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 and author of the book All Consuming.

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

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David Cameron's fatal insouciance

Will future historians remember the former prime minister for anything more than his great Brexit bungle?

On 13 July 2016, after a premiership lasting six years and 63 days, David Cameron left Downing Street for the last time. On the tarmac outside the black door, with his wife and children at his side, he gave a characteristically cool and polished parting statement. Then he got in his car for the last journey to Buckingham Palace – the picture, as ever, of insouciant ease. As I was watching the television pictures of Cameron’s car gliding away, I remembered what he is supposed to have said some years earlier, when asked why he wanted to be prime minister. True or not, his answer perfectly captured the public image of the man: “Because I think I’d be rather good at it.”

A few moments later, a friend sent me a text message. It was just six words long: “He’s down there with Chamberlain now.”

At first I thought that was a bit harsh. People will probably always disagree about Cameron’s economic record, just as they do about Margaret Thatcher’s. But at the very least it was nowhere near as bad as some of his critics had predicted, and by some standards – jobs created, for instance – it was much better than many observers had expected. His government’s welfare and education policies have their critics, but it seems highly unlikely that people will still be talking about them in a few decades’ time. Similarly, although Britain’s intervention in Libya is unlikely to win high marks from historians, it never approached the disaster of Iraq in the public imagination.

Cameron will probably score highly for his introduction of gay marriage, and although there are many people who dislike him, polls suggested that most voters regarded him as a competent, cheerful and plausible occupant of the highest office in the land. To put it another way, from the day he entered 10 Downing Street until the moment he left, he always looked prime ministerial. It is true that he left office as a loser, humiliated by the EU referendum, and yet, on the day he departed, the polls had him comfortably ahead of his Labour opposite number. He was, in short, popular.
On the other hand, a lot of people liked Neville Chamberlain, too. Like Chamberlain, Cameron seems destined to be remembered for only one thing. When students answer exam questions about Chamberlain, it’s a safe bet that they aren’t writing about the Holidays with Pay Act 1938. And when students write about Cameron in the year 2066, they won’t be answering questions about intervention in Libya, or gay marriage. They will be writing about Brexit and the lost referendum.

It is, of course, conceivable, though surely very unlikely, that Brexit will be plain sailing. But it is very possible that it will be bitter, protracted and enormously expensive. Indeed, it is perfectly conceivable that by the tenth anniversary of the referendum, the United Kingdom could be reduced to an English and Welsh rump, struggling to come to terms with a punitive European trade deal and casting resentful glances at a newly independent Scotland. Of course the Brexiteers – Nigel Farage, Boris Johnson, Michael Gove, Daniel Hannan et al – would get most of the blame in the short run. But in the long run, would any of them really be remembered? Much more likely is that historians’ fingers would point at one man: Cameron, the leader of the Conservative and Unionist Party, the prime minister who gambled with his future and lost the Union. The book by “Cato” that destroyed Chamberlain’s reputation in July 1940 was entitled Guilty Men. How long would it be, I wonder, before somebody brought out a book about Cameron, entitled Guilty Man?

Naturally, all this may prove far too pessimistic. My own suspicion is that Brexit will turn out to be a typically European – or, if you prefer, a typically British – fudge. And if the past few weeks’ polls are anything to go by, Scottish independence remains far from certain. So, in a less apocalyptic scenario, how would posterity remember David Cameron? As a historic failure and “appalling bungler”, as one Guardian writer called him? Or as a “great prime minister”, as Theresa May claimed on the steps of No 10?

Neither. The answer, I think, is that it would not remember him at all.

***

The late Roy Jenkins, who – as Herbert Asquith’s biographer, Harold Wilson’s chancellor and Jim Callaghan’s rival – was passionately interested in such things, used to write of a “market” in prime ministerial futures. “Buy Attlee!” he might say. “Sell Macmillan!” But much of this strikes me as nonsense. For one thing, political reputations fluctuate much less than we think. Many people’s views of, say, Wilson, Thatcher and Blair have remained unchanged since the day they left office. Over time, reputations do not change so much as fade. Academics remember prime ministers; so do political anoraks and some politicians; but most people soon forget they ever existed. There are 53 past prime ministers of the United Kingdom, but who now remembers most of them? Outside the university common room, who cares about the Marquess of Rockingham, the Earl of Derby, Lord John Russell, or Arthur Balfour? For that matter, who cares about Asquith or Wilson? If you stopped people in the streets of Sunderland, how many of them would have heard of Stanley Baldwin or Harold Macmillan? And even if they had, how much would they ­really know about them?

In any case, what does it mean to be a success or a failure as prime minister? How on Earth can you measure Cameron’s achievements, or lack of them? We all have our favourites and our prejudices, but how do you turn that into something more dispassionate? To give a striking example, Margaret Thatcher never won more than 43.9 per cent of the vote, was roundly hated by much of the rest of the country and was burned in effigy when she died, long after her time in office had passed into history. Having come to power promising to revive the economy and get Britain working again, she contrived to send unemployment well over three million, presided over the collapse of much of British manufacturing and left office with the economy poised to plunge into yet another recession. So, in that sense, she looks a failure.

Yet at the same time she won three consecutive general elections, regained the Falklands from Argentina, pushed through bold reforms to Britain’s institutions and fundamentally recast the terms of political debate for a generation to come. In that sense, clearly she was a success. How do you reconcile those two positions? How can you possibly avoid yielding to personal prejudice? How, in fact, can you reach any vaguely objective verdict at all?

It is striking that, although we readily discuss politicians in terms of success and failure, we rarely think about what that means. In some walks of life, the standard for success seems obvious. Take the other “impossible job” that the tabloids love to compare with serving as prime minister: managing the England football team. You can measure a football manager’s success by trophies won, qualifications gained, even points accrued per game, just as you can judge a chief executive’s performance in terms of sales, profits and share values.

There is no equivalent for prime ministerial leadership. Election victories? That would make Clement Attlee a failure: he fought five elections and won only two. It would make Winston Churchill a failure, too: he fought three elections and won only one. Economic growth? Often that has very little to do with the man or woman at the top. Opinion polls? There’s more to success than popularity, surely. Wars? Really?

The ambiguity of the question has never stopped people trying. There is even a Wikipedia page devoted to “Historical rankings of Prime Ministers of the United Kingdom”, which incorporates two surveys of academics carried out by the University of Leeds, a BBC Radio 4 poll of Westminster commentators, a feature by BBC History Magazine and an online poll organised by Newsnight. By and large, there is a clear pattern. Among 20th-century leaders, there are four clear “successes” – Lloyd George, Churchill, Attlee and Thatcher – with the likes of Macmillan, Wilson and Heath scrapping for mid-table places. At the bottom, too, the same names come up again and again: Balfour, Chamberlain, Eden, Douglas-Home and Major. But some of these polls are quite old, dating back to the Blair years. My guess is that if they were conducted today, Major might rise a little, especially after the success of Team GB at the Olympics, and Gordon Brown might find himself becalmed somewhere towards the bottom.

***

So what makes the failures, well, failures? In two cases, the answer is simply electoral defeat. Both ­Arthur Balfour and John Major were doomed to failure from the moment they took office, precisely because they had been picked from within the governing party to replace strong, assertive and electorally successful leaders in Lord Salisbury and Margaret Thatcher, respectively. It’s true that Major unexpectedly won the 1992 election, but in both cases there was an atmosphere of fin de régime from the very beginning. Douglas-Home probably fits into this category, too, coming as he did at the fag end of 13 years of Conservative rule. Contrary to political mythology, he was in fact a perfectly competent prime minister, and came much closer to winning the 1964 election than many people had expected. But he wasn’t around for long and never really captured the public mood. It seems harsh merely to dismiss him as a failure, but politics is a harsh business.

That leaves two: Chamberlain and Eden. Undisputed failures, who presided over the greatest foreign policy calamities in our modern history. Nothing to say, then? Not so. Take Chamberlain first. More than any other individual in our modern history, he has become a byword for weakness, naivety and self-deluding folly.

Yet much of this picture is wrong. Chamberlain was not a weak or indecisive man. If anything, he was too strong: too stubborn, too self-confident. Today we remember him as a faintly ridiculous, backward-looking man, with his umbrella and wing collar. But many of his contemporaries saw him as a supremely modern administrator, a reforming minister of health and an authoritative chancellor who towered above his Conservative contemporaries. It was this impression of cool capability that secured Chamberlain the crown when Baldwin stepped down in 1937. Unfortunately, it was precisely his titanic self-belief, his unbreakable faith in his own competence, that also led him to overestimate his influence over Adolf Hitler. In other words, the very quality that people most admired – his stubborn confidence in his own ability – was precisely what doomed him.

In Chamberlain’s case, there is no doubt that he had lost much of his popular prestige by May 1940, when he stepped down as prime minister. Even though most of his own Conservative MPs still backed him – as most of Cameron’s MPs still backed him after the vote in favour of Brexit – the evidence of Mass Observation and other surveys suggests that he had lost support in the country at large, and his reputation soon dwindled to its present calamitous level.

The case of the other notable failure, Anthony Eden, is different. When he left office after the Suez crisis in January 1957, it was not because the public had deserted him, but because his health had collapsed. Surprising as it may seem, Eden was more popular after Suez than he had been before it. In other words, if the British people had had their way, Eden would probably have continued as prime minister. They did not see him as a failure at all.

Like Chamberlain, Eden is now generally regarded as a dud. Again, this may be a bit unfair. As his biographers have pointed out, he was a sick and exhausted man when he took office – the result of two disastrously botched operations on his gall bladder – and relied on a cocktail of painkillers and stimulants. Yet, to the voters who handed him a handsome general election victory in 1955, Eden seemed to have all the qualities to become an enormously successful prime minister: good looks, brains, charm and experience, like a slicker, cleverer and more seasoned version of Cameron. In particular, he was thought to have proved his courage in the late 1930s, when he had resigned as foreign secretary in protest at the appeasement of Benito Mussolini before becoming one of Churchill’s chief lieutenants.

Yet it was precisely Eden’s great asset – his reputation as a man who had opposed appeasement and stood up to the dictators – that became his weakness. In effect, he became trapped by his own legend. When the Egyptian dictator Gamal Abdel Nasser nationalised the Suez Canal in July 1956, Eden seemed unable to view it as anything other than a replay of the fascist land-grabs of the 1930s. Nasser was Mussolini; the canal was Abyssinia; ­failure to resist would be appeasement all over again. This was nonsense, really: Nasser was nothing like Mussolini. But Eden could not escape the shadow of his own political youth.

This phenomenon – a prime minister’s greatest strength gradually turning into his or her greatest weakness – is remarkably common. Harold Wilson’s nimble cleverness, Jim Callaghan’s cheerful unflappability, Margaret Thatcher’s restless urgency, John Major’s Pooterish normality, Tony Blair’s smooth charm, Gordon Brown’s rugged seriousness: all these things began as refreshing virtues but became big handicaps. So, in that sense, what happened to Chamberlain and Eden was merely an exaggerated version of what happens to every prime minister. Indeed, perhaps it is only pushing it a bit to suggest, echoing Enoch Powell, that all prime ministers, their human flaws inevitably amplified by the stresses of office, eventually end up as failures. In fact, it may not be too strong to suggest that in an age of 24-hour media scrutiny, surging populism and a general obsession with accountability, the very nature of the job invites failure.

***

In Cameron’s case, it would be easy to construct a narrative based on similar lines. Remember, after all, how he won the Tory leadership in the first place. He went into the 2005 party conference behind David Davis, the front-runner, but overhauled him after a smooth, fluent and funny speech, delivered without notes. That image of blithe nonchalance served him well at first, making for a stark contrast with the saturnine intensity and stumbling stiffness of his immediate predecessors, Michael Howard and Iain Duncan Smith. Yet in the end it was Cameron’s self-confidence that really did for him.

Future historians will probably be arguing for years to come whether he really needed to promise an In/Out referendum on the UK’s membership of the EU, as his defenders claim, to protect his flank against Ukip. What is not in doubt is that Cameron believed he could win it. It became a cliché to call him an “essay crisis” prime minister – a gibe that must have seemed meaningless to millions of people who never experienced the weekly rhythms of the Oxford tutorial system. And yet he never really managed to banish the impression of insouciance. The image of chillaxing Dave, the PM so cockily laidback that he left everything until the last minute, may be a caricature, but my guess is that it will stick.

As it happens, I think Cameron deserves more credit than his critics are prepared to give him. I think it would be easy to present him as a latter-day Baldwin – which I mean largely as a compliment. Like Baldwin, he was a rich provincial Tory who posed as an ordinary family man. Like Baldwin, he offered economic austerity during a period of extraordinary international financial turmoil. Like Baldwin, he governed in coalition while relentlessly squeezing the Liberal vote. Like Baldwin, he presented himself as the incarnation of solid, patriotic common sense; like Baldwin, he was cleverer than his critics thought; like Baldwin, he was often guilty of mind-boggling complacency. The difference is that when Baldwin gambled and lost – as when he called a rash general election in 1923 – he managed to save his career from the ruins. When Cameron gambled and lost, it was all over.

Although I voted Remain, I do not share many commentators’ view of Brexit as an apocalyptic disaster. In any case, given that a narrow majority of the electorate got the result it wanted, at least 17 million people presumably view Cameron’s gamble as a great success – for Britain, if not for him. Unfortunately for Cameron, however, most British academics are left-leaning Remainers, and it is they who will write the history books. What ought also to worry Cameron’s defenders – or his shareholders, to use Roy Jenkins’s metaphor – is that both Chamberlain and Eden ended up being defined by their handling of Britain’s foreign policy. There is a curious paradox here, ­because foreign affairs almost never matters at the ballot box. In 1959, barely three years after Suez, the Conservatives cruised to an easy re-election victory; in 2005, just two years after invading Iraq, when the extent of the disaster was already apparent, Blair won a similarly comfortable third term in office. Perhaps foreign affairs matters more to historians than it does to most voters. In any case, the lesson seems to be that, if you want to secure your historical reputation, you can get away with mishandling the economy and lengthening the dole queues, but you simply cannot afford to damage Britain’s international standing.

So, if Brexit does turn into a total disaster, Cameron can expect little quarter. Indeed, while historians have some sympathy for Chamberlain, who was, after all, motivated by a laudable desire to avoid war, and even for Eden, who was a sick and troubled man, they are unlikely to feel similar sympathy for an overconfident prime minister at the height of his powers, who seems to have brought his fate upon himself.

How much of this, I wonder, went through David Cameron’s mind in the small hours of that fateful morning of 24 June, as the results came through and his place in history began to take shape before his horrified eyes? He reportedly likes to read popular history for pleasure; he must occasionally have wondered how he would be remembered. But perhaps it meant less to him than we think. Most people give little thought to how they will be remembered after their death, except by their closest friends and family members. There is something insecure, something desperately needy, about people who dwell on their place in history.

Whatever you think about Cameron, he never struck me as somebody suffering from excessive insecurity. Indeed, his normality was one of the most likeable things about him.

He must have been deeply hurt by his failure. But my guess is that, even as his car rolled away from 10 Downing Street for the last time, his mind was already moving on to other things. Most prime ministers leave office bitter, obsessive and brooding. But, like Stanley Baldwin, Cameron strolled away from the job as calmly as he had strolled into it. It was that fatal insouciance that brought him down. 

Dominic Sandbrook is a historian, broadcaster and columnist for the Daily Mail. His book The Great British Dream Factory will be published in paperback by Penguin on 1 September

Dominic Sandbrook is a historian and author. His books include Never Had It So Good: A History of Britain from Suez to the Beatles and White Heat: A History of Britain in the Swinging Sixties. He writes the What If... column for the New Statesman.

This article first appeared in the 25 August 2016 issue of the New Statesman, Cameron: the legacy of a loser