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NHS is heading for the "perfect storm"

Hamish Meldrum, head of the BMA, says Andrew Lansley is forcing unworkable, unprecedented “efficienc

The tall, slim career GP with a clipped grey beard and smoothly parted hair who greets me in his spacious offices scarcely resembles the union baron of popular imagination. He is urbane rather than confrontational, he speaks in measured sentences and seeks to emolliate not agitate. But Dr Hamish Meldrum, who spent much of his career at a medical practice in East Yorkshire and is now resident in Edinburgh, is the head of what has been called the most powerful union in Britain - the British Medical Association (BMA) - and his assessment of the coalition government's reform programme is devastating, all the more effective for being delivered with the calm of a doctor seeking to reassure a particularly anxious patient.

Meldrum knows that - unlike politicians and indeed journalists - doctors, his members, largely retain the respect and admiration of the public. He would agree with Nigel Lawson that "the NHS is the closest thing we have to a national religion in this country". And he knows that BMA members, denounced by many ideologues on the right as reactionary and unwilling to embrace necessary market reforms, are more powerful than any other interest group when they choose to mobilise against what they consider to be unnecessary and dogmatic interference by politicians.

Mission impossible

He is anxious that the principles of "universality" and "comprehensives", on which the NHS was founded, are imperilled by the fantasy of the Health and Social Care Bill and the creation of a utopian marketplace in which private providers compete with state care. "We are facing a perfect storm, or should that be an imperfect storm," Meldrum says as he sits perfectly still in a stiff-backed chair in his dimly lit office at the BMA's headquarters in Tavistock Square, central London. The "perfect storm", as he outlines it, is this - "impossible efficiency savings being forced on the service", the biggest reorganisation in the NHS's history, "rising medical unemployment", "pay cuts for doctors", "increased waiting lists" and the fear that the strain on the service will lead to more disasters such as the one at Mid Staffordshire NHS Trust.

“The health-care system is being asked to make £20bn of efficiency savings," he says gravely. "In real terms that's savings of 4 per cent year on year, which has never been done in one year before, far less four years in a row. And you've now added into the mix a major structural reorganisation, with lots of people either losing or changing their jobs; or their minds being focused on the reorganisation rather than on making the savings. We are facing various levels of impossibility."

He says even Andrew Lansley has conceded that "the substance of what he wanted to do could have been done without legislation. But in choosing to have legislation, and such permissive legislation - this was to be the legislation to end all legislation - he set a huge number of hares running, some intentionally, some unintentionally, and those who were most against his reforms were given a field day . . . They were able to say that he wanted a market red in tooth and claw, to let competition run rife, to bring private providers in from all over the place . . . ."

Should the Health Secretary resign or be reshuffled out of the cabinet? Even Lansley's supporters believe that he could have been smarter, more pragmatic. His "big bang" reorganisation need not have been so permissive; he could have acted as Michael Gove has done with education. After all, the free schools and academies reform programme is merely a continuation of what was started under New Labour: evolution rather than revolution, with Gove recast as a more zealous (and Scottish) version of Andrew Adonis.

“The policies have to change," says Meldrum of the hapless Lansley, self-styled all-knowing impresario of NHS politics. "Even if the only way the policies change means the current incumbent goes - they have to change."

The good doctor continues: "The Lansley reforms are a folly in terms of health-care issues but politically they are a huge folly as well . . . Leaving aside the reforms, because of the present economic and budgetary pressures, there's no doubt by the time of the next election, if not before, there will be increased waiting lists, [for which] everybody will blame the reforms."

Fewer young people are applying to study medicine at university, perhaps because of the introduction of higher tuition fees. "Will it lead to a shortage?" Meldrum asks. "We are educating and training more doctors than we used to, but can we afford to employ them? In the UK we have below-average numbers of doctors per head of population compared to Germany, France and others. On average every GP looks after about 2,000 patients. As people live longer, have more complex and long-term conditions . . . I think that ratio is wrong. Do we need more doctors? Yes. Can we afford more? Much more difficult."

Overworked, understaffed

Meldrum worries about the "potential for medical unemployment. In the past, we have scandalously relied on doctors from overseas, often from countries that can least afford to give them to us, to back up the gaps . . . We are already seeing [the impact of not having enough doctors] - consultants taking on more of the work that junior doctors used to do; that in some places the time available for continuing education and continued training is being limited and that can only be bad, not only for doctors but for patients.

“Also you get trusts that try to stretch rotas or stretch the staffing of wards too thinly - well, then accidents will happen and people will fall through the gaps and you may see the sort of things that happened in Mid Staffs, where part of the problem was the failure to attract enough doctors and nurses to cope with the work that was being asked of them."

What is most worrying for Meldrum and the medical profession he represents is that the Lansley reforms have made it much easier for opponents of the NHS to say that "it's the system that's bust rather than the funding of it, [and we will] see increasing pressure for co-payment or top-up payments, for limiting the scope and comprehensiveness of the health care provided by the NHS, and . . . it will be done on the wrong premise".

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 23 January 2012 issue of the New Statesman, Has the Arab Spring been hijacked?

Photo: Getty Images
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What's to be done about racial inequality?

David Cameron's words on equal opportunities are to be welcomed - now for some action, says Sunder Katwala.

David Cameron made the strongest, clearest and most high profile statement about ethnic inequalities and the need to tackle discrimination ever yet offered by a British Prime Minister in his leader’s speech to the Conservative Party conference in Manchester.
“Picture this. You’ve graduated with a good degree. You send out your CV far and wide. But you get rejection after rejection. What’s wrong? It’s not the qualifications or the previous experience. It’s just two words at the top: first name, surname. Do you know that in our country today: even if they have exactly the same qualifications, people with white-sounding names are nearly twice as likely to get call backs for jobs than people with ethnic-sounding names? … That, in 21st century Britain, is disgraceful. We can talk all we want about opportunity, but it’s meaningless unless people are really judged equally”, said Cameron.
While the proof of the pudding will be in the eating, this was a powerfully argued Prime Ministerial intervention – and a particularly well-timed one, for three reasons.

Firstly, the Prime Minister was able to root his case in an all-but-universally accepted appeal for equal opportunities. It will always prove more difficult in practice to put political energy and resources behind efforts to remedy discrimination against a minority of the population unless a convincing fairness case is made that values cherished across our whole society are at stake. Cameron’s argument, that any party which tells itself that it is the party of the ‘fair chance’ and ‘the equal shot’ must have a response when there is such clear evidence of discrimination, should prove persuasive to a Conservative Party that has not seen race inequalities as its natural territory. Cameron argued that the same principles should animate responses to discrimination when it comes to race, gender and social class. Put like that, wanting job interviews to be fair – by eradicating conscious and unconscious patterns of bias wherever possible – would strike most Britons as offering as clear a case of the values of fair play as wanting the best baker to win the Great British Bake-Off on television.
Secondly, Cameron’s intervention comes at a potential "tipping point" moment for fair opportunities across ethnic groups. Traditionally, ethnic discrimination has been discussed primarily through the lens of its impact on the most marginalised. Certainly, persistent gaps in the criminal justice system, mental health provision and unemployment rates remain stark for some minority groups. What has been less noticed is the emergence of a much more complex pattern of opportunity and disadvantage – not least as a consequence of significant ethnic minority progress.

Most strikingly of all, in educational outcomes, historic attainment gaps between ethnic minorities and their white British peers have disappeared over the last decade. In the aggregate, ethnic minorities get better GCSE results on average. Ethnic minority Britons are more likely, not less likely, to be university graduates than their fellow citizens. 

As a result of that progress, Cameron’s intervention comes at a moment of significant potential – but significant risk too. Britain’s ethnic minorities are the youngest and fastest-growing sections of British society. If that educational progress translates into economic success, it will make a significant contribution to the "Great British Take-Off" that the Prime Minister envisions. But if that does not happen, with educational convergence combined with current ‘ethnic penalties’ in employment and income persisting, then that potential could well curdle into frustration that the British promise of equal opportunities is not being kept.  Cameron also mirrored his own language in committing himself to both a ‘fight against extremism’ and a ‘fight against discrimination’: while those are distinct challenges and causes, actively pursuing both tracks simultaneously has the potential, at least, depolarise some debates about responses to extremism  - and so to help deepen the broad social coalitions we need for a more cohesive society too.

Thirdly, Cameron’s challenge could mark an important deepening in the political competition between the major parties on race issues. Many have been struck by the increase in political attention on the centre-right to race issues over the last five to ten years. The focus has been on the politics of representation. By increasing the number of non-white Conservative MPs from two to seventeen since 2005, Cameron has sent a powerful signal that Labour’s traditional claim to be ‘the party of ethnic minorities’ would now be contested. Cameron was again able to celebrate in Manchester several ways in which his Cabinet and Parliamentary benches demonstrate many successful journeys of migrant and minority integration in British society. That might perhaps help to ease the fears, about integration being impossible in an era of higher immigration, which the Home Secretary had articulated the previous day.

So symbolism can matter. But facial diversity is not enough. The politics of ethnic minority opportunity needs to be about more than visits to gurdwaras, diversity nights at the party conference fringes and unveiling statues of Mahatma Gandhi in Parliament Square. Jeremy Corbyn’s first speech as Labour leader did include one brief celebratory reference to Britain’s ethnic diversity – “as I travelled the country during the leadership campaign it was wonderful to see the diversity of all the people in our country” – and to Labour bringing in more black, Asian and ethnic minority members - but it did not include any substantial content on discrimination. Tim Farron acknowledged during his leadership campaign that the Liberal Democrats have struggled to get to the starting-line on race and diversity at all. The opposition parties too will no doubt now be challenged to match not just the Prime Minister’s rhetorical commitment to challenging inequalities but also to propose how it could be done in practice.

Non-white Britons expect substance, not just symbolism from all of the parties on race inequalites.  Survation’s large survey of ethnic minority voters for British Future showed the Conservatives winning more ethnic minority support than ever before – but just 29 per cent of non-white respondents were confident that the Conservatives are committed to treating people of every ethnic background equally, while 54 per cent said this of Labour. Respondents were twice as likely to say that the Conservatives needto do more to reach out – and the Prime Minister would seem to be committed to showing that he has got that message.  Moreover, there is evidence that ethnic inclusion could be important in broadening a party’s appeal to other younger, urban and more liberal white voters too – which is why it made sense for this issue to form part of a broader attempt by David Cameron to colonise the broad centre of British politics in his Manchester speech.

But the case for caution is that there has been limited policy attention to ethnic inequalities under the last two governments. Restaurateur Iqbal Wahhab decided to give up his role chairing an ethnic minority taskforce for successive governments, unconvinced there was a political commitment to do much more than convene a talking shop. Lib Dem equalities minister Lynne Featherstone did push the CV discrimination issue – but many Conservatives were sceptical. Cameron’s new commitment may face similar challenges from those whose instinct is to worry that more attention to discrimination or bias in the jobs market will mean more red tape for business.

Labour had a separate race inequalities manifesto in 2015, outside of its main election manifesto, while the Conservative manifesto did not contain significant commitments to racial inequality. The mid-campaign launch in Croydon of a series of race equality pledges showed an increasing awareness of the growing importance of ethnic minority votes - though the fact that they all involved aiming for increases of 20 per cent by 2020 gave them a slightly back-of-the-envelope feel. 

Prime Ministerial commitments have an important agenda-setting function. A generation ago the Stephen Lawrence case opened the eyes of middle England to racist violence and police failures, particularly through the Daily Mail’s persistent challenging of those injustices. A Conservative Prime Minister’s words could similarly make a big difference in the mainstreaming of the issue of inequalities of opportunity. What action should follow words? Between now and next year’s party conference season, that must will now be the test for this Conservative government – and for their political opponents too. 

Sunder Katwala is director of British Future and former general secretary of the Fabian Society.