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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Does the working class need to ask for its Labour Party back?

The more working class voters there were in a constituency in 2017, the more it tended to swing to the Tories.

When Theresa May called the general election nearly two months ago, all the evidence – opinion polls and local election results especially – pointed to the expectation that the Labour Party would be crushed, with many of its MPs losing their seats.

The assumption was that Labour under Jeremy Corbyn would be unable to win over Conservative voters, because he was too left-wing to appeal to those close to the political centre ground.

Some commentators, myself included, took this a little further, arguing that Corbyn was left-wing in a way that would alienate the very people he claimed to speak for, ie working class people, while appealing primarily to virtue-signalling middle class romantics like Corbyn himself, who have no more interest than he does in the business of parliament but love a good rally or social media spat.

The local elections that took place in May appeared to confirm the above expectation and analysis, with hundreds of Labour councillors losing their seats. However, opinion polls began to shift, and while different polling companies’ methodologies led to different estimates of support for the two main parties, all showed Labour on the rise – with YouGov predicting two days before the election that the Conservatives would win a mere 305 out of 650 seats, while Labour would win 266.

Despite a miserable campaign in support of a depressing manifesto, enlivened only by the promised revival of an anachronistic bloodsport beloved of the rural elite – indeed, a campaign so bad that political historian Glen O’Hara joked about having ‘watched and wondered whether Mrs May was a Corbynite sleeper agent’ – the Conservatives actually did slightly better than this prediction, winning their highest share of the vote since 1983 and coming to hold 317 seats to the Labour Party’s 262.

This left them only 55 seats ahead of their historic rival: a gap only very slightly wider than the 48-seat lead that they had after the 2010 general election, when David Cameron defeated the supposedly very unpopular Gordon Brown. The 2017 result would have been impossible without the activists who have stuck with the Labour Party regardless of their feelings about the leader, some of whom are now publicly expressing shame at the part they played in what is widely seen as Corbyn’s triumph.

Does the Labour Party’s unexpectedly narrow defeat refute the diagnosis of Corbynism as a middle class politics that alienates the party’s traditionally working class base, but doesn’t really care? Constituency-by-constituency analysis of the 2017 results by Paula Surridge, of the University of Bristol, suggests that it does not.

The Leave vote

We should perhaps begin with a pattern that was already apparent on election night. Parts of the country that voted strongly to quit the European Union appeared to show a swing away from Labour towards the Conservative Party, while areas that voted strongly for Remain appeared to show a swing in the opposite direction.* 

Surridge’s analysis confirms that this was indeed a trend: the higher the estimated Leave vote, the more the Labour vote share fell between 2010 and 2017, and the more the Conservative vote share rose during the same period. Blue dots represent actual constituencies; the red line represents the trend.

On the face of it, this is baffling. Both the Labour Party and the Conservative Party are officially committed to leaving the EU, and Jeremy Corbyn famously used a three-line whip to force his MPs to support the Tory Brexit bill in February.

The anti-Brexit parties were the Liberal Democrats, the Scottish National Party, and the Greens. There was therefore no sense in which a vote for Labour could have been a vote against leaving the EU. Why, then, should a constituency’s support or opposition to Brexit have made any difference?

This brings us to the paradox that the Labour MP John Mann has called the ‘Bolsover question’: why the second-largest Labour-to-Conservative swing in the country should have occurred in the constituency of Dennis Skinner.

Skinner is not only – as Mann observed – one of Jeremy Corbyn’s staunchest supporters in the Commons, but also  – although Mann did not draw attention to this fact  – one of the Labour Party’s staunchest advocates of Brexit. Why should a constituency that voted for Brexit by 29,730 votes to 12,242 have swung so heavily against a strongly pro-Brexit candidate for a pro-Brexit party?

Here’s a thought: maybe constituencies swung away from Corbyn’s Labour Party for the same sorts of reasons that they voted Leave, and swung towards it for the same sorts of reasons that they voted Remain? Or to put it another way: what if Corbynism appeals to the kinds of people to whom EU membership seems advantageous, and repels the kinds of people to whom it seems an encumbrance, regardless of the fact that Corbyn – as a disciple of Tony Benn  – is resolutely anti-EU?

Let’s take a look at some of the other things that Surridge found.

Educational level

Exit polling after last year’s EU referendum found that the more educated a person was, the more likely they were to have voted Remain. While some Remainers might like to dismiss this as ignorance on the part of Leavers, it can also be interpreted as an expression of anger at being left behind in Britain’s ever-more highly globalised economy.

So we should take note of Surridge’s finding that the higher the percentage of university degree holders in a constituency, the more it would tend to swing towards Labour from 2010 to 2017, and the lower the percentage of degree holders, the more it would tend to swing towards the Conservatives.

Ethnicity

While a bare majority of white voters opted for Leave last year, large majorities of black and Asian voters chose Remain. The reasons for this are complex – but it is notable that Surridge finds that the lower the percentage of white British voters in a constituency, the more it would tend to swing towards Labour, and the higher the percentage of white British voters, the more it would tend to swing towards the Conservatives.

While it is certainly good news for Labour that it is winning votes in more diverse communities, it should think carefully about why this is not happening in less ethnically diverse parts of the country – particularly as these are often economically struggling areas unattractive to immigrants.

Class

Now the biggest question of all. The Labour Party was set up to provide parliamentary representation for working class people, and the far left trumpeted Corbyn’s leadership as a triumph for "working class politics". But opinion polls showed something very different: under Corbyn, working class support for Labour rapidly fell to its lowest point ever.

Moreover, by-election results in the strongly working class constituencies of Stoke-on-Trent Central and Copeland showed swings from Labour to the Conservatives, as indeed they had during the Labour Party’s last flirtation with Bennism in 1983. Did the general election see working class voters change their minds and flock back to Corbyn’s "socialist" party?

My goodness. Surridge’s analysis shows that the more working class voters there are in a constituency, the more it tended to swing Conservative, and the fewer there are, the more it tended to swing Labour. To put some figures on that, she found that for every 10 per cent more working class voters in a constituency, there tended to have been a fall of about 3 per cent in the Labour vote and a rise of about 5 per cent in the Tory vote between 2010 and 2017.

Think about that for a moment. This is Corbyn bringing the party back to its "working class, socialist roots"?

Correlations, 2010-2017 and 2015-2017

I sense an objection: these figures show the swing from 2010 to 2017, and Corbyn’s only been in charge since 2015. Maybe it’s all Ed Miliband’s fault?

Apparently not. Surridge calculated the correlations between all the above variables and the change in the Conservative and Labour vote, both for the period of 2010-2017, and for the period of 2015-2017. And here they are:

While it is true that many correlations are weaker for the period 2015-2017 than for 2010-2017, the positive correlations remain positive and the negative correlations remain negative.

In other words, working class voters, voters not educated to college level, and voters in ethnically homogeneous areas love Corbyn’s Labour Party even less than they loved Miliband’s. Meanwhile middle class voters, those educated to college level or higher, and voters in ethnically diverse areas love it even more.

It should also be noted that the positive correlation between the percentage of working class voters and the change in the Conservative vote, and the negative correlation between the percentage of voters with degrees and the change in the Conservative vote, are both stronger for the period 2015-2017 than they are for 2010-2017, indicating a rapid growth of support for the Conservative Party among the very social groups that Labour traditionally represented.

This should worry Labour politicians with ambitions to be in government, because there is simply no way that a Labour leader can become prime minister without persuading Conservative voters in Tory seats to switch to Labour. Corbyn may have put together an unexpectedly large anti-Tory coalition of voters, but it’s largely concentrated in areas that already vote Labour – and traditional Labour voters are being driven faster than ever into the Tories’ arms.

The triumph of the "socialism fan"

In recent decades, Labour has become the party of anti-racism. It can be proud of the fact that its vote share has risen in ethnically diverse constituencies – although it seems to me that the racism many Labour supporters (and in some cases, activists and even politicians) have shown towards the Jewish community ought to be treated with rather more alarm than it apparently is.

But whatever the positives in this mixed achievement, it should be hard indeed for the party to find cause for celebration in the fact that the Conservatives are so rapidly becoming the party of the "left behind".

In the post-New Labour era – and even more so under Corbyn than under Miliband – Labour has become a party of highly educated middle class people, "socialism fans" especially. I said it before the election, and it remains the case today.

Indeed, the Labour leadership’s understanding of this point seems the most likely explanation for their manifesto pledge to end student fees (a policy that would benefit only higher-earning graduates, since people who do not go to university do not incur student fees, and people who do but end up in lower-paying jobs don’t have to repay their loans) while maintaining the Conservative "benefit cap", which negatively affects low earners, disabled people and the unemployed.

To what extent Labour’s new middle class voters will continue to back the party in the future seems unclear. After all, Corbyn can’t really do anything about their student fees, since he is not prime minister, and while he could do something about Brexit (since Labour, the anti-Brexit parties, and pro-EU Tories such as Ken Clarke now collectively hold a majority of seats in the Commons), he’s promised not to (good Bennite that he is).

Then again, he might publicly change his lifelong position on Europe just as he has publicly changed his lifelong positions on terrorism, nuclear weapons and Nato. He wouldn’t be the first leader to decide that Paris was worth a mass.

Fair play to him, though. In losing the election by only slightly more seats than Gordon Brown, he won the anticipated leadership contest in advance. So if the working class asks for its Labour Party back, he can confidently tell it to get lost.


* Canterbury is a notable exception here, having narrowly voted Leave in 2016 but swung to Labour in 2017. A very small city with two well-known universities, it hosts a very big student population during term time (when the general election took place), a large proportion of whom would typically have been expected to be resident elsewhere during the holidays when the EU referendum took place.

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