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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The New Times: Brexit, globalisation, the crisis in Labour and the future of the left

With essays by David Miliband, Paul Mason, John Harris, Lisa Nandy, Vince Cable and more.

Once again the “new times” are associated with the ascendancy of the right. The financial crash of 2007-2008 – and the Great Recession and sovereign debt crises that were a consequence of it – were meant to have marked the end of an era of runaway “turbocapitalism”. It never came close to happening. The crash was a crisis of capitalism but not the crisis of capitalism. As Lenin observed, there is “no such thing as an absolutely hopeless situation” for capitalism, and so we discovered again. Instead, the greatest burden of the period of fiscal retrenchment that followed the crash was carried by the poorest in society, those most directly affected by austerity, and this in turn has contributed to a deepening distrust of elites and a wider crisis of governance.

Where are we now and in which direction are we heading?

Some of the contributors to this special issue believe that we have reached the end of the “neoliberal” era. I am more sceptical. In any event, the end of neoliberalism, however you define it, will not lead to a social-democratic revival: it looks as if, in many Western countries, we are entering an age in which centre-left parties cannot form ruling majorities, having leaked support to nationalists, populists and more radical alternatives.

Certainly the British Labour Party, riven by a war between its parliamentary representatives and much of its membership, is in a critical condition. At the same time, Jeremy Corbyn’s leadership has inspired a remarkable re-engagement with left-wing politics, even as his party slumps in the polls. His own views may seem frozen in time, but hundreds of thousands of people, many of them young graduates, have responded to his anti-austerity rhetoric, his candour and his shambolic, unspun style.

The EU referendum, in which as much as one-third of Labour supporters voted for Brexit, exposed another chasm in Labour – this time between educated metropolitan liberals and the more socially conservative white working class on whose loyalty the party has long depended. This no longer looks like a viable election-winning coalition, especially after the collapse of Labour in Scotland and the concomitant rise of nationalism in England.

In Marxism Today’s “New Times” issue of October 1988, Stuart Hall wrote: “The left seems not just displaced by Thatcherism, but disabled, flattened, becalmed by the very prospect of change; afraid of rooting itself in ‘the new’ and unable to make the leap of imagination required to engage the future.” Something similar could be said of the left today as it confronts Brexit, the disunities within the United Kingdom, and, in Theresa May, a prime minister who has indicated that she might be prepared to break with the orthodoxies of the past three decades.

The Labour leadership contest between Corbyn and Owen Smith was largely an exercise in nostalgia, both candidates seeking to revive policies that defined an era of mass production and working-class solidarity when Labour was strong. On matters such as immigration, digital disruption, the new gig economy or the power of networks, they had little to say. They proposed a politics of opposition – against austerity, against grammar schools. But what were they for? Neither man seemed capable of embracing the “leading edge of change” or of making the imaginative leap necessary to engage the future.

So is there a politics of the left that will allow us to ride with the currents of these turbulent “new times” and thus shape rather than be flattened by them? Over the next 34 pages 18 writers, offering many perspectives, attempt to answer this and related questions as they analyse the forces shaping a world in which power is shifting to the East, wars rage unchecked in the Middle East, refugees drown en masse in the Mediterranean, technology is outstripping our capacity to understand it, and globalisation begins to fragment.

— Jason Cowley, Editor 

Tom Kibasi on what the left fails to see

Philip Collins on why it's time for Labour to end its crisis

John Harris on why Labour is losing its heartland

Lisa Nandy on how Labour has been halted and hollowed out

David Runciman on networks and the digital revolution

John Gray on why the right, not the left, has grasped the new times

Mariana Mazzucato on why it's time for progressives to rethink capitalism

Robert Ford on why the left must reckon with the anger of those left behind

Ros Wynne-Jones on the people who need a Labour government most

Gary Gerstle on Corbyn, Sanders and the populist surge

Nick Pearce on why the left is haunted by the ghosts of the 1930s

Paul Mason on why the left must be ready to cause a commotion

Neal Lawson on what the new, 21st-century left needs now

Charles Leadbeater explains why we are all existentialists now

John Bew mourns the lost left

Marc Stears on why democracy is a long, hard, slow business

Vince Cable on how a financial crisis empowered the right

David Miliband on why the left needs to move forward, not back

This article first appeared in the 22 September 2016 issue of the New Statesman, The New Times