Old battle lines between public and private are now blurred

Last summer, for the 60th anniversary of the NHS, the Nuffield Trust published a book in which key former secretaries of state for health gave their views as to whether the NHS should "rejuvenate or retire". There was considerable consensus on four particular points.

First, there was strong public support for the collective value underpinning the NHS - fairness. Second, that funding by taxation would remain for the vast majority of the population. Third, that the NHS was too big and too complex to be run by politicians. Fourth, that there should be a diversity of providers (not just those owned by the NHS) offering care to patients, and that some level of competition between them was healthy.

The recent advice to government by Mike Richards, recommending that individuals be allowed to pay privately for care not available on the NHS, without losing NHS entitlement, opens the door to allowing more people to supplement tax-funded care with privately-funded care. Former secretary of state Stephen Dorrell noted, "What has changed is the balance between the collective and the individual in society...and that is a challenge for the health service. To recognise that is not to walk away from its collective aspiration which...is overwhelmingly right."

The old battle lines, between those on the left, who believe in more funding, greater central or local democratic control to achieve improvements, and those on the right, who believe in privatisation and competition, are now very blurred. The debate is now essentially about two related things: power and levers.

First, what is the right blend of levers? In England, the political battle over the merits of allowing non-NHS hospitals and clinics to provide care to NHS-funded patients, and paying them according to the number of patients treated, has largely been won. This is still not the case in Scotland or Wales. Regarding direct financial incentives, central direction, regulation, local accountability, and encouraging stronger professionalism, research evidence is often not strong enough to give real-time answers as to where to go next. Instead we are left with experience (largely the domain of civil servants, managers and the few clinicians who engage in reform discussions) or instinct (largely the domain of politicians). While this can lead the NHS up some blind alleys, the long-term direction in England is surprisingly similar to that seen in other health systems across the OECD.

Second, to what extent should power be shifted from Whitehall and distributed locally to allow more innovation to flourish? Some argue that we need to break it up into manageable chunks; others argue that that will reduce fairness in access. So far the most meaningful step to allow local autonomy has been to liberalise hospitals - over half now are foundation trusts, where there is a legal lock to prevent Whitehall from interfering. The obvious future battle will be whether NHS commissioning should be similarly autonomous.

Jennifer Dixon is director of The Nuffield Trust

This article first appeared in the 02 February 2009 issue of the New Statesman, Interview: Alistair Darling

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The New Times: Brexit, globalisation, the crisis in Labour and the future of the left

With essays by David Miliband, Paul Mason, John Harris, Lisa Nandy, Vince Cable and more.

Once again the “new times” are associated with the ascendancy of the right. The financial crash of 2007-2008 – and the Great Recession and sovereign debt crises that were a consequence of it – were meant to have marked the end of an era of runaway “turbocapitalism”. It never came close to happening. The crash was a crisis of capitalism but not the crisis of capitalism. As Lenin observed, there is “no such thing as an absolutely hopeless situation” for capitalism, and so we discovered again. Instead, the greatest burden of the period of fiscal retrenchment that followed the crash was carried by the poorest in society, those most directly affected by austerity, and this in turn has contributed to a deepening distrust of elites and a wider crisis of governance.

Where are we now and in which direction are we heading?

Some of the contributors to this special issue believe that we have reached the end of the “neoliberal” era. I am more sceptical. In any event, the end of neoliberalism, however you define it, will not lead to a social-democratic revival: it looks as if, in many Western countries, we are entering an age in which centre-left parties cannot form ruling majorities, having leaked support to nationalists, populists and more radical alternatives.

Certainly the British Labour Party, riven by a war between its parliamentary representatives and much of its membership, is in a critical condition. At the same time, Jeremy Corbyn’s leadership has inspired a remarkable re-engagement with left-wing politics, even as his party slumps in the polls. His own views may seem frozen in time, but hundreds of thousands of people, many of them young graduates, have responded to his anti-austerity rhetoric, his candour and his shambolic, unspun style.

The EU referendum, in which as much as one-third of Labour supporters voted for Brexit, exposed another chasm in Labour – this time between educated metropolitan liberals and the more socially conservative white working class on whose loyalty the party has long depended. This no longer looks like a viable election-winning coalition, especially after the collapse of Labour in Scotland and the concomitant rise of nationalism in England.

In Marxism Today’s “New Times” issue of October 1988, Stuart Hall wrote: “The left seems not just displaced by Thatcherism, but disabled, flattened, becalmed by the very prospect of change; afraid of rooting itself in ‘the new’ and unable to make the leap of imagination required to engage the future.” Something similar could be said of the left today as it confronts Brexit, the disunities within the United Kingdom, and, in Theresa May, a prime minister who has indicated that she might be prepared to break with the orthodoxies of the past three decades.

The Labour leadership contest between Corbyn and Owen Smith was largely an exercise in nostalgia, both candidates seeking to revive policies that defined an era of mass production and working-class solidarity when Labour was strong. On matters such as immigration, digital disruption, the new gig economy or the power of networks, they had little to say. They proposed a politics of opposition – against austerity, against grammar schools. But what were they for? Neither man seemed capable of embracing the “leading edge of change” or of making the imaginative leap necessary to engage the future.

So is there a politics of the left that will allow us to ride with the currents of these turbulent “new times” and thus shape rather than be flattened by them? Over the next 34 pages 18 writers, offering many perspectives, attempt to answer this and related questions as they analyse the forces shaping a world in which power is shifting to the East, wars rage unchecked in the Middle East, refugees drown en masse in the Mediterranean, technology is outstripping our capacity to understand it, and globalisation begins to fragment.

— Jason Cowley, Editor 

Tom Kibasi on what the left fails to see

Philip Collins on why it's time for Labour to end its crisis

John Harris on why Labour is losing its heartland

Lisa Nandy on how Labour has been halted and hollowed out

David Runciman on networks and the digital revolution

John Gray on why the right, not the left, has grasped the new times

Mariana Mazzucato on why it's time for progressives to rethink capitalism

Robert Ford on why the left must reckon with the anger of those left behind

Ros Wynne-Jones on the people who need a Labour government most

Gary Gerstle on Corbyn, Sanders and the populist surge

Nick Pearce on why the left is haunted by the ghosts of the 1930s

Paul Mason on why the left must be ready to cause a commotion

Neal Lawson on what the new, 21st-century left needs now

Charles Leadbeater explains why we are all existentialists now

John Bew mourns the lost left

Marc Stears on why democracy is a long, hard, slow business

Vince Cable on how a financial crisis empowered the right

David Miliband on why the left needs to move forward, not back

This article first appeared in the 22 September 2016 issue of the New Statesman, The New Times