHS, an unquestionably mammoth, dynamic organisation, will seldom be transparent to the average patient but, if further entry points are introduced to the system that merely serve to compound confusion, this would be a missed opportunity to truly widen access. Yes, in the short term, seven-days-a-week health centres will benefit those who cannot take time off work to see their GP, or who cannot wait the best part of a day to have a routine blood test carried out. However, there will be gaps or duplications in commissioning and priorities that would be shamefully senseless in an environment where money is tight and the ultimate goal of high-quality patient care is common.

It doesn't matter to patients that a procedure once carried out in a hospital outpatients department is now taken care of at their local GP practice. No one bothers - and neither should they - that funding for a health check comes from primary, rather than secondary care coffers. As far as the taxpayer is concerned, they are paying for the lot.

People will take the path that gives them what they need when they need it. If that means going to A&E because their GP practice has unacceptably lengthy waiting times, so be it. It doesn't have to be that way but patients may not know any different and, until they do (which is the responsibility of NHS providers), change may be hard fought and "choice" may simply equate to confusion.

Joy Persaud is a freelance journalist and can be reached here.

This article first appeared in the 03 November 2008 issue of the New Statesman, Israel v Hamas

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Twilight of the postwar era

This Brexit-focused election is just one milestone in a long and complex relationship between the UK and the EU.

On 25 March the European Union celebrated its 60th birthday in Rome. Of the 28 members, only the United Kingdom declined to attend, signalling, to quote one senior EU diplomat, that it didn’t think the occasion was “appropriate for us”. The Daily Express called this a blatant “snub” to Brussels.

On 29 March Theresa May sent her “Dear Donald” letter – not, of course, to that dear Donald but to “President Tusk” at the EU in Brussels. It was delivered by a senior British diplomat with an antique and strained politesse reminiscent of his predecessors in Berlin in August 1914 and September 1939.

On 18 April the PM declared that it was in the national interest to hold a snap general election on 8 June, having five times in person or through official sources denounced the idea of going to the country before the set date in 2020.

On 29 April, a month after the PM’s letter, Donald Tusk secured agreement from the remaining 27 member states for the EU’s negotiating guidelines.

The following day the press reported a total face-off between May and Jean-Claude Juncker, the head of the European Commission, and EU negotiators at a Downing Street dinner. She was living “in a different galaxy”, Juncker is said to have exclaimed. May dismissed the story as “Brussels gossip”. But then, on 3 May, in an address outside 10 Downing Street, the Prime Minister hit back, accusing senior EU politicians and officials of meddling in the British election campaign.

Whom you believe depends, as usual, on which side of our national chasm you are standing. Of one thing we can be sure. The spin and the propaganda will go on remorselessly, day after day, for years to come, as this country tries to talk its way out of a European union in which it has never felt at home. To keep our bearings amid the dizzying intergalactic spin, it is worth taking a longer view. Because history matters in this debate and few of our “leaders” seem to have any historical perspective.

***

At 60 the EU is a senior citizen – rather stiff in the joints, grossly overweight and often a bit of a bore. It’s hard now to recall the heady hopes that its birth aroused. After two ruinous wars in three decades, many western European leaders were determined to escape from the vortex of belligerent nationalism.

Six countries signed the original Treaty of Rome in March 1957 to set up the European Economic Community. The EEC was a common market and customs union between Belgium, France, Luxembourg, the Netherlands and two defeated Axis powers from 1945 – Italy and West Germany. Britain could have been present at the creation; in fact, most of the six wanted us to join. But then, as now, the message was: “We don’t think it is appropriate for us.”

In part, the motives behind founding the EEC were economic. Hard borders and high tariffs would hamper recovery after the war. Belgium, Luxembourg and the Netherlands had already formed the Benelux customs union in 1948. They were also natural trading partners with Germany, sharing the Rhine-Meuse-Scheldt Delta, and Germany had vied with France for decades over the mineral resources of the Saar and the Ruhr. Now the six countries decided to pool these vital assets. The European Coal and Steel Community (ECSC) of 1952 was a stepping stone to the Treaty of Rome.

None of these states had abandoned the pursuit of national interests; rather, they were going about it in less confrontational ways. Electorates, still haunted by the Depression of the 1930s, now expected their governments not only to ensure order and security but also to stimulate growth and provide welfare. In these circumstances, some erosion of national sovereignty seemed necessary, even desirable. Prosperity wasn’t a zero-sum game, built on hard-nosed “us first” policies, but would be fostered by calculated yet enlightened interdependence. For the modern state, in short, absolute sovereignty could not be an end in itself.

That said, the essential imperative of European integration was not economic but political. For France and Germany, 1914 and 1939 were just the most recent manifestations of their bloody past, a cycle of wars that stretched back to the days of Bismarck, Napoleon and Louis XIV. Sedan 1870, Leipzig 1813, Jena 1806, Valmy 1792, Turckheim 1675 – the victories were emblazoned on public monuments and celebrated in school textbooks, the defeats quietly forgotten. ­European integration offered a chance for the French and the Germans to break free from centuries of tit-for-tat conflicts; a belated acceptance of the dictum “If you can’t beat them, join them”.

The Benelux countries were caught in the jaws of that Franco-German antagonism: whenever the two big beasts bit on each other, the three little ones felt the pain. ­Italy, the other founding member, was – like West Germany – desperate to jettison its pariah status from the Fascist era. So Rome 1957 served as a belated peace treaty, drawing a line under the Second World War for western Europe.

This zeal to transcend hard nationalism is seen most strikingly in the life of Robert Schuman, the man now celebrated as the “Father of Europe”. Born in 1886, Schuman grew up in Luxembourg but was educated at German universities and practised law in the city of Metz, in Lorraine – then part of Germany thanks to its victory in 1870-71. When the next war broke out in 1914, he was conscripted into the kaiser’s army: only medical problems saved him from having to fight against the French.

In 1919 France recovered Alsace and Lorraine, so Schuman became a French citizen and got into French politics. From 1942 to 1945 he fought in the wartime Resistance and then, amid France’s postwar kaleidoscopic politics, served variously as finance minister, prime minister and foreign minister. It was Schuman’s celebrated declaration of 9 May 1950 that paved the way for the ECSC and the Treaty of Rome.

Today the “Schuman roundabout” lies at the heart of the EU quarter in Brussels – an apt memorial, because his experience of the (un)merry-go-round of belligerent nationalism inspired his commitment to European integration. He was not alone. The West German chancellor Konrad Adenauer (born 1876) was a Rhinelander from Cologne who served as that city’s mayor from 1917 to 1933, until he was sacked by the Nazis. Over the years he had in turn chafed at Prussian domination of the Rhineland, feared French annexation, and endured two stretches of British military occupation.

The Italian premier Alcide De Gasperi (born 1881) had started his political life in the Austrian parliament before 1914, when his homeland, Trentino/South Tyrol, still belonged to the Habsburg empire. After the region was transferred to Italy in 1919, De Gasperi resumed his political career not in Vienna but in Rome, opposing first the Fascists and then the Communists.

The early lives of these three men along the shifting borderlands of war-torn Europe brought home to them the suicidal futility of hard nationalism. They also shared a profound sense of Catholic Europe, extending back through the Holy Roman empire to the era of Charlemagne.

It was from this historical platform that Schuman approached European integration. “If we don’t want to fall back into the old errors in dealing with the German problem,” he said, “there is only one solution: that is the European solution.” Coal and steel were an ideal starting point because they were double-edged – vital for industrial growth but also for waging war. Surrendering national control over these critical assets could enhance prosperity and peace.

***

The British approach to “Europe” was very different. In the mid-20th century Britain still saw itself as a global power. The sterling area took half of all British exports: western Europe, struggling to recover from the war, less than a quarter. In 1951 British industrial production equalled that of France and West Germany combined. And although Britain worked closely with France in 1947-49 over the Marshall Plan and the North Atlantic Treaty, its engagement with the Continent had clear limits.

“Our policy should be to assist Europe to recover, as far as we can,” senior British civil servants advised in 1949. “But the concept must be one of limited liability. In no circumstances must we assist them beyond the point at which the assistance leaves us too weak to be a worthwhile ally for USA if Europe collapses . . .”

“Limited liability” was a philosophy rooted in Britain’s experience of the war – also markedly different from that of the Six. In May and June of 1940, Germany conquered France, Belgium, Luxembourg and the Netherlands, with Italy jumping in to grab some of the spoils. That summer is now engraved in British national mythology. It was immortalised in David Low’s Very Well, Alone cartoon for the Evening Standard, depicting a pugnacious Tommy breathing defiance to the world from a rock in storm-tossed seas.

Victory was eventually achieved not with the Continentals, who seemed to be either foes or failures, but in alliance with those whom Churchill called “the English-speaking peoples” – above all, the United States. From this perspective, “sovereignty” clearly worked: we successfully defended our iconic southern border, the white cliffs of Dover, and gained ultimate victory. Only those who had been defeated (in 1940 or 1945) would imagine surrendering any national powers to a higher authority.

In 1950, therefore, when the Labour cabinet decided that the Schuman Plan was not appropriate for us, it was following the majority view in Whitehall and Westminster. Ernest Bevin, the ailing but still doughty foreign secretary who had led Britain’s drive for closer intergovernmental co-operation with France in the 1940s, had no time for the dread word “federalism”. In his inimitable phrase, “If you open that Pandora’s box, you never know what Trojan ’orses will jump out.” Pressed by the Americans to take these ideas more seriously, he questioned how he could go to his London dockland constituents in Woolwich, blitzed by the Luftwaffe in 1940, and explain that the Germans would help them in a war with Russia. As for France, he sniffed, “the man in the street, coming back from a holiday there, was almost invariably struck by the defeatist attitude of the French”. Great Britain, he exclaimed, was “not part of Europe”; she was “not simply a Luxembourg”.

This was a bipartisan attitude, endorsed by the Tories when they regained office in 1951. Churchill conjured up the image of three overlapping “circles” of global power, with Britain involved in each but not confined to any: the Commonwealth and empire; the “English-speaking world”; and, as he put it to the cabinet in November that year, “United Europe, to which we are a separate, closely and specially related ally and friend”. He and his successor Anthony Eden welcomed European integration for “them”, not “us” – as a way of reconciling France and Germany. After the Six embarked in 1956-57 on talks in Brussels about further integration, the British sent not a government minister but a Board of Trade official, and then merely as an “observer”.

The accepted wisdom in London remained that Britain’s trading interests were global and that a protectionist European bloc would be dangerous. Yet that kind of common market was not a foregone conclusion. Britain had a powerful potential ally within the Six in the form of West Germany, and especially its influential economics minister, Ludwig Erhard.

Almost as much as London, Bonn’s trading interests were global: 40 per cent of its exports went beyond Europe and much of West Germany’s European trade was outside the Six, with Austria, Scandinavia, Switzerland and the UK. Like the British, Erhard wanted a reduction of global tariff barriers to promote free trade, rather than the high-tariff, protectionist bloc favoured by Paris to defend France’s flabby economy. Yet a common market was inconceivable without the French, and Chancellor Adenauer – focused on postwar reconciliation – insisted that politics mattered more than economics. Erhard was told to get the best deal he could as long as France was “in”.

So that left the French able largely to dictate their terms. Among these were a steep external tariff, inclusion within the EEC of France’s overseas territories, acceptance across the Six of France’s high welfare payments and the development of a Common Agricultural Policy (Cap), which subsidised inefficient farming. By 1970 the Cap consumed 70 per cent of the EEC budget. But, as a senior Italian official observed ruefully, “Europe cannot organise without France and, to get her in, prices must be paid which may seem exorbitant.”

What would have happened if Britain had been fully engaged in these negotiations from the start? Might it have strengthened Erhard’s hand and helped forge a strong
Anglo-German axis in favour of a looser, more open free-trade area? That would have put pressure on Paris to accept London and Bonn’s terms, or be left out in the cold. In which case European integration could have developed along very different lines, with a Franco-German-British triangle operating in creative tension at the heart of the new Europe in an EEC that, in effect, would have been 3 + 4. A tantalising “what if”, but it would have required a very different attitude
in Britain towards its future and its past.

***

And so the EEC was born on New Year’s Day 1958 with six founder members, not seven. The British had been completely wrong-footed. In 1950 they expected Schuman’s pipe dream to go up in smoke; they were equally complacent about the Brussels talks in 1956-57; and they repeated the mistake yet again in assuming it would take years for the EEC to become a reality. Instead, not only was the EEC now a fact, but the Six made rapid progress in dismantling tariff barriers and agreeing the basics of the Cap. By 1961 they were seriously debating political union, or at least a common foreign policy.

London struggled to believe that those despised Continentals, who in their various ways had botched the Second World War, could bury the hatchet and work together. British complacency, even arrogance, has aptly been called the “price of victory”. And we’ve been paying the bill ever since.

Once the Six was up and running, there was a grave danger of Britain being marginalised. The European community threatened
to become “the only Western bloc approaching in importance the Big Two – the USSR and the United States”, a senior Whitehall committee warned in 1960. Aside from the economic damage that would ensue, “if we try to remain aloof from them” Britain would “run the risk of losing political influence and of ceasing to be able to exercise any claim to be a world Power”. The economic case for membership was still finely balanced: commercial and emotional ties with the Commonwealth, strengthened by the war, remained strong. Yet, for Harold Macmillan, like Adenauer in 1956, politics took precedence over economics. In August 1961 his government applied to join the EEC.

But the price of victory kicked in again. Charles de Gaulle had not forgotten or forgiven Roosevelt and Churchill for treating his Free French as second-class members of the wartime alliance. A fierce nationalist, he accepted the European project but sought to turn it to France’s advantage, or his conception of this. Crucial to his strategy was keeping Britain out of the EEC.

“My dear chap, it’s very simple,” the French agriculture minister told his British counterpart. “At the moment, with the Six, there are five hens and one cock. If you join, with other countries, there will be perhaps seven or eight hens. But there will be two cocks. Well, that is not so pleasant.”

Determined to rule the roost, de Gaulle blocked first Macmillan’s application to join and then Harold Wilson’s. By the time he retired and Edward Heath had negotiated terms of entry, 15 years had elapsed since 1 January 1958. The original deal-making among the Six had set hard, to their advantage. Any new member had to accept the club rules as given: the “acquis commun­autaire”, in Eurospeak. Worse still, in 1973, just months after Denmark, Ireland and the UK had joined the community, the bottom fell out of the world economy with the oil crisis, recession and stagflation, making it nigh impossible amid all the crisis management to force the EEC into reform as Heath had hoped. The good ship Europe had been launched on the high tide of postwar prosperity. But as the Six became the Nine, that tide began to ebb. We have never had it so good – ever again.

Since the 1970s and Britain’s “entry” into Europe, successive prime ministers have tried to undo the damage caused by their aloof predecessors. Most have done so “alone” – in 1940 mode – rather than working to form alliances with reform-minded colleagues on the Continent. In particular, as in the mid-1950s, they failed to build creative partnerships with the Germans.

Margaret Thatcher was a notable example. Her cantankerous “handbagging” secured rebates on British budget contributions in excess of what probably could have been obtained by “normal” diplomacy, but it alienated many of her European colleagues. And her visceral suspicion of the Germans, dating back to the Second World War, poisoned relations with Bonn. “She doesn’t really believe that there’s any such thing as useful negotiation,” observed Sir Nicholas Henderson, a high-ranking British diplomat. “She doesn’t see foreign policy as it is, which is a lot of give and take.”

Yet Thatcher was only the extreme case. Even prime ministers who were more “pro-Europe”, such as John Major and Tony Blair, were hamstrung by domestic politics – meaning both the rooted Euroscepticism of Tory backbenchers and also the tabloids’ determination to treat every encounter with “Europe” as a replay of old battles. Woe betide any British PM who returned from Brussels without being able to proclaim victory in another Waterloo (though the 1815 battle was won in tandem with the Germans, plus Dutch and Belgian support).

The Brexit frenzy is only the latest round in that story. Even on the Remain side, the Cameron-Osborne campaign – a breathtaking blend of arrogance and incompetence – chose to make its case almost entirely by economic scaremongering about the dangers of Leave (through “Project Fact”, aka “Project Fear”), rather than highlighting positives of the European project, especially its enduring contribution to postwar peace.

Of course, the EU has often been its own worst enemy. Reform has been slow: the Cap, for instance, accounted for 73 per cent of total EU spending as late as 1985 and did not fall below 40 per cent until 2013, still a remarkable figure for one of the most industrialised regions of the world. Institutionally, the bureaucracy is flabby; financial control is weak; decision-making is ponderous; the European Commission frequently locks horns with the European Council (the heads of government); and the persistent “democratic deficit” has exacerbated a popular sense of alienation.

Repeatedly, too, politics has trumped economics, particularly over the question of enlargement. In the 1980s the Nine ­became 12 in order to embrace three underdeveloped countries that had recently thrown off authoritarian regimes: Greece, Spain and Portugal. In the 1990s the euro was driven not just by the ambition of Jacques Delors but by the determination of François Mitterrand and Helmut Kohl to anchor the financial and industrial power of a unified Germany firmly in European structures – updating, if you like, Schuman’s vision. And since 2000, the EU has welcomed in from the Cold (War) those countries of eastern Europe that were anxious to escape the Russian bear hug. All these politically inspired moves have come at an economic price. To be sure, the EU28 is far more truly “European” geographically, but the original Six (apart from southern Italy) had a coherence as developed economies and functioning democracies that today’s mixed bag of members conspicuously lacks. Yet the EU project has continued to be animated by aspirations for close economic and political union that date from the 1950s.

***

Sixty is a ripe age. Many institutions do not survive that long and the EU (like Nato, founded in 1949) is painfully aware of the need to think imaginatively about its form and direction. The “Future of Europe” was firmly on the menu even at the Rome birthday party. On 29 March 2017 the UK, by contrast, began Year Zero – reborn into a brave new, Britain-shaped world, if you believe the Prime Minister; tumbling into the abyss, if you heed remaindered Remainers. Now Old EU@60 is about to meet New UK@0 for a long and bruising battle.

The stakes are high on both sides. Brussels is in no mood to let Britain off lightly: an easy exit would encourage other waverers and jeopardise the whole European project. Across the Channel, if May puts politics before economics (“control” of borders over access to the single market) her hard nationalism could alienate Scotland, undermine the Irish settlement, rupture the United Kingdom and end in no deal. A “full English” Brexit might prove very expensive.

The tabloids will doubtless report it as a replay of 1940 and “Our Finest Hour”: an earlier Brexit moment. Attentive as ever to them, May has embraced the description of herself as a “bloody difficult woman” who is eager to “fight for Britain”, in Churchill-Thatcher mode. Is her snap election intended to pave the way for a hard, nativist Brexit? Or does she just hope that a bigger majority will give her more room for manoeuvre in battling Brussels? No one knows, probably not even May herself. Current negotiating strategies, like battle plans, will not survive the first encounter with “the enemy”.

That is why it is important, amid the daily barrage of spin, sneers and aggro, to keep the bigger historical picture in mind. Because we may be entering the twilight of what can be called the postwar era, which began in the decade after 1945, when the horrors of belligerent nationalism prompted a fervent effort to make peace and build truly international institutions. The UN, Nato and the EEC were all products of that creative moment; likewise the General Agreement on Tariffs and Trade and the Universal Declaration of Human Rights.

This fabric of postwar internationalism is now ageing and strained – often in need of radical modification – yet in a world where nationalism, protectionism and racism are on the rise, it provides some flimsy protection against the law of the jungle. If Brexit is handled belligerently, it could help to pull the threads from that thin tissue of coexistence and co-operation.

Our leaders show little awareness of what is at stake historically. According to US Vogue’s recent interview with Theresa May, “She says she doesn’t read much history and tries not to picture how things will be in advance.” Jeremy Corbyn seems to live in an ideological time warp of his own. Boris Johnson does have historical sensitivity, but of a typically self-serving sort: see his entertaining little (auto)biography of Churchill.

This Brexit election is just an early milestone on a long and painful road. It took the UK over 11 years from first applying to joining the EEC. It may take as long to complete a full, legally watertight exit from the EU. Certainly, for the next few years, at a time when so many global problems are crying out for creative policymaking, the EU and the UK will confront each other obsessively to the exclusion of almost everything else. A dysfunctional union and a disunited kingdom – each captivated by its contrasting past – will struggle and muddle towards divergent futures.

David Reynolds’s books include “Britannia Overruled” (Routledge) and “The Long Shadow: the Great War and the 20th Century” (Simon & Schuster)

This article first appeared in the 25 May 2017 issue of the New Statesman, Why Islamic State targets Britain

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