The Tory stealth attack on the NHS

If the Tories have their way, they will break apart the health system, just like our schools. This i

The new coalition government has made a great deal out of ring-fencing the health budget, giving the public the impression that the National Health Service will not suffer the cuts that other departments are facing. It is fast becoming clear, however, that there will be significant cuts in health like everywhere else. Plans put forward by the Conservative Secretary of State for Health, Andrew Lansley, if allowed to proceed, will undermine the structure and principles of the NHS in the largest overhaul of the service since its foundation.

The idea is to hand over the NHS budget to GPs, who will then commission services on behalf of individual patients. There has been little public discussion of the proposals, and the extent of the planned reorganisation - and the commensurate cuts in budget - is only now leaking from private briefings to key managers.

The NHS budget for 2010-2011 is £110bn and there are around 40,000 GPs working in England and Wales. At present, the budget is divided among the ten strategic health authorities (SHAs), which devolve it down to primary care trusts (PCTs). The strategic authorities set strategy and hold local delivery agents to account. The PCTs commission services from hospitals, GPs, opticians and primary services. Trusts have increasingly been forging strong links with local authorities to provide social care to the elderly and people with disabilities or other needs.
Under the plans, this infrastructure will be demolished and the SHAs abolished. The PCTs might survive, but with reduced powers and little or no authority over budgets or services; it is most likely that they will simply be employed by doctors as the administrative mechanism to purchase health services for individual patients. Richard Sykes, chairman of the London SHA, recently resigned in protest.

The last major reorganisation of the NHS took place in 2002 and has therefore had less than a decade to settle. The PCTs are midway through a restructuring process to separate the provider arm from the commissioners; now, no one seems to be sure whether this will proceed. There are undoubtedly bureaucratic tangles, but these are not insurmountable.

Stealth care

The new vision for GP-led commissioning envisages both sole practitioners and group practices handling the entire budget and commissioning services for their patients from hospitals, local authorities, private companies and primary services. There are questions concerning the details, not least whether GPs will want to take on this responsibility. Will single GPs be prepared or be able to commission such a wide range of services, or will they delegate to a consortium of local doctors? Will they subcontract the commissioning process to private companies involved in health care and so bring privatisation to the NHS by stealth?

It is not clear where public consultation fits into the GP-led model. The Health Secretary may argue that, because decisions are made with individual patients, this is inherently a form of consultation. But it would constitute a fragmentation of the pro­cess, as there would be no forum for leading discussion on, for example, investing in new specialist trauma services at particular hospitals, or reconfiguring stroke services. The SHAs have been the lead agencies conducting consultations. If they are abolished, this kind of consultation may also be lost.

It is also unclear how strategic decision-making will be conducted, if at all. Just as the schools system is being broken apart, taking away the strategic responsibilities of local authorities, so it is with health. The "big society" seems to mean the abolition of the collective.

Public health will be another casualty. Lives are saved through the promotion of healthy lifestyles and public education, as well as programmes to help people, say, give up smoking. Focusing such attention on health inequalities is one of the ways that we direct health services at the poor. But it appears that the expenditure on public health initiatives will be slashed from 7 per cent of the allocated budget to just 4 per cent.

PCTs are being told to reduce their management and administrative costs by roughly 50 per cent. The effect of this is to hobble any attempt at strategic management. Many targets have now been abandoned. Although there has been some unease at the rigidity of target culture, it is undeniable that imposing targets and holding people to account for specific time limits in accident and emergency units, for seeing a consultant and for performing operations have saved and improved the lives of millions of people.

Cities will be particularly hard hit by Lansley's shake-up. In London, there are probably several hundred thousand people who are not registered with a GP and they will not be able to get any access to health care. Anyone who is not eligible to register with a GP could be denied medical and health services.

Ask a doctor

Since its foundation, the NHS has been redistributive. It was designed to redistribute to the poor so that health inequalities are reduced. Its success has been patchy, but that objective is embedded at all levels and in every service. If strategic planning is abolished and service purchasing is fragmented, the aim of reducing inequality will be abandoned, too.

Lansley is a man on a mission who has been developing these ideas from his constituency, South Cambridgeshire. No one I have spoken to seems to know if he has been talking to the doctors themselves.

If his plans are fully instituted, GPs' contracts would have to be renegotiated and they would be well advised to consider whether it is to their advantage - and that of their patients - to take over responsibility for managing the NHS. It could be a poisoned chalice. Doctors could be made to take the blame if the plan collapses, leading the way to the wholesale privatisation of the NHS.

Also opaque is the extent to which these proposals form part of an ideological programme under the leadership of the Prime Minister, David Cameron, and the coalition cabinet, or whether ministers are being left to their own devices. There are similarities between the proposed education and health policies, but they do not appear to be co-ordinated as part of a coherent vision for the country. Every postwar government has come in with a clear ideology and a plan; for good or for ill, we knew what we were getting. The Conservatives have not presented this health plan to the public, and it is not even evident that they have made it clear to their coalition partners.

NHS agencies are being told that the new structure should be in place by 1 April 2012. There has been no announcement about any
of these changes - no public consultation and no critical review. Yet here they come.

Frances Crook is a non-executive director of a primary care trust and writes here in a personal capacity.

Journey of the GP

Before the Second World War, health care in the UK was piecemeal at best. The poor had little right to care - the lowest-paid workers could consult a GP, but their families could not - and many relied on charity.

This changed with the creation of the National Health Service in 1948. In a huge shift, each resident of the UK was from this point registered with a GP, who would act as the individual's point of entry into the medical system. In the early days of the NHS, GPs were demoralised, suffering from low pay and status. GP practices as they exist now began in 1955, when money was made available for individual doctors to develop grouppractices.

In 1990, while Margaret Thatcher was still prime minister, the "internal market" was formed; this allowed certain practices to buy services from other parts of the NHS. Successive reforms under Labour have left a similar system in place.

Meanwhile, GPs' status has improved, with recent contract changes allowing them to opt out of working during weekends and in the evenings. The press has criticised their pay as excessive. The figure is extremely variable, but a full-time practice partner now earns about £110,000, while a salaried GP earns approximately £74,000. A 2006 report showed that some GPs were earning £250,000 a year.

Samira Shackle.

Frances Crook is the Chief Executive of the Howard League for Penal Reform.

This article first appeared in the 05 July 2010 issue of the New Statesman, The cult of the generals

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The lost magic of England

The great conservative journalist Peregrine Worsthorne reflects on a long life at the heart of the establishment.

In a recent editorial meeting, our subscriptions manager happened to mention that Peregrine Worsthorne was still a New Statesman subscriber. A former editor of the Sunday Telegraph and, during a long Fleet Street career, a self-styled “romantic reactionary” scourge of liberals and liberalism, Worsthorne used to be something of a pantomime villain for the left, a role he delighted in. He had close friends among the “Peterhouse right”, the group of High Tory intellectuals who gathered around Maurice Cowling at the small, conspiratorial Cambridge college. He was a frequent contributor to Encounter (which turned out to be funded by the CIA) and an ardent cold warrior. His social conservatism and lofty affectations offended lefty Islingtonian sensibilities. On several occasions he was the Guardian’s reviewer of choice for its annual collection of journalism, The Bedside Guardian, and he invariably delivered the required scornful appraisal while praising its witty television critic, Nancy Banks-Smith. There is no suggestion, he wrote in 1981, that the “Guardian ever sees itself as part of the problem; itself as having some responsibility for the evils its writers described so well”.

His prose style was Oxbridge high table, more Walter Pater than George Orwell. It was essential not to take Worsthorne too seriously, because he delighted in mischief-making and wilful provocation – one of his targets for remorseless ridicule was Andrew Neil, when Neil edited the abrasively Thatcherite Sunday Times. He ended up suing Worsthorne, who was famous for his silk shirts and Garrick Club lunches, for libel; he was awarded damages of £1, the then cover price of the Sunday Times.

“I wrote that in the old days editors of distinguished Sunday papers could be found dining at All Souls, and something must have changed when they’re caught with their trousers down in a nightclub,” Worsthorne told me when we met recently. “I had no idea he was going to sue. I was teasing. I occasionally run into him and we smile at each other, so it’s all forgotten and forgiven.”

After his retirement in 1989, Worsthorne, although he remained a resolute defender of aristocracy, seemed to mellow, and even mischievously suggested that the Guardian had replaced the Times as the newspaper of record. In the 1990s he began writing occasionally for the New Statesman – the then literary editor, Peter Wilby, commissioned book reviews from him, as I did after I succeeded Wilby. Like most journalists of his generation, Worsthorne was a joy to work with; he wrote to length, delivered his copy on time and was never precious about being edited. (Bill Deedes and Tony Howard were the same.) He might have had the mannerisms of an old-style toff but he was also a tradesman, who understood that journalism was a craft.

Shortly before Christmas, I rang Wors­thorne at the home in Buckinghamshire he shares with his second wife, Lucinda Lambton, the charming architectural writer. I asked how he was. “I’m like a squeezed lemon: all used up,” he said. Lucy described him as being “frail but not ill”. I told him that I would visit, so one recent morning I did. Home is a Grade II-listed old rectory in the village of Hedgerley. It is grand but dishevelled and eccentrically furnished. A sign on the main gates warns you to “Beware of the Dog”. But the dog turns out to be blind and moves around the house uneasily, poignantly bumping into objects and walls. At lunch, a small replica mosque in the dining room issues repeated mechanised calls to prayer. “Why does it keep doing that?” Perry asks. “Isn’t it fun,” Lucy says. She then turns to me: “Have some more duck pâté.”

As a student, I used to read Worsthorne’s columns and essays with pleasure. I did not share his positions and prejudices but I admired the style in which he articulated them. “The job of journalism is not to be scholarly,” he wrote in 1989. “The most that can be achieved by an individual newspaper or journalist is the articulation of an intelligent, well-thought-out, coherent set of prejudices – ie, a moral position.”

His Sunday Telegraph, which he edited from 1986 to 1989, was like no other newspaper. The recondite and reactionary comment pages (the focus of his energies) were unapologetically High Tory, contrary to the prevailing Thatcherite orthodoxies of the time, but were mostly well written and historically literate. Bruce Anderson was one of the columnists. “You never knew what you were going to get when you opened the paper,” he told me. “Perry was a dandy, a popinjay, and of course he didn’t lack self-esteem. He had a nostalgia for Young England. In all the time I wrote for him, however, I never took his approval for granted. I always felt a tightening of the stomach muscles when I showed him something.”

***

Worsthorne is 92 now and, though his memory is failing, he remains a lucid and engaging conversationalist. Moving slowly, in short, shuffling steps, he has a long beard and retains a certain dandyish glamour. His silver hair is swept back from a high, smooth forehead. He remains a stubborn defender of the aristocracy – “Superiority is a dread word, but we are in very short supply of superiority because no one likes the word” – but the old hauteur has gone, replaced by humility and a kind of wonder and bafflement that he has endured so long and seen so much: a journalistic Lear, but one who is not raging against the dying of the light.

On arrival, I am shown through to the drawing room, where Perry sits quietly near an open fire, a copy of that morning’s Times before him. He moves to a corner armchair and passes me a copy of his book Democracy Needs Aristocracy (2005). “It’s all in there,” he says. “I’ve always thought the English aristocracy so marvellous compared to other ruling classes. It seemed to me that we had got a ruling class of such extraordinary historical excellence, which is rooted in England
almost since the Norman Conquest.

“Just read the 18th-century speeches – the great period – they’re all Whig or Tory, but all come from that [the aristocracy]. If they didn’t come directly from the aristocracy, they turned themselves very quickly into people who talk in its language. Poetic. If you read Burke, who’s the best in my view, it’s difficult not to be tempted to think what he says has a lot of truth in it . . .”

His voice fades. He has lost his way and asks what we were talking about. “Oh, yes,” he says. “It survived when others – the French and Russians and so on – were having revolutions. It was absolutely crazy to set about destroying that. There was something magical . . . the parliamentary speeches made by Burke and so on – this is a miracle! No other country has it apart from America in the early days. And I thought to get rid of it, to undermine it, was a mistake.”

I ask how exactly the aristocracy was undermined. Even today, because of the concentration of the ownership of so much land among so few and because of the enduring influence of the old families, the great schools and Oxbridge, Britain remains a peculiar hybrid: part populist hyper-democracy and part quasi-feudal state. The Tory benches are no longer filled by aristocrats but the old class structures remain.

“Equality was the order of the day after the war,” Worsthorne replies. “And in a way it did a lot of good, equalising people’s chances in the world. But it didn’t really get anywhere; the ruling class went happily on. But slowly, and I think unnecessarily dangerously, it was destroyed – and now there are no superior people around [in politics]. The Cecil family – Lord Salisbury, he was chucked out of politics. The Cecil family is being told they are not wanted. The institutions are falling apart . . .

“But there were people who had natural authority, like Denis Healey. I’m not saying it’s only aristocrats – a lot of Labour people had it. But now we haven’t got any Denis Healeys.”

Born in 1923, the younger son of Alexander Koch de Gooreynd, a Belgian banker, Worsthorne (the family anglicised its name) was educated at Stowe and was an undergraduate at both Cambridge (Peterhouse, where he studied under the historian Herbert Butterfield, the author of The Whig Interpretation of History) and Oxford (Magdalen College). “I have always felt slightly underprivileged and de-classed by having gone to Stowe, unlike my father who went to Eton,” Worsthorne wrote in 1985.

Yet his memories of Stowe remain pellucid. There he fell under the influence of the belle-lettrist John Davenport, who later became a close friend of Dylan Thomas. “He was a marvellous man, a famous intellectual of the 1930s, an ex-boxer, too. But in the war he came to Stowe and he was preparing me for a scholarship to Cambridge. He told me to read three books, and find something to alleviate the boredom of an examiner, some little thing you’ll pick up. And I duly did and got the scholarship.”

Can you remember which three books he recommended?

“Tawney. Something by Connolly, um . . . that’s the terrible thing about getting old, extremely old – you forget. And by the time you die you can’t remember your brother’s name. It’s a terrible shock. I used to think old age could be a joy because you’d have more time to read. But if you push your luck and get too far, and last too long, you start finding reading really quite difficult. The connections go, I suppose.”

Was the Connolly book Enemies of Promise (1938)?

“Yes, that’s right. It was. And the other one was . . . Hang on, the writer of the book . . . What’s the country invaded by Russia, next to Russia?

Finland, I say. Edmund Wilson’s To the Finland Station (1940)?

“Yes. Wilson. How did you get that?”

We both laugh.

***

Worsthorne is saddened but not surprised that so many Scots voted for independence and his preference is for Britain to remain a member of the European Union. “What’s happening is part of the hopelessness of English politics. It’s horrible. I can’t think why the Scots would want to be on their own but it might happen. The youth will vote [for independence]. This is part of my central theme: the Scots no longer think it’s worthwhile belonging to England. The magic of England has gone – and it’s the perversity of the Tory party to want to get us out of the European Union when of course we’re much more than ever unlikely to be able to look after ourselves as an independent state because of the quality of our political system.

“The people who want to get us out are obviously of an undesirable kind. That the future should depend on [Nigel] Farage is part of the sickness. I mean the real horror is for him to have any influence at all. And when you think of the great days of the Labour Party, the giants who strode the stage – famous, lasting historical figures, some of them: Healey, Attlee, who was probably the greatest, [Ernest] Bevin. I’m well aware that Labour in the good days produced people who were superior.”

He digresses to reflect on his wartime experience as a soldier – he served in Phantom, the special reconnaissance unit, alongside Michael Oakeshott, the philosopher of English conservatism who became a close friend, and the actor David Niven, our “prize colleague”.

“I remember Harold Macmillan saying to me, after the Second World War, the British people needed their belt enlarged; they’d done their job and they deserved a reward. And that’s what he set about doing. And he wasn’t a right-wing, unsympathetic man at all. But he didn’t – and this is what is good about conservatism – he didn’t turn it into an ‘ism’. It was a sympathetic feel, an instinctive feel, and of course people in the trenches felt it, too: solidarity with the rest of England and not just their own brotherhood. Of course he didn’t get on with Margaret Thatcher at all.”

Worsthorne admired Thatcher and believed that the “Conservatives required a dictator woman” to shake things up, though he was not a Thatcherite and denounced what he called her “bourgeois triumphalism”. He expresses regret at how the miners were treated during the bitter strike of 1984-85. “I quarrelled with her about the miners’ strike, and the people she got around her to conduct it were a pretty ropey lot.

“I liked her as a person. I was with her that last night when she wasn’t prime minister any more, but she was still in Downing Street and had everything cut off. The pressman [Bernard Ingham] got several of us to try to take her mind off her miseries that night. There’s a photograph of me standing at the top of the stairs.”

In the summer of 1989, Peregrine Wors­thorne was sacked as the editor of the Sunday Telegraph by Andrew Knight, a former journalist-turned-management enforcer, over breakfast at Claridge’s. He wrote about the experience in an elegant diary for the Spectator: “I remember well the exact moment when this thunderbolt, coming out of a blue sky, hit me. It was when the waiter had just served two perfectly poached eggs on buttered toast . . . In my mind I knew that the information just imparted was a paralysingly painful blow: pretty well a professional death sentence.”

He no longer reads the Telegraph.

“Politically they don’t have much to say of interest. But I can’t put the finger on exactly what it is I don’t like about it. Boredom, I think!”

You must read Charles Moore?

“He is my favourite. Interesting fellow. He converted to Catholicism and started riding to hounds in the same week.”

He has no regrets about pursuing a long career in journalism rather than, say, as a full-time writer or academic, like his friends Cowling and Oakeshott. “I was incredibly lucky to do journalism. What people don’t realise – and perhaps you don’t agree – but it’s really a very easy life, compared to many others. And you have good company in other journalists and so on. I was an apprentice on the Times, after working [as a sub-editor] on the Glasgow Herald.”

How does he spend the days?

“Living, I suppose. It takes an hour to get dressed because all the muscles go. Then I read the Times and get bored with it halfway through. Then there’s a meal to eat. The ­answer is, the days go. I used to go for walks but I can’t do that now. But Lucy’s getting me all kinds of instruments to facilitate people with no muscles, to help you walk. I’m very sceptical about it working, but then again, better than the alternative.”

He does not read as much as he would wish. He takes the Statesman, the Spectator and the Times but no longer the Guardian. He is reading Niall Ferguson’s biography of Kissinger, The Maisky Diaries by Ivan Maisky, Stalin’s ambassador to London from 1932 to 1943, and Living on Paper, a selection of letters by Iris Murdoch, whom he knew. “I get these massive books, thinking of a rainy day, but once I pick them up they are too heavy, physically, so they’re stacked up, begging to be read.”

He watches television – the news (we speak about Isis and the Syrian tragedy), the Marr show on Sunday mornings, and he has been enjoying War and Peace on BBC1. “Andrew Marr gave my book a very good review. He’s come back. He’s survived [a stroke] through a degree of hard willpower to get back to that job, almost as soon as he came out of surgery. But I don’t know him; he was a Guardian man.” (In fact, Marr is more closely associated with the Independent.)

Of the celebrated Peterhouse historians, both Herbert Butterfield (who was a Methodist) and Maurice Cowling were devout Christians. For High Tories, who believe in and accept natural inequalities and the organic theory of society, Christianity was a binding force that held together all social classes, as some believe was the order in late-Victorian England.

“I was a very hardened Catholic,” Worsthorne says, when I mention Cowling’s book Religion and Public Doctrine in Modern England. “My mother was divorced [her second marriage was to Montagu Norman, then the governor of the Bank of England] and she didn’t want my brother and me to be Catholic, so she sent us to Stowe. And I used to annoy her because I read [Hilaire] Belloc. I tried to annoy the history master teaching us Queen Elizabeth I. I said to him: ‘Are you covering up on her behalf: don’t you know she had syphilis?’

“Once I felt very angry about not being made Catholic. But then I went to Cambridge and there was a very Catholic chaplain and he was very snobbish. And in confession I had to tell him I masturbated twice that morning or something, and so it embarrassed me when half an hour later I had to sit next to him at breakfast. I literally gave up going to Mass to get out of this embarrassing situation. But recently I’ve started again. I haven’t actually gone to church but I’ve made my confessions, to a friendly bishop who came to the house.”

So you are a believer?

“Yes. I don’t know which bit I believe. But as Voltaire said: ‘Don’t take a risk.’”

He smiles and lowers his head. We are ready for lunch. 

Jason Cowley is editor of the New Statesman. He has been the editor of Granta, a senior editor at the Observer and a staff writer at the Times.

This article first appeared in the 11 February 2016 issue of the New Statesman, The legacy of Europe's worst battle