Wanted: a new bedside manner

After years of the wrong reforms, the NHS needs democratising and popularising. The left must win th

The government has gone at least two weeks without a disaster. If the froth is settling, what is the actual story as the election is pushed on to the back burner? The purpose of any centre-left government is to use the state to ensure that accidents of birth do not blight people's lives. The brute luck of not being born rich, bright or healthy demands social action to ensure that all have the resources and opportunity to make the most of their lives.

This is why public services matter and why the goal of new Labour was to renew them, in particular the National Health Service. When he got the top job, Gordon Brown said health was his priority but education was his passion. The NHS needs to be both. After years of Tory neglect, Labour pledged to treat it with equal measures of investment and reform. A decade on, however, the attempt to reinvent a role for the state is clearly running out of steam. The issue is not yet the money, but the wrong reforms. Never has so much been spent creating so much disillusionment among staff and public alike.

In his New Year message Brown said he would make the right long-term decisions. He refloated the idea of a written constitution for the NHS, setting out the rights and responsibilities of staff, patients and all stakeholders. This portrays it as a depoliticised, "what works" organisation and speaks of an underlying loss of direction. Meanwhile, Lord Darzi, the health minister with the task of rethinking the future of the service, gave an interview calling for it to be more like Tesco. Surely he knows the NHS cannot work like a supermarket, providing choice through excess supply thrown away each night?

While ministers want the NHS to be more like a market, the government still operates it like a machine, with all the unintended risk of failure. News that accident and emergency departments are wasting £2bn hastily putting patients into beds and discharging them the next day, so that they don't miss their four-hour waiting target, exposes a system of Stalinist dysfunctionality.

Diversity and equity

If Brown wants to use the gap before the next election to put the NHS on a sound footing he must start by understanding it as a political entity. It is a social democratic bubble in a capitalist society, a place where we feel free from commercial pressures but that can't avoid being contaminated by market forces and values surrounding it. It is perhaps the key battleground in the ongoing struggle between society and the market.

The market has long eyed the NHS and its huge budgets and limitless demand as a cash cow. Without sufficient regulatory and moral barriers, the market will cherry-pick patients and services that return the highest margins. Yet new Labour refuses to recognise any contradictions between the needs of society and the demands of the market. Everything is opened up to the market, which is deemed the most efficient way of allocating resources.

In awe of the likes of Tesco, new Labour has created the supermarket state - but one run by a politburo. By combining US free markets with Soviet-style planning, we leave ourselves with the worst of all worlds: a mix of machines and markets that are unaccoun table, unjust and inefficient.

If machines and markets are the wrong reform models, what should the centre left advocate? We must embrace reform because the world has changed. The NHS of 1948 is no longer fit for purpose: the world of deference has given way to a world of autonomy in which people rightly want a say in shaping institutions such as the NHS.

But there lies the problem. The centre left wants equity (its core value), but must embrace diversity (the modern setting) to ensure both innovation and responsive delivery. Yet diversity leads to difference, not equity. This creates a paradox that cannot be solved, only managed. But how?

Instead of wave after wave of reform, bouncing from concerns about equity to diversity and back again, the people who experience the paradox - the staff and users - should be directly engaged in deciding the shifting relationship between how much equity and how much diversity. They must live and manage the paradox. This is the argument for democratisation of the NHS and other crucial public services.

Democracy has two distinct benefits. On instrumental grounds, opening up the design of services to staff and users would transform the productivity and efficiency of the NHS. It is the people at the sharp end of providing and receiving care who know best how to deliver it and what they want. Reform then becomes organic and truly adaptable, and not forced through a rigid machine or unjust markets.

There is an equally important intrinsic benefit of democracy. Through our collective voice, we demonstrate the common ownership of the NHS as a site of social citizenship, which we value not just because it makes us well, but because it makes us more equal and puts us in control of our world. Democracy is the means and ends of the good society.

So, at every level, the reform programme of the government should be democratisation. General practices could be revolutionised through collective patient power, primary care trusts scrutinised by local authorities, and health boards elected at the regional level. Spreading the notion that services are best co-produced by staff and patients would lead to a quantum leap in personalisation and performance.

The process of democratisation would allow the NHS to be remoralised rather than demoralised. It is crucial that we place this moral safety net under the NHS. As the economy takes a turn for the worse and public spending declines, the service needs a moral underpinning. Competence is never enough. This was Labour's failure over the Winter of Discontent in 1979, which opened the door to Thatcherism.

I have written about all this in a pamphlet, to be published on 10 January by Compass, called Machines, Markets and Morals: the New Politics of a Democratic NHS. Just before the Christmas break, I asked Alan Johnson to debate the pamphlet. The Health Secretary's office declined, not because he was busy or disagreed with all of it, but because some of it was "off-message". Now Johnson is a capable politician whom I like a lot, but surely he can see the irony of refusing to discuss the democratisation of the NHS because we don't agree on every dot and comma. I know he can do better than that.

He must - because democracy offers a permanent settlement for the NHS. Not sclerosis, but a way of dealing with the paradox of equity and diversity as we search for a politics that is both modern and left, new and Labour.

If Labour cannot popularise the National Health Service as an institution that embodies the values of the left, the notion of solidarity will come under threat of extinction in an increasingly individualised and consumerised world. After all, we should all be equal in our pyjamas.

Neal Lawson is chair of Compass. His pamphlet on the future of the National Health Service is available by emailing: info@compassonline.org.uk

Martin Bright returns next week

Neal Lawson is chair of the pressure group Compass, which brings together progressives from all parties and none. His views on internal Labour matters are personal ones. 

This article first appeared in the 07 January 2008 issue of the New Statesman, Pakistan plot

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Paul Mason: How the left should respond to Brexit

It's up to the labour movement to rescue the elite from the self-inflected wound of Brexit.

For the first time in a generation there is a tangible split between the Tory leadership and the business elite. Forget the 41 per cent poll rating, forget Theresa May’s claim to have moved towards “the centre”; the most important thing to emerge since the Tory conference is a deep revulsion, among wide sections of normally Conservative voters, at the xenophobia, nationalism and economic recklessness on display.

Rhetorically, May has achieved a lot. She quashed any possibility of a soft Brexit strategy. She ended 30 years of openness to migration. She scrapped the Tories’ commitment to balanced books by 2020 – though she neglected to replace this keystone policy with anything else. And she pledged to stop constitutional scrutiny over the Brexit process from Holyrood, Westminster or the courts.

Yet in reality she achieved nothing. May’s government is not in control of the crucial process that will define its fate – the Brexit negotiations. And on Scotland, she has triggered a sequence of events that could lead to the end of the UK within the next five years.

In the light of this, the left has to be refocused around the facts that have emerged since the referendum on 23 June. Britain will leave the EU – but it faces a choice between May’s hubristic nonsense and a strategy to salvage 30 years of engagement with the biggest market in the world. Scotland will hold its second referendum. Labour will be led through all this by a man who, for the first time in the party’s history, cannot be relied on to do the elite’s bidding.

Brexit, on its own, need not have caused a great shift in British politics. It is the new, visceral split between Tory xenophobia and the implicitly liberal and globalist culture in most boardrooms that makes this a turning point. It is a challenge for the left as big as the ones Labour faced in 1931, when the gold standard collapsed; or in 1940, when the reality of total war dawned. It represents a big opportunity – but only if we jolt our brains out of the old patterns, think beyond party allegiances, and react fast.

Let’s start with the facts around which May, Philip Hammond and Amber Rudd constructed their rhetorical body swerve at the Tory conference. Britain is £1.7trn in debt. Its budget deficit cannot be eradicated by 2020 because, even on the steroids of quantitative easing, growth is low, wages are stagnant and its trade situation deeply negative. Austerity, in short, did not work.

With sterling weakened, by next year we’ll begin to feel the pressure of imported inflation on real wages, re-creating the economic pain of 2011-12. On top of that, by attempting a “hard Brexit”, May has created damaging uncertainty for investment that no degree of short-term positivity can mitigate. Even if the range of outcomes only widens, investment will get delayed – and with May’s commitment to hard Brexit the range of outcomes will get significantly worse: 7.5 per cent lopped off GDP, according to a leaked Treasury assessment.

Civil servants believe Britain’s negotiating position is so weak that it will have to leverage its intelligence-providing services to Europe and concede “free movement of high-skilled workers”, just to persuade the French and the Germans to cut any kind of decent bilateral deal. Yet in the two years of brinkmanship that begin when Article 50 is triggered, the EU27 will have no reason whatsoever to concede favourable terms for bilateral trade. By adopting hard Brexit and hard xenophobia, Theresa May has scheduled a 24-month slow-motion car crash.

To orient the Labour Party, trade unions and the wider progressive movement, we need first to understand the scale of the break from normality. Labour already faced deep problems. First, without Scotland it cannot govern; yet many of its members in Scotland are so dislocated from the progressive Scottish national movement that the party is bereft of answers.

Next, the old relationship between the urban salariat and the ex-industrial working class has inverted. With a vastly expanded membership, Labour is the de facto party of the urban salariat. Its heartland is Remainia – the cities that voted to stay in Europe. Its electoral battlegrounds are now places such as Bury, Nuneaton, Corby and Portsmouth, where the “centre” (as measured by the Lib Dem vote) has collapsed, to be replaced by thousands of Green voters and thousands more voting Ukip.

This was the known problem on the eve of Brexit, though layers of Labour MPs and councillors refused to understand it or respond to it. The solution to it was, even at that point, obvious: Labour can only attract back a million Green voters and hundreds of thousands of Ukip voters in winnable marginals with a combination of social liberalism and economic radicalism.

The alternative, as outlined in the Blue Labour project of Maurice Glasman and Jon Cruddas, was an overt return to social conservatism. That cannot work, because it might win back some ex-Labour Ukip voters but could not inspire Labour’s new urban core to go on the doorstep and fight for it. On the contrary, it could easily inspire many of them to tear up their membership cards.

A new strategy – to combine social liberalism, multiculturalism and environmentalism with left-wing economic policies aimed at reviving the “communities left behind” – was, for me, always the heart of Corbynism. Jeremy Corbyn himself, whatever his personal strengths and weaknesses, was a placeholder for a political strategy.

Brexit, the attempted Labour coup and the Tory swing to hard Brexit have changed things all over again. And Labour’s leadership needs to move fast into the political space that has opened up. The starting point is to understand May’s administration as a regime of crisis. It is held together by rhetoric and a vacuum of press scrutiny, exacerbated by Labour’s civil war and the SNP’s perennial dithering over strategy to achieve Scottish independence. The crisis consists of the perils of hard Brexit combined with a tangible split between the old party of capital and capital itself. The elite – the bankers, senior managers, the super-rich and the ­upper middle class – do not want Brexit. Nor does a significant proportion of Middle Britain’s managerial and investing classes.




All this presents Labour with a series of achievable goals – as an opposition in Westminster, in London, as the likely winner in many of the forthcoming mayoral battles, and at Holyrood. The first aim should be: not just oppose hard Brexit, but prevent it. This entails the Labour front bench committing to an attempt to remain inside the European Economic Area.

The wariness – shared by some on the Corbyn side, as well as the Labour right – is born of the assumption that if you commit to the single market, you must accept free movement of labour. The party’s new spokesman on Brexit, Keir Starmer, expressed perfectly what is wrong with this approach: first it’s a negotiation, not a finished relationship; second, you start from the economics, not the migration issue.

Leaving the single market will be a macroeconomic disaster, compounded by a social catastrophe, in which all the European protections – of citizens’ rights, labour rights, consumer and environmental standards – will get ripped up. That’s why the Labour front bench must commit to staying inside the single market, while seeking a deal on free movement that gives Britain time and space to restructure its labour market.

John McDonnell’s “red lines”, produced hurriedly in the days after Brexit, embody this principle – but not explicitly. McDonnell has said Labour would vote against any Brexit deal that did not involve some form of single-market access, and preserve the City’s passporting arrangement, where banks are authorised to trade across an entire area without having to be incorporated separately in each country. Freedom of movement is not included in the red lines.

May, meanwhile, insists there will be no parliamentary scrutiny of the negotiating stance, or of the outcome. This position cannot stand, and overthrowing it provides a big, early target for Labour and the other opposition parties. They should use their constitutional influence – not only in Westminster but at Holyrood, Cardiff and the mayor-run cities, to bust open the Conservatives’ secrecy operation.

By declaring – formally, in a written pact – that they will refuse to ratify a Brexit deal based on World Trade Organisation tariffs, the progressive parties can destroy May’s negotiating position in Brussels overnight. Let the Conservative press accuse us of being “citizens of the world”, undermining the national interest. They will dig their own political grave even faster.

In parallel, Labour needs to lead – intellectually, morally and practically – the fight for a coherent, pro-globalist form of Brexit. In order for this to embody the spirit of the referendum, it would have to include some repatriation of sovereignty, as well as a significant, temporary retreat from freedom of movement. That means – and my colleagues on the left need to accept this – that the British people, in effect, will have changed Labour’s position on immigration from below, by plebiscite.

In response, Labour needs to design a proposal that permits and encourages high beneficial migration, discourages and mitigates the impact of low-wage migration and – forgotten in the rush to “tinder box” rhetoric by the Blairites – puts refugees at the front of the queue, not the back. At its heart must be the assurance, already given to three million EU-born workers, that they will not be used as any kind of bargaining chip and their position here is inviolable.

Finally Labour needs to get real about Scotland. The recent loss of the council by-election in Garscadden, with a 20 per cent swing to the SNP, signals that the party risks losing Glasgow City Council next year.

It is a problem beyond Corbyn’s control: his key supporters inside Scottish Labour are long-standing and principled left-wing opponents of nationalism. Which would be fine if tens of thousands of left-wing social democrats were not enthused by a new, radical cultural narrative of national identity. Corbyn’s natural allies – the thousands of leftists who took part in the Radical Independence Campaign – are trapped outside the party, sitting inside the Scottish Greens, Rise or the left of the SNP.

The interim solution is for Scottish Labour to adopt the position argued by its deputy leader, Alex Rowley: embrace “home rule” – a rejigged devo-max proposal – and support a second independence referendum. Then throw open the doors to radical left-wing supporters of independence. If, for that to happen, there has to be a change of leadership (replacing Kezia Dugdale), then it’s better to do it before losing your last bastion in local government.

The speed with which Labour’s challenge has evolved is a signal that this is no ordinary situation. To understand how dangerous it would be to cling to the old logic, you have only to extrapolate the current polls into an electoral ground war plan. Sticking to the old rules, Labour HQ should – right now – be planning a defensive campaign to avoid losing 60 seats to May. Instead, it can and must lay a plan to promote her administration’s chaotic demise. It should have the ambition to govern – either on its own, or with the support of the SNP at Westminster.

To achieve this, it must confront the ultimate demon: Labour must show willing to make an alliance with the globalist section of the elite. Tony Blair’s equivocation about a return to politics, the constant noise about a new centrist party, and signs of a Lib Dem revival in local by-elections are all straws in the wind. If significant sections of the middle class decide they cannot live with Tory xenophobia, the liberal centre will revive.

The best thing for Labour to do now is to claim as much of the high ground before that. It must become the party of progressive Brexit. The worst thing would be to start worrying about “losing the traditional working class”.

The “traditional working class” knows all too well how virulent Ukip xenophobia is: Labour and trade union members spend hours at the pub and in the workplace and on the doorstep arguing against it.

All over Britain, the labour movement is a line, drawn through working-class communities, which says that migrants are not to blame for poor housing, education, low pay and dislocated communities. For the first time in a generation Labour has a leader prepared to say who is to blame: the neoliberal elite and their addiction to privatisation, austerity and low wages.

It was the elite’s insouciance over the negative impacts of EU migration on the lowest-skilled, together with their determination to suppress class politics inside Labour, that helped get us into this mess. An alliance with some of them, to achieve soft Brexit, democratic scrutiny and to defeat xenophobic solutions, must be conditional.

We, the labour movement, will dig the British ruling class out of a self-made hole, just as we did in May 1940. The price is: no return to the philosophy of poverty and inequality; a strategic new deal, one that puts state ownership, redistribution and social justice at the heart of post-Brexit consensus.

That is the way forward. If Labour politicians can bring themselves to explain it clearly, cajole the party apparatus out of its epic sulk and make a brave new offer to Scotland – it can work. But time is important. We are up against a corrosive nationalist bigotry that now echoes direct from the front page of the Daily Mail to Downing Street. Every day it goes unchallenged it will seep deeper into Britain’s political pores.

Paul Mason is the author of “PostCapitalism: a Guide to Our Future” (Penguin)

This article first appeared in the 13 October 2016 issue of the New Statesman, England’s revenge