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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As bad as stealing bacon – why did the Victorians treat acid attacks so leniently?

In an era of executions and transportation, 19th century courts were surprisingly laissez-faire about acid attacks. 

"We are rather anxious to see the punishment of death rescinded in all cases except that of Murder," stated the Glasgow publication, The Loyal Reformers’ Gazette, in 1831. But it did not share this opinion when it came to Hugh Kennedy.

Previously of “irreproachable character", Kennedy fell out with a fellow servant and decided to take his revenge by pouring acid on the man while he was asleep. “He awoke in agony, one of his eyes being literally burned out,” The Gazette reported.

Lamenting the rise in acid attacks, the otherwise progressive journal recommended “the severest punishment” for Kennedy:

“We would have their arms cut off by the shoulders, and, in that state, send them to roam as outcasts from society without the power of throwing vitriol again."

More than 180 years later, there are echoes of this sentiment in the home secretary’s response to a spate of acid attacks in London. “I quite understand when victims say they feel the perpetrators themselves should have a life sentence,” Amber Rudd told Sky News. She warned attackers would feel “the full force of the law”.

Acid attacks leave the victims permanently disfigured, and often blinded. Surprisingly, though, the kind of hardline punishment advocated by The Gazette was actually highly unusual, according to Dr Katherine Watson, a lecturer in the history of medicine at Oxford Brookes University. Hugh Kennedy was in fact the only person hung for an acid attack.

“If you look at the cases that made it to court, you see there is a huge amount of sympathy for the perpetrators,” she says.

"You want your victim to suffer but you don’t want them to die”

Acid attacks emerged with the industrial revolution in Britain. From the late 1700s, acid was needed to bleach cotton and prevent metals from rusting, and as a result became widely available.

At first, acid was a weapon of insurrection. “Vitriol throwing (that is, the throwing of corrosive substances like sulphuric acid) was a big problem in 1820s Glasgow trade disputes,” says Shane Ewen, an urban historian at Leeds Beckett University. Other cases involved revenge attacks on landlords and employers.

Faced with this anarchic threat, the authorities struck back. Scotland introduced a strict law against acid attacks in the 1820s, while the 1861 Offences Against the Person Act s.29 placed provided for a maximum sentence of life in England and Wales.

In reality, though, acid attackers could expect to receive far more lenient sentences. Why?

“They had sad stories,” says Watson, a leading historian of acid attacks. “Although they had done something terrible, the journalists and juries could empathise with them.”

Acid attacks were seen as expressions of revenge, even glorified as crimes of passion. As Watson puts it: “The point is you want your victim to suffer but you don’t want them to die.”

Although today, around the world, acid attacks are associated with violence against women, both genders used acid as a weapon in 19th century and early 20th century Britain. Acid crept into popular culture. Arthur Conan Doyle’s 1924 Sherlock Holmes story, The Adventure of the Illustrious Client, featured a mistress throwing vitriol in her former lover’s face. In Brighton Rock, Graham Greene’s 1938 novel, the gangster Pinkie attacks his female nemesis Ida Arnold with his vial of acid, before falling to his death.

Lucy Williams, the author of Wayward Women: Female Offending in Victorian England, agrees that Victorians took a lenient attitude to acid attacks. “Historically speaking sentences for acid attacks were quite low,” she says. “Serious terms of imprisonment would only usually be given if the injury caused permanent blindness, death, or was life-threatening.

“If this was not the case, a defendant might spend just a few months in prison - sometimes even less.”

Courts would weigh up factors including the gender of the attacker and victim, and the strength of the substance.

But there was another factor, far removed from compassion “Many of the sentences that we would now consider extremely lenient were a product of a judicial system that valued property over people,” says Williams. It was quite common for violent offences to receive just a few weeks or months in prison.

One case Williams has researched is that of the 28 year old Sarah Newman, who threw sulphuric acid at Cornelius Mahoney, and was tried for the “intent to burn and disfigure him” at the Old Bailey in 1883. The attacker and victim had been living together, and had three children together, but Mahoney had abandoned Newman to marry another woman.

Although Mahoney lost the sight in his right eye, his attacker received just 12 months imprisonment with hard labour.

Two other cases, uncovered by Ancestry.co.uk, illustrate the Victorian attitude to people and property. Mary Morrison, a servant in her 40s, threw acid in the face of her estranged husband after he didn’t give her a weekly allowance. The attack disfigured and blinded him.

In 1883, Morrison was jailed for five years, but released after two and a half. The same year, Dorcas Snell, also in her 40s, received a very similar sentence – for stealing a piece of bacon.

"People just had more options"

If Victorian attitudes become clearer with research, why acid attacks receded in the 20th century remains something of a mystery.

“My theory is people just had more options,” says Watson. With manufacturing on the wane, it became a little harder to get hold of corrosive fluid. But more importantly, the underlying motivation for acid attacks was disappearing. “Women can just walk away from relationships, they can get divorced, get a job. And maybe men don’t feel the same shame if women leave.”

Acid attacks did not disappear completely, though. Yardie gangs – mainly comprised of Jamaican immigrants – used acid as a weapon in the 1960s. Other gangs may have used it too, against victims who would rather suffer in silence than reveal themselves to the police.

Meanwhile, in 1967, the first acid attacks in Bangladesh and India were recorded. This would be the start of a disturbing, misogynistic trend of attacks across Asia. “Acid attacks, like other forms of violence against women, are not random or natural phenomena,” Professor Yakin Ertürk, the UN’s special rapporteur on violence against women, wrote in 2011. “Rather, they are social phenomena deeply embedded in a gender order that has historically privileged patriarchal control over women and justified the use of violence to ‘keep women in their places’.”

The re-emergence of acid attacks in Britain has been interpreted by some as another example of multiculturalism gone wrong. “The acid attacks of London’s Muslim no-go zones”, declared the right-wing, US-based Front Page magazine.

In fact, descriptions of the recent attackers include white men, and black and minority ethnic groups are disproportionately among the victims. A protest by delivery drivers against acid attacks was led by Asian men. 

Jaf Shah, from the Acid Survivors Trust International, suspects the current spate of attacks in fact originates from gang-related warfare that has in turn inspired copycat attacks. “In the UK because of the number of men attacked, it goes against the global pattern,” he says. “It’s complicated by multiple motivations behind these attacks.” Unlike other weapons in the UK, acid is easy to obtain and carry, while acid attacks are prosecuted under the non-specific category of grievous bodily harm. 

Among the recent victims is a British Muslim businessman from Luton, who says he was attacked by a bald white man, two teenage boys in east London, a delivery man, also in east London, who had his moped stolen at the same time, and a man in Leicester whose girlfriend – in a move Hugh Kennedy would recognise – poured acid on him while he slept.

Shah believes the current anxiety about acid attacks stems from the fact the general public is being attacked, rather than simply other members of gangs. Perhaps, also, it relates to the fact that, thanks to advances in our understanding of trauma since the Victorian period, 21st century lawmakers are less interested in the theft of a moped than the lifetime of scars left on the driver who was attacked.

With Rudd promising a crackdown, the penalties for acid throwing are only likely to get harsher. “Many survivors feel the sentencing is too lenient,” Shah says. Still, the rise and fall and rise again of acid throwing in the UK suggests the best way to eradicate the crime may lie outside the courts.

Julia Rampen is the digital news editor of the New Statesman (previously editor of The Staggers, The New Statesman's online rolling politics blog). She has also been deputy editor at Mirror Money Online and has worked as a financial journalist for several trade magazines. 

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