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 French millennials marching behind Marine Le Pen

A Front National rally attracts former socialists with manicured beards, and a lesbian couple. 

“In 85 days, Marine will be President of the French Republic!” The 150-strong crowd cheered at the sound of the words. On stage, the speaker, the vice-president of the far-right Front National (FN), Florian Philippot, continued: “We will be told that it’s the apocalypse, by the same banks, media, politicians, who were telling the British that Brexit would be an immediate catastrophe.

"Well, they voted, and it’s not! The British are much better off than we are!” The applause grew louder and louder. 

I was in the medieval city of Metz, in a municipal hall near the banks of the Moselle River, a tributary of the Rhine from which the region takes its name. The German border lies 49km east; Luxembourg City is less than an hour’s drive away. This is the "Country of the Three Borders", equidistant from Strasbourg and Frankfurt, and French, German and French again after various wars. Yet for all that local history is deeply rooted in the wider European history, votes for the Front National rank among the highest nationally, and continue to rise at every poll. 

In rural Moselle, “Marine”, as the Front National leader Marine Le Pen is known, has an envoy. In 2014, the well-spoken, elite-educated Philippot, 35, ran for mayor in Forbach, a former miner’s town near the border. He lost to the Socialist candidate but has visited regularly since. Enough for the locals to call him “Florian".

I grew up in a small town, Saint-Avold, halfway between Metz and Forbach. When my grandfather was working in the then-prosperous coal mines, the Moselle region attracted many foreign workers. Many of my fellow schoolmates bore Italian and Polish surnames. But the last mine closed in 2004, and now, some of the immigrants’ grandchildren are voting for the National Front.

Returning, I can't help but wonder: How did my generation, born with the Maastricht treaty, end up turning to the Eurosceptic, hard right FN?

“We’ve seen what the other political parties do – it’s always the same. We must try something else," said Candice Bertrand, 23, She might not be part of the group asking Philippot for selfies, but she had voted FN at every election, and her family agreed. “My mum was a Communist, then voted for [Nicolas] Sarkozy, and now she votes FN. She’s come a long way.”  The way, it seemed, was political distrust.

Minutes earlier, Philippot had pleaded with the audience to talk to their relatives and neighbours. Bertrand had brought her girlfriend, Lola, whom she was trying to convince to vote FN.  Lola wouldn’t give her surname – her strongly left-wing family would “certainly not” like to know she was there. She herself had never voted.

This infuriated Bertrand. “Women have fought for the right to vote!” she declared. Daily chats with Bertrand and her family had warmed up Lola to voting Le Pen in the first round, although not yet in the second. “I’m scared of a major change,” she confided, looking lost. “It’s a bit too extreme.” Both were too young to remember 2002, when a presidential victory for the then-Front National leader Jean-Marie Le Pen, was only a few percentage points away.

Since then, under the leadership of his daughter, Marine, the FN has broken every record. But in this region, the FN’s success isn’t new. In 2002, when liberal France was shocked to see Le Pen reach the second round of the presidential election, the FN was already sailing in Moselle. Le Pen grabbed 23.7 per cent of the Moselle vote in the first round and 21.9 per cent in the second, compared to 16.9 per cent and 17.8 per cent nationally. 

The far-right vote in Moselle remained higher than the national average before skyrocketing in 2012. By then, the younger, softer-looking Marine had taken over the party. In that year, the FN won an astonishing 24.7 per cent of the Moselle vote, and 17.8 per cent nationwide.

For some people of my generation, the FN has already provided opportunities. With his manicured beard and chic suit, Emilien Noé still looks like the Young Socialist he was between 16 and 18 years old. But looks can be deceiving. “I have been disgusted by the internal politics at the Socialist Party, the lack of respect for the low-ranked campaigners," he told me. So instead, he stood as the FN’s youngest national candidate to become mayor in his village, Gosselming, in 2014. “I entered directly into action," he said. (He lost). Now, at just 21, Noé is the FN’s youth coordinator for Eastern France.

Metz, Creative Commons licence credit Morgaine

Next to him stood Kevin Pfeiffer, 27. He told me he used to believe in the Socialist ideal, too - in 2007, as a 17-year-old, he backed Ségolène Royal against Sarkozy. But he is now a FN local councillor and acts as the party's general co-ordinator in the region. Both Noé and Pfeiffer radiated a quiet self-confidence, the sort that such swift rises induces. They shared a deep respect for the young-achiever-in-chief: Philippot. “We’re young and we know we can have perspectives in this party without being a graduate of l’ENA,” said another activist, Olivier Musci, 24. (The elite school Ecole Nationale d’Administration, or ENA, is considered something of a mandatory finishing school for politicians. It counts Francois Hollande and Jacques Chirac among its alumni. Ironically, Philippot is one, too.)

“Florian” likes to say that the FN scores the highest among the young. “Today’s youth have not grown up in a left-right divide”, he told me when I asked why. “The big topics, for them, were Maastricht, 9/11, the Chinese competition, and now Brexit. They have grown up in a political world structured around two poles: globalism versus patriotism.” Notably, half his speech was dedicated to ridiculing the FN's most probably rival, the maverick centrist Emmanuel Macron. “It is a time of the nations. Macron is the opposite of that," Philippot declared. 

At the rally, the blue, red and white flame, the FN’s historic logo, was nowhere to be seen. Even the words “Front National” had deserted the posters, which were instead plastered with “in the name of the people” slogans beneath Marine’s name and large smile. But everyone wears a blue rose at the buttonhole. “It’s the synthesis between the left’s rose and the right’s blue colour”, Pfeiffer said. “The symbol of the impossible becoming possible.” So, neither left nor right? I ask, echoing Macron’s campaign appeal. “Or both left and right”, Pfeiffer answered with a grin.

This nationwide rebranding follows years of efforts to polish the party’s jackass image, forged by decades of xenophobic, racist and anti-Semitic declarations by Le Pen Sr. His daughter evicted him from the party in 2015.

Still, Le Pen’s main pledges revolve around the same issue her father obsessed over - immigration. The resources spent on "dealing with migrants" will, Le Pen promises, be redirected to address the concerns of "the French people". Unemployment, which has been hovering at 10 per cent for years, is very much one of them. Moselle's damaged job market is a booster for the FN - between 10 and 12 per cent of young people are unemployed.

Yet the two phenomena cannot always rationally be linked. The female FN supporters I met candidly admitted they drove from France to Luxembourg every day for work and, like many locals, often went shopping in Germany. Yet they hoped to see the candidate of “Frexit” enter the Elysee palace in May. “We've never had problems to work in Luxembourg. Why would that change?” asked Bertrand. (Le Pen's “144 campaign pledges” promise frontier workers “special measures” to cross the border once out of the Schengen area, which sounds very much like the concept of the Schengen area itself.)

Grégoire Laloux, 21, studied history at the University of Metz. He didn't believe in the European Union. “Countries have their own interests. There are people, but no European people,” he said. “Marine is different because she defends patriotism, sovereignty, French greatness and French history.” He compared Le Pen to Richelieu, the cardinal who made Louis XIV's absolute monarchy possible:  “She, too, wants to build a modern state.”

French populists are quick to link the country's current problems to immigration, and these FN supporters were no exception. “With 7m poor and unemployed, we can't accept all the world's misery,” Olivier Musci, 24, a grandchild of Polish and Italian immigrants, told me. “Those we welcome must serve the country and be proud to be here.”

Lola echoed this call for more assimilation. “At our shopping centre, everyone speaks Arabic now," she said. "People have spat on us, thrown pebbles at us because we're lesbians. But I'm in my country and I have the right to do what I want.” When I asked if the people who attacked them were migrants, she was not so sure. “Let's say, they weren't white.”

Trump promised to “Make America Great Again”. To where would Le Pen's France return? Would it be sovereign again? White again? French again? Ruled by absolutism again? She has blurred enough lines to seduce voters her father never could – the young, the gay, the left-wingers. At the end of his speech, under the rebranded banners, Philippot invited the audience to sing La Marseillaise with him. And in one voice they did: “To arms citizens! Form your battalions! March, march, let impure blood, water our furrows...” The song is the same as the one I knew growing up. But it seemed to me, this time, a more sinister tune.