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 strange death of boozy Britain: why are young people drinking less?

Ditching alcohol for work.

Whenever horrific tales of the drunken escapades of the youth are reported, one photo reliably gets wheeled out: "bench girl", a young woman lying passed out on a public bench above bottles of booze in Bristol. The image is in urgent need of updating: it is now a decade old. Britain has spent that time moving away from booze.

Individual alcohol consumption in Britain has declined sharply. In 2013, the average person over 15 consumed 9.4 litres of alcohol, 19 per cent less than 2004. As with drugs, the decline in use among the young is particularly notable: the proportion of young adults who are teetotal increased by 40 per cent between 2005 and 2013. But decreased drinking is not only apparent among the young fogeys: 80 per cent of adults are making some effort to drink less, according to a new study by consumer trends agency Future Foundation. No wonder that half of all nightclubs have closed in the last decade. Pubs are also closing down: there are 13 per cent fewer pubs in the UK than in 2002. 

People are too busy vying to get ahead at work to indulge in drinking. A combination of the recession, globalisation and technology has combined to make the work of work more competitive than ever: bad news for alcohol companies. “The cost-benefit analysis for people of going out and getting hammered starts to go out of favour,” says Will Seymour of Future Foundation.

Vincent Dignan is the founder of Magnific, a company that helps tech start-ups. He identifies ditching regular boozing as a turning point in his career. “I noticed a trend of other entrepreneurs drinking three, four or five times a week at different events, while their companies went nowhere,” he says. “I realised I couldn't be just another British guy getting pissed and being mildly hungover while trying to scale a website to a million visitors a month. I feel I have a very slight edge on everyone else. While they're sleeping in, I'm working.” Dignan now only drinks occasionally; he went three months without having a drop of alcohol earlier in the year.

But the decline in booze consumption isn’t only about people becoming more work-driven. There have never been more alternate ways to be entertained than resorting to the bottle. The rise of digital TV, BBC iPlayer and Netflix means most people means that most people have almost limitless about what to watch.

Some social lives have also partly migrated online. In many ways this is an unfortunate development, but one upshot has been to reduce alcohol intake. “You don’t need to drink to hang out online,” says Dr James Nicholls, the author of The Politics of Alcohol who now works for Alcohol Concern. 

The sheer cost of boozing also puts people off. Although minimum pricing on booze has not been introduced, a series of taxes have made alcohol more expensive, while a ban on below-cost selling was introduced last year. Across the 28 countries of the EU, only Ireland has higher alcohol and tobacco prices than the UK today; in 1998 prices in the UK were only the fourth most expensive in the EU.

Immigration has also contributed to weaning Britain off booze. The decrease in alcohol consumption “is linked partly to demographic trends: the fall is largest in areas with greater ethnic diversity,” Nicholls says. A third of adults in London, where 37 per cent of the population is foreign born, do not drink alcohol at all, easily the highest of any region in Britain.

The alcohol industry is nothing if not resilient. “By lobbying for lower duty rates, ramping up their marketing and developing new products the big producers are doing their best to make sure the last ten years turn out to be a blip rather than a long term change in culture,” Nicholls says.

But whatever alcohol companies do to fight back against the declining popularity of booze, deep changes in British culture have made booze less attractive. Forget the horrific tales of drunken escapades from Magaluf to the Bullingdon Club. The real story is of the strange death of boozy Britain. 

Tim Wigmore is a contributing writer to the New Statesman and the author of Second XI: Cricket In Its Outposts.

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What Jeremy Corbyn can learn from Orwell

Corbyn’s ideas may echo George Orwell’s – but they’d need Orwell’s Britain to work. It’s time Corbyn accepted the British as they are today.

All Labour Party leaderships since 1900 have offered themselves as “new”, but Tony Blair’s succession in 1994 triggered a break with the past so ruthless that the Labour leadership virtually declared war on the party. Now it is party members’ turn and they, for now at any rate, think that real Labour is Jeremy.

To Keir Hardie, real Labour had been a trade union lobby expounding Fellowship. To the Webbs, real Labour was “common ownership” by the best means available. Sidney’s Clause Four (adopted 1918) left open what that might be. In the 1920s, the Christian Socialist R H Tawney stitched Equality into the banner, but during the Depression young intellectuals such as Evan Durbin and Hugh Gaitskell designated Planning as Labour’s modern mission. After the Second World War, Clement Attlee followed the miners (and the London Passenger Transport Board) into Nationalisation. Harold Wilson tried to inject Science and Technology into the mix but everything after that was an attempt to move Labour away from state-regulated markets and in the direction of market-regulated states.

What made the recent leadership contest so alarming was how broken was the intellectual tradition. None of the candidates made anything of a long history of thinking about the relationship between socialism and what the people want. Yvette Cooper wanted to go over the numbers; only they were the wrong numbers. Andy Burnham twisted and turned. Liz Kendall based her bid on two words: “Have me.” Only Jeremy Corbyn seemed to have any kind of Labour narrative to tell and, of course, ever the ­rebel, he was not responsible for any of it. His conference address in Brighton was little more than the notes of a street-corner campaigner to a small crowd.

Given the paucity of thinking, and this being an English party for now, it is only a matter of time before George Orwell is brought in to see how Jeremy measures up. In fact, it’s happened already. Rafael Behr in the Guardian and Nick Cohen in the Spectator both see him as the kind of hard-left intellectual Orwell dreaded, while Charles Cooke in the National Review and Jason Cowley in the New Statesman joined unlikely fashion forces to take a side-look at Jeremy’s dreadful dress sense – to Orwell, a sure sign of a socialist. Cooke thought he looked like a “burned-out geography teacher at a third-rate comprehensive”. Cowley thought he looked like a red-brick university sociology lecturer circa 1978. Fair enough. He does. But there is more. Being a middle-class teetotal vegetarian bicycling socialistic feministic atheistic metropolitan anti-racist republican nice guy, with allotment and “squashily pacifist” leanings to match, clearly puts him in the land of the cranks as described by Orwell in The Road to Wigan Pier (1937) – one of “that dreary tribe of high-minded women and sandal-wearers and bearded fruit-juice drinkers who come flocking towards the smell of ‘progress’ like bluebottles to a dead cat”. And though Corbyn, as “a fully fledged, fully bearded, unabashed socialist” (Huffington Post), might make all true Orwellians twitch, he really made their day when he refused to sing the National Anthem. Orwell cited precisely that (see “The Lion and the Unicorn”, 1941) as an example of the distance between left-wing intellectuals and the people. It seemed that, by standing there, mouth shut, Comrade Corbyn didn’t just cut his wrists, he lay down full length in the coffin and pulled the lid shut.


Trouble is, this line of attack not only misrepresents the Labour leader, it misrepresents Orwell. For the great man was not as unflinchingly straight and true as some people think. It is impossible, for instance, to think of Orwell singing “God Save the King”, because he, too, was one of that “dreary tribe” of London lefties, and even when he joined Labour he remained ever the rebel. As for Corbyn, for a start, he is not badly dressed. He just doesn’t look like Chuka or Tristram. He may look like a threadbare schoolteacher, but Orwell was one twice over. Orwell was never a vegetarian or a teetotaller, but, like Corbyn, neither was he interested in fancy food (or drink), he kept an allotment, drove a motorbike, bicycled, cared about the poor, cared about the environment, loathed the empire, came close to pacifism at one point, and opposed war with Germany well past the time when it was reasonable to do so.

In Orwell’s thinking about socialism, for too long his main reference point was the London Marxist left. Not only did he make speeches in favour of revolutions, he took part in one with a gun in his hand. Orwell was far more interested, as Corbyn has been far more interested, in speaking truth to power than in holding office. His loyalty was to the movement, or at least the idea of the movement, not to MPs or the front bench, which he rarely mentioned. There is nothing in Corbyn’s position that would have shocked Orwell and, should they have met, there’d have been much to talk about: belief in public ownership and non-economic values, confidence in the state’s ability to make life better, progressive taxation, national health, state education, social care, anti-socially useless banking, anti-colonialism and a whole lot of other anti-isms besides. It’s hard to be sure what Orwell’s position would have been on Trident and immigration. Not Corbyn’s, I suspect. He was not as alert to feminism as he might have been but equally, few men try to write novels from a woman’s point of view and all Orwellians recognise that Julia is the dark hero of Nineteen Eighty-Four. In truth they are both austere types, not in it for themselves and not on anyone else’s expense account either. Corbyn won the leadership because this shone through from the very beginning. He came across as unaffected and straightforward – much as Orwell tried to be in his writing.

Except, as powerfully expressed in these pages by John Gray, Corbyn’s politics were made for another world. What sort of world would he need? First off, he’d need a regulated labour market: regulated by the state in partnership with a labour movement sensitive to what people wanted and experienced in trying to provide it. He would also need capital controls, a manufacturing base capable of building the new investment with Keynesian payback, an efficient and motivated Inland Revenue, a widespread public-service ethos that sees the country as an asset, not a market, and an overwhelming democratic mandate to get things done. In other words, Corbyn needs Orwell’s Britain – not this one – and at the very least, if he can’t have that, he needs the freedom to act that the European Commission forbids.

There’s another problem. Orwell did not trust left-wing intellectuals and spent half his life trying to work out their motivations as a class who spoke for the people, went in search of the people, and praised the people, but did not know them or believe in them. True, Corbyn says he wants to be open and inclusive, but we know he can’t possibly mean it when he says it will be the party, not him or the PLP, that will decide policy, just as we knew it couldn’t possibly be true when he said he’d turn PMQs into the People’s Question Time. Jeremy hasn’t changed his mind in forty years, appears to have great difficulty (unlike Tony Benn) in fusing socialism to national identity or experience (Hardie, Ben Okri and Maya Angelou were bolted on to his Brighton speech) and seems to think that not being happy with what you are given somehow captures the historic essence of socialism (rather than its opposite).

Granted, not thinking outside the ­circle is an inherent fault of the sectarian left but some of our most prominent left-wing journalists have it, too. Working-class support for nationalisation? Good. Right answer! Working-class opposition to benefit scroungers and further mass immigration? Bad. Wrong answer! Would you like to try again? In his essay “In Defence of Comrade Zilliacus” (1947) Orwell reckoned that left-wing intellectuals saw only what they wanted to see. For all their talk of representing the people, they hated the masses. “What they are frightened of is the prevailing opinion within their own group . . . there is always an orthodoxy, a parrot-cry . . .”

The game is hard and he may go down in a welter of knives, yet Corbyn still has time. He may go on making the same speech – on the benefits of apple pie to apple growers – but at some point he will have to drop the wish-list and get on the side of the British people as they are, and live with that, and build into it. Only the nation state can even begin to do the things he wants to do. The quicker he gets that, the quicker we can see if the latest incarnation of new Labour has a future.

Robert Colls is the author of “George Orwell: English Rebel” (Oxford University Press)

This article first appeared in the 08 October 2015 issue of the New Statesman, Putin vs Isis