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

Andre Carhillo
Show Hide image

The decline of the Fifth Republic

With the far right and far left surging in the run-up to a defining presidential election, the French seem intent on blowing up the political establishment.

On a cold Saturday evening in late February, cycling back to my flat in southern Paris, I accidentally ran into a pack of lads on a rampage. They were turning over bins, kicking over expensive motorbikes parked on the street, and obviously looking for someone to fight.

It wasn’t the first time that I’d seen this sort of thing, even in this relatively gentrified part of the city. Usually the best course of action is to stop, let them swarm past and allow the police to do their job. But on this particular night, although I could hear the buzz of a police helicopter above us, there were no officers on the ground. As I nervously became aware of this, one of the lads, no more than five yards away, looked at me and screamed: “T’es qui toi?” (“Who the f*** are you?”). His mates turned and gathered round. Now panicking, I saw that he was pointing a screwdriver at me.

I pelted down the street, heart racing as the young men followed me, so shocked that when I reached my apartment building I twice tapped in the wrong entry code. It was only once indoors, now safe but genuinely scared and sweating, that I understood what had happened.

This was a gang from one of the local ­cités – council estates – that border this part of Paris. They had been flushed out of their normal dens, where they deal in weed and mess about, by police using helicopters and unmarked cars, and were now taking their revenge on these unfamiliar surroundings. When they saw me, a tall, white, male figure, watching in the dark on my bike (stupidly the same dark blue as a police bike), they assumed I could only be one thing: a police spotter. In other words, their most hated enemy.

In the past few weeks, in Paris and across France, there has been a new and special danger in being identified by such gangs as a lone policeman. This is because the ever-present tensions between police and the youth of the cités have become particularly acute following the so-called Affaire Théo. On 2 February in Seine-Saint-Denis, north-east of Paris, four police officers violently attacked an innocent black man, identified only as Théo. The assault was caught on camera and allegedly involved the man’s “rape” with a telescopic baton.

The details of the case caused widespread outrage, right up to the highest level of ­government. In the banlieue, the suburbs where many young people feel excluded from mainstream French life, some felt a desire for revenge. And though their anger related to a specific incident, it was in keeping with the emotions sweeping across France, at all levels of society, in the lead-up to the first round of this year’s presidential election on 23 April.

***

France is in a state of political disarray. This much was obvious during the first live “great debate” on 20 March, organised by the television channel TF1, featuring five front-runners for the presidency.

Probably the greatest loser on the night was François Fillon of the centre-right party les Républicains, who served as prime minister from 2007 to 2012. Fillon has gone from being a sure favourite to outsider in the presidential contest, following allegations of dodgy financial dealings. Most damagingly, a formal judicial investigation has been launched into reports that he paid upwards of €800,000 of taxpayers’ money to his wife and other family members for jobs they didn’t actually do. Fillon, who denies any wrongdoing, has also been accused of failing to declare a €50,000 loan from a French businessman in 2013 (which he has since repaid). He held himself in check during the debate, trying to look dignified and presidential, but he has become the object of scorn from all sides, including his own.

Benoît Hamon, the candidate for the Parti Socialiste (PS), the party of the outgoing and discredited president, François Hollande, did not perform much better in the debate. Hamon identifies with the far left and green wings of the PS and favours a basic income, the legalisation of cannabis, and euthanasia. He resigned from Hollande’s government in 2014 claiming that the president had abandoned socialist values. But at every public appearance Hamon still looks surprised to be in the race. Although he has positioned himself as the “anti-Hollande” candidate – no surprise, as Hollande has the lowest polls ratings of any French president – even Hamon’s supporters concede that he has no reach outside the party faithful, and his dismal poll ratings reflect this.

In recent weeks, Jean-Luc Mélenchon, a veteran left-winger and now leader of his own party, France Insoumise (“Unsubmissive France”), has surged in the polls. He has been compared to Jeremy Corbyn but is more like George Galloway, in that he can be trenchant and biting and speaks fluently without notes. Some of his views – anti-EU, anti-Nato, pro-Russia – are close to those of Marine Le Pen, the leader of the far-right Front National (FN). The candidate of the centre or centre-left is Emmanuel Macron, a 39-year-old former investment banker and protégé of Hollande, under whom he served as minister of the economy, industry and digital data. Macron broke with the PS in 2016 to set himself up as an independent candidate with his new movement, En Marche! (“onward”). He presents himself as a voice of moderation and common sense. He defends the EU and the eurozone and is an unashamed liberal globaliser. But Macron is also hard to love: his enemies claim that he is self-serving, an opportunist who cannot be trusted, and, worse, that he lacks experience of high office. On television he can be vain and testy – as was the case when he came under attack from Marine Le Pen, during the TF1 debate.

In many ways, Macron was a gift to Le Pen. She accused him of being out of touch and of not knowing what he was talking about. Even non-FN supporters, who didn’t necessarily agree with her views on security and immigration, conceded that Le Pen was the most convincing speaker. As I was told by a neighbour with an impeccable PS background, it was as if she was the only politician on the night of the debate in charge of what she believed. Le Pen’s popularity increased as a consequence.

So is it now possible to think the unthinkable: that Marine Le Pen could triumph not only in the first round of the presidential election but in the second as well? If that happens, not only would she become the first female president of France but she would transform French politics and further destabilise the European Union.

***

When I put this to Jean-Pierre Legrand, the leader of the Front National in Roubaix, a town of 90,000 inhabitants in the north of France, he shook his head. He wishes Le Pen well but fears that in the second round the mainstream parties will gang up and back whoever her opponent is. “This is what always happens,” he told me. “This is why so-called French democracy is actually a form of dictatorship. You can never really get your hands on power. It belongs to an elite, people like Emmanuel Macron.”

Legrand, 69, has been a supporter of the FN for decades. He smiles a lot and can be witty, but he also likes talking tough, like the hard-headed factory boss he used to be. He admires the way Le Pen has reinvented the party, shedding some of the old-school neo-Nazi trappings. But he is also faithful to, maybe even nostalgic for, the old FN of her father, Jean-Marie Le Pen, who reached the second round of the 2002 presidential election (he lost to the centre-right Jacques Chirac). So I asked him if he was not really a democrat but, like Le Pen père, basically a fascist. “I am not afraid of being called a fascist, or even a Gaullist,” he said. “But all I really believe in is order and authority. And that is what France needs now.”

I had come to Roubaix because it is officially the poorest town in France. It is also, according to most media reports, one of the most troubled. It’s not far from Paris – just over 90 minutes on a fast train – but when you get there it feels like a different, distant place. The train station is scruffy and there is little sense of the usual Gallic civic pride; the stroll down the main boulevard to the Grand Place is drab and quiet, unlike in most French towns.

Roubaix has a large immigrant population, mainly from North Africa but comprising more than 60 nationalities. It has a reputation as a refuge for illegal migrants making for Calais and then the UK, and as a hotbed of Islamist radicalisation. In May last year the conservative news weekly Valeurs actuelles described Roubaix as “le Molenbeek français”. The magazine was referring to the suburb of Brussels where several of the terrorists and sympathisers involved in the November 2015 attacks on Paris, which killed 130 people, including 89 at the Bataclan concert hall, grew up.

Legrand and his FN colleague Astrid Leplat offered to show me around the town, just as they had done with the writer from Valeurs actuelles. The article was criticised by the local newspaper La Voix du Nord as depicting a fantasy version of France conjured up by the FN. I was aware of this argument, but also keen to take up the offer of a tour: it was a rare chance to see an ordinary French town through the eyes of the FN.

I quite liked Roubaix. With its sooty terraced houses, empty textile mills, iron bridges and dirty canals, it reminded me of Salford in the 1970s. The town is neatly laid out even if the streets are scruffy. It is also busy with small businesses – Arabic-language bookshops, kebab houses and tea shops, as well as traditional French cafés and bistros. It looked no more menacing than Bradford or Rusholme in Manchester.

Legrand is proud of Roubaix, or at least of what Roubaix used to be, and has chosen to live here rather than in nearby Lille. Having been a blue-collar worker, too, he admires the noble ambitions and graft of the people who built the town. These were the original indépendants – the aspiring working class, much cherished by the FN, who believe in the values of hard work and public service. But Legrand told me that when he looks at the streets today he sees not the cluttered life of 21st-century, multicultural France but what he called “conquered territory”.

There are problems in Roubaix: 45 per cent of the town’s residents live below the official French poverty line of €977 a month. Describing the local poverty, Legrand used the term “misère”, a word that also translates as “wretchedness”. The unemployment rate is high (40 per cent in parts of town) and on a typical weekday afternoon there are many young men sitting around with nothing to do.

As we drove through some of the tougher areas, Legrand pointed out so-called Salafist mosques, most of them shielded from the streets by the high walls of disused factories. It is these places, unknown and unvisited by outsiders, which have given Roubaix its reputation for radicalism.

It is true that in the recent past Roubaix has produced many extremists. The most notorious is Lionel Dumont, a former soldier who is white and working class, and is viewed as the leader of radical Islam in the French prison system, where he is serving a 25-year sentence for terrorism offences that include trying to set off a car bomb during a G7 meeting in Lille in 1996. Islamists such as Dumont are, in effect, beyond the control of the penal authorities because French laws forbid the monitoring of prisoners on grounds of race or religion. One frustrated director of prisons in the Paris region complained to me that the French penal system was “the real engine room of radicalisation”.

The main reason why Roubaix has produced so many terrorists – including Mehdi Nemmouche, the gunman who fired the shots at the Jewish Museum in Brussels in May 2014 that killed four people – is not immigration, as the Front National would have it, but geography. This part of France is depicted in the media as “a security black hole”, partly because of its proximity to the Belgian border. You can drive into Belgium from Roubaix in ten minutes, as I did with Legrand; the border is just a roundabout and unmonitored. The French and Belgian intelligence services are minutes away from each other but do not share information or collaborate properly. This allowed some of the terrorists who led the 2015 Paris attacks to escape after the killing spree.

***

Crossing the border to Belgium, you notice that the roads are lined with gleaming new warehouses belonging to Amazon and other technology companies. ­Roubaix suddenly seems like a ruin from the early 20th century. It must be difficult for its people not to feel trapped and abandoned – by the French elite to the south and the new economy to the north.

“If you live in Roubaix it is hard to feel connected to the rest of France,” said Hélène Robillard, a junior civil servant. I had come across her in the centre of town. She was leading a group of young women, merrily banging tambourines, blowing whistles and chanting slogans outside one of the
offices of the local council. They were striking against work conditions at the council, but having a laugh, too, in the best Made in Dagenham style.

I asked the women about the film Chez nous (This Is Our Land), which had been released only a few weeks earlier and was playing to packed houses across France. Set in a fictionalised town much like Roubaix, it tells the story of a young woman, Pauline Duhez, a nurse who is seduced into joining the FN and standing for a seat on the council. As she learns the party’s true positions, she becomes disillusioned and angry. The film ends with Pauline returning to the socialist values of her unemployed father, a former steelworker, culminating in a family trip to watch a game featuring the local football team Lens.

The women protesting with Robillard were all determinedly anti-FN. Those who had seen the film were full of enthusiasm. “It is our real life,” said one of them, laughing. “It shows our true values – not fascism, but football, beer and chips.”

Like Pauline in the film, the FN’s Astrid Leplat is a nurse. Jean-Pierre Legrand explained to me that this was why she had been hand-picked by Marine Le Pen to stand
as a regional councillor. The party has adopted a policy of recruiting fonctionnaires (civil servants), especially those who work in the health and support services. This is partly to demonstrate that the FN has left behind its neo-Nazi origins and is now the party of everyday folk, but also to undermine PS dominance of the public services.

When I asked Leplat why she supported the FN, she said that she had witnessed the disastrous effects of repeated budget cuts on hospitals, with overstretched departments and increasingly run-down facilities. “The Front National are there to protect us,” she said.

Leplat told me she hadn’t seen Chez nous and that she probably wouldn’t, because it would upset her. There were also political reasons why she didn’t want to see it: it had been financed with public money from Hauts-de-France, the northern region that covers Roubaix, as well as the television companies France 2 and France 3. When I pointed out that most French cinema relies on public subsidy, she argued that the film’s release had been deliberately timed to undermine the February launch of the FN’s presidential campaign.

“How else can this be explained?” she said. “The Front National is always persecuted by the establishment elites in culture and politics.”

***

Back in Paris, as part of a documentary I was making for BBC Radio 4, I interviewed Émilie Dequenne, the actress who plays Pauline in Chez nous, and the film’s director, Lucas Belvaux. We met at the production company’s office just off the rue du Faubourg Saint-Honoré in the swish heart of Paris – a corner of the city that couldn’t be further removed from the streets of Roubaix. But both Dequenne and Belvaux are intimately connected with the region and the northern working-class life, because they grew up near the Franco-Belgian border and still have family ties there. I asked them whether the FN had a point about the film.

“The film is not ambiguous,” Dequenne said. “It is clearly a warning about being ­seduced by the far right. But it also has lots of [different] ambiguities. The main character, Pauline, is a good person, and not stupid. She wants to help people. She thinks that this is not the case with the main pol­itical parties. So she is attracted by a party that seems to care.”

“I agree it is a warning,” Belvaux said. “We are not yet a fascist country, but I do fear that this could happen.

“There are big social and cultural divisions in France. Not everybody who will vote for the Front National is a bad person, but there are many angry people in this country who feel hurt and damaged. When this is the case, fascism can arrive much more quickly than you think.”

Until now, voting for the FN has been a sign of protest, historically a safety valve for releasing discontent. Whenever the FN has got near to victory, right and left have come together as a bloc to exclude it from power. This is what happened in 2002, of course, when Jean-Marie Le Pen, the then leader of the FN, made it through to the second round of the presidential elections. Jacques Chirac won the run-off with 82 per cent of the vote, despite accusations of corruption. The rallying cry across all non-FN political lines was: “Vote for the crook, not the fascist!” Yet there is no guarantee that this will happen again, because Marine Le Pen has successfully reinvented and rebranded the FN, making it more acceptable to mainstream voters.

Even if Marine loses, there is another danger. If those French parties of the left and right which historically have been strongest continue to implode, there will be a new constituency of voters who in future will be “homeless”. Even if Macron wins – having blurred the lines between right and left – he will disappoint at some stage. When this happens, those who supported him may not find their way back to the established parties, thus opening up an avenue to power for the far right. Sylvain Bourmeau, an associate professor at the École des Hautes Études en Sciences Sociales in Paris, told me that this was part of the Front National’s long-term strategy.

The withering of a historically strong party has already happened in the UK, where voters’ movement to Ukip and the SNP has undermined, if not destroyed, Labour as a national force. Marine Le Pen has already voiced her admiration for Ukip for “breaking the mould”. However, it is important to remember that the FN is not “populist” in the way that Ukip, or indeed Donald Trump, is. Nor are Roubaix and the north of France the same as the “rust belt” of the United States.

Rather, the present conflicts in France are ideological, with roots in the antagonisms and turmoil of French history. The FN’s ultimate goal is to get rid of the present French Republic – the result of the “mistake” of the “liberal revolution” of 1789. In other words, the promise of liberté, égalité, fraternité is to be replaced by an “awakening”, which would lead to a “national movement”: that is, the rebirth of the French nation. The FN is not just about racism, immigration or identity: it wants to send French history into reverse gear.

That is how high the stakes are, and why the coming elections are the most important in France since the Second World War. There is a generalised tension right now – the tension that I encountered on my bike on my own street in southern Paris – which sometimes finds expression in gang violence, anti-police riots and even terrorism, all fuelling the rise of the FN.

For all the polls, signs and omens, it is ­impossible to predict the election result. Whatever happens in the coming weeks and months, with the old political certainties melting away, it seems more than ever that France is set on a long and unstoppable journey into darkness. L

Andrew Hussey is the author of “The French Intifada” (Granta Books). He lives in Paris. His documentary “Culture, Class and Le Pen” will be broadcast on BBC Radio 4 on 24 April (8pm)

This article first appeared in the 20 April 2017 issue of the New Statesman, May's gamble

0800 7318496