Treat with extreme caution

Homoeopathic medicine is founded on a bogus philosophy. Its continued use is a drain on NHS resource

Two years ago, a loose coalition of like-minded scientists wrote an open letter to chief executives of the National Health Service Trusts. The signatories simply stated that homoeopathy and other alternative therapies were unproven, and that the NHS should reserve its funds for treatments that had been shown to work. The letter marked an extraordinary downturn in the fortunes of homoeopathy in the UK over the following year, because the overwhelming majority of trusts either stopped sending patients to the four homoeopathic hospitals, or introduced measures to strictly limit referrals.

Consequently, the future of these hospitals is now in doubt. The Tunbridge Wells Homoeopathic Hospital is set to close next year and the Royal London Homoeopathic Hospital is likely to follow in its wake. Homoeo paths are now so worried about the collapse of their flagship hospitals that they are organising a march to deliver a petition to Downing Street on 22 June. Local campaign groups are being formed and patients are being urged to sign the petition.

Homoeopaths believe that the medical Establishment is crushing a valuable healing tradition that dates back more than two centuries and that still has much to offer patients. Homoeopaths are certainly passionate about the benefits of their treatment, but are their claims valid, or are they misguidedly promoting a bogus philosophy?

This is a question that I have been considering for the past two years, ever since I began co-authoring a book on the subject of alternative medicine with Professor Edzard Ernst. He was one of the signatories of the letter to the NHS trusts and is the world's first professor of complementary medicine. Before I present our conclusion, it is worth remembering why homoeo pathy has always existed beyond the borders of mainstream medicine.

Homoeopathy relies on two key principles, namely that like cures like, and that smaller doses deliver more powerful effects. In other words, if onions cause our eyes to stream, then a homoeopathic pill made from onion juice might be a potential cure for the eye irritation caused by hay fever. Crucially, the onion juice would need to be diluted repeatedly to produce the pill that can be administered to the patient, as homoeopaths believe that less is more.

Initially, this sounds attractive, and not dissimilar to the principle of vaccination, whereby a small amount of virus can be used to protect patients from viral infection. However, doctors use the principle of like cures like very selectively, whereas homoeopaths use it universally. Moreover, a vaccination always contains a measurable amount of active ingredient, whereas homoeopathic remedies are usually so dilute that they contain no active ingredient whatsoever.

A pill that contains no medicine is unlikely to be effective, but millions of patients swear by this treatment. From a scientific point of view, the obvious explanation is that any perceived benefit is purely a result of the placebo effect, because it is well established that any patient who believes in a remedy is likely to experience some improvement in their condition due to the psychological impact. Homoeopaths disagree, and claim that a "memory" of the homoeopathic ingredient has a profound physiological effect on the patient. So the key question is straightforward: is homoeopathy more than just a placebo treatment?

Fortunately, medical researchers have conducted more than 200 clinical trials to investigate the impact of homoeopathy on a whole range of conditions. Typically, one group of patients is given homoeopathic remedies and another group is given a known placebo, such as a sugar pill. Researchers then examine whether or not the homoeopathic group improves on average more than the placebo group. The overall conclusion from all this research is that homoeopathic remedies are indeed mere placebos.

In other words, their benefit is based on nothing more than wishful thinking. The latest and most definitive overview of the evidence was published in the Lancet in 2005 and was accompanied by an editorial entitled "The end of homoeopathy". It argued that ". . . doctors need to be bold and honest with their patients about homoeopathy's lack of benefit".

An unsound investment

However, even if homoeopathy is a placebo treatment, anybody working in health care will readily admit that the placebo effect can be a very powerful force for good. Therefore, it could be argued that homoeopaths should be allowed to flourish as they administer placebos that clearly appeal to patients. Despite the undoubted benefits of the placebo effect, however, there are numerous reasons why it is unjustifiable for the NHS to invest in homoeopathy.

First, it is important to recognise that money spent on homoeopathy means a lack of investment elsewhere in the NHS. It is estimated that the NHS spends £500m annually on alternative therapies, but instead of spending this money on unproven or disproven therapies it could be used to pay for 20,000 more nurses. Another way to appreciate the sum of money involved is to consider the recent refurbishment of the Royal Homoeopathic Hospital in London, which was completed in 2005 and cost £20m. The hospital is part of the University College London Hospitals NHS Foundation Trust, which contributed £10m to the refurbishment, even though it had to admit a deficit of £17.4m at the end of 2005. In other words, most of the overspend could have been avoided if the Trust had not spent so much money on refurbishing the spiritual home of homoeopathy.

Second, the placebo effect is real, but it can lull patients into a false sense of security by improving their sense of well-being without actually treating the underlying conditions. This might be all right for patients suffering from a cold or flu, which should clear up given time, but for more severe illnesses, homoeopathic treatment could lead to severe long-term problems. Because those who administer homoeopathic treatment are outside of conventional medicine and therefore largely unmonitored, it is impos sible to prove the damage caused by placebo. Never theless, there is plenty of anecdotal evidence to support this claim.

For example, in 2003 Professor Ernst was working with homoeopaths who were taking part in a study to see if they could treat asthma. Unknown to the professor or any of the other researchers, one of the homoeopaths had a brown spot on her arm, which was growing in size and changing in colour. Convinced that homoeopathy was genuinely effective, the homoeopath decided to treat it herself using her own remedies. Buoyed by the placebo effect, she continued her treatment for months, but the spot turned out to be a malignant melanoma. While she was still in the middle of treating asthma patients, the homoeopath died. Had she sought conventional treatment at an early stage, there would have been a 90 per cent chance that she would have survived for five years or more. By relying on homoeopathy, she had condemned herself to an inevitably early death.

The third problem is that anybody who is aware of the vast body of research and who still advises homoeopathy is misleading patients. In order to evoke the placebo effect, the patient has to be fooled into believing that homoeopathy is effective. In fact, bigger lies encourage bigger patient expectations and trigger bigger placebo effects, so exploiting the benefits of homoeopathy to the full would require homoeopaths to deliver the most fantastical justifications imaginable.

Over the past half-century, the trend has been towards a more open and honest relationship between doctor and patient, so homoeopaths who mislead patients flagrantly disregard ethical standards. Of course, many homoeopaths may be unaware of or may choose to disregard the vast body of scientific evidence against homoeo pathy, but arrogance and ignorance in health care are also unforgivable sins.

If it is justifiable for the manufacturers of homoeopathic remedies in effect to lie about the efficacy of their useless products in order to evoke a placebo benefit, then maybe the pharmaceutical companies could fairly argue that they ought to be allowed to sell sugar pills at high prices on the basis of the placebo effect as well. This would undermine the requirement for rigorous testing of drugs before they go on sale.

A fourth reason for spurning placebo-based medicines is that patients who use them for relatively mild conditions can later be led into dangerously inappropriate use of the same treatments. Imagine a patient with back pain who is referred to a homoeopath and who receives a moderate, short-term placebo effect. This might impress the patient, who then returns to the homoeopath for other advice. For example, it is known that homoeopaths offer alternatives to conventional vaccination - a 2002 survey of homoeopaths showed that only 3 per cent of them advised parents to give their baby the MMR vaccine. Hence, directing patients towards homoeo paths for back pain could encourage those patients not to have their children vaccinated against potentially dangerous diseases.

Killer cures

Such advice and treatment is irresponsible and dangerous. When I asked a young student to approach homoeopaths for advice on malaria prevention in 2006, ten out of ten homoeopaths were willing to sell their own remedies instead of telling the student to seek out expert advice and take the necessary drugs.

The student had explained that she would be spending ten weeks in West Africa; we had decided on this backstory because this region has the deadliest strain of malaria, which can kill within three days. Nevertheless, homoeopaths were willing to sell remedies that contained no active ingredient. Apparently, it was the memory of the ingredient that would protect the student, or, as one homoeopath put it: "The remedies should lower your susceptibility; because what they do is they make it so your energy - your living energy - doesn't have a kind of malaria-shaped hole in it. The malarial mosquitoes won't come along and fill that in. The remedies sort it out."

The homoeopathic industry likes to present itself as a caring, patient-centred alternative to conventional medicine, but in truth it offers disproven remedies and often makes scandalous and reckless claims. On World Aids Day 2007, the Society of Homoeopaths, which represents professional homoeopaths in the UK, organised an HIV/Aids symposium that promoted the outlandish ambitions of several speakers. For example, describing Harry van der Zee, editor of the International Journal for Classical Homoeo pathy, the society wrote: "Harry believes that, using the PC1 remedy, the Aids epidemic can be called to a halt, and that homoeopaths are the ones to do it."

There is one final reason for rejecting placebo-based medicines, perhaps the most important of all, which is that we do not actually need placebos to benefit from the placebo effect. A patient receiving proven treatments already receives the placebo effect, so to offer homoeopathy instead - which delivers only the placebo effect - would simply short-change the patient.

I do not expect that practising homoeopaths will accept any of my arguments above, because they are based on scientific evidence showing that homoeopathy is nothing more than a placebo. Even though this evidence is now indisputable, homoeopaths have, understandably, not shown any enthusiasm to acknowledge it.

For now, their campaign continues. Although it has not been updated for a while, the campaign website currently states that its petition has received only 382 signatures on paper, which means that there's a long way to go to reach the target of 250,000. But, of course, one of the central principles of homoeopathy is that less is more. Hence, in this case, a very small number of signatures may prove to be very effective. In fact, perhaps the Society of Homoeopaths should urge people to withdraw their names from the list, so that nobody at all signs the petition. Surely this would make it incredibly powerful and guaranteed to be effective.

"Trick or Treatment? Alternative Medicine on Trial" (Bantam Press, £16.99) by Simon Singh and Edzard Ernst is published on 21 April

Homoeopathy by numbers

3,000 registered homoeopaths in the UK

1 in 3 British people use alternative therapies such as homoeopathy

42% of GPs refer patients to homoeopaths

0 molecules of an active ingredient in a typical "30c" homoeopathic solution

$1m reward offered by James Randi for proof that homoeopathy works

This article first appeared in the 21 April 2008 issue of the New Statesman, Food crisis

Photo: Getty
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The conditions for Labour's previous successes are falling apart. Where do we go from here?

This summer saw our Labour Party engaged in another lengthy period of introspection, culminating in the re-election of Jeremy Corbyn as leader thanks in large part to the transformation of our membership base since last spring. For those who haven’t read it, Ian Warren’s piece in Newsweek on why Owen Smith’s campaign was probably doomed by the circumstances of its birth rather than by the specifics of its execution is very much worth a read, not least because it offers a telling set of clues to the challenge we will face at the next general election. Whenever it comes, we will find that the electorate – or at least the elements of the electorate whose support is most necessary for us to win an overall majority – do not merely judge us on our values, policies, or competence as we might like them to do, but through other frames beyond our control. They will consider our fitness for office, our relevance to their concerns, and the image that we project – deliberately or otherwise. Insurgent campaigns, especially those run from opposition, are often interpreted by the public in a way that is difficult to predict. That will be a huge challenge for us all, whether we backed Jeremy or Owen, and combined with where we are electorally, a very daunting prospect.

Lest we forget, last May was a disaster. We did not just lose: we were smashed. All but one of our MPs gone in Scotland, with little sign of a recovery so far. We could be out for a decade – at least. 2015 was, I fear, the 1983 of my generation. Notwithstanding future boundary changes, to win a working majority of fifteen next time means making a hundred or so gains in England and Wales. Nobody has achieved that, except Tony Blair, since Britain moved to one-adult-one-vote. We should not kid ourselves that a victory on that scale is remotely straightforward, no matter how fervently we might hope for it or whoever the leader is. It's worth briefly revisiting what happened, unhappy as it was. We did after all win a handful of seats from the Tories in England: a few in London, plus another small handful outside – Hove, Dewsbury, Wirral West, Wolverhampton, City of Chester. Both inside and outside the M25, the seats we gained have much in common. Most of them are rich in either the liberal middle classes or in ethnic minority communities, Not to put too fine a point on it, people who don’t read the Guardian or the Mirror were not convinced by our message. Labour has a problem.

More depressing even than the paucity of gains is the fact that they were almost matched by our losses to the Tories. Many of the seats we had hoped and expected to gain instead saw Tory majorities increase sharply. To lose Bolton West, Vale of Clwyd, Gower and Morley and Outwood, to be down to only Southampton Test and Hove on the south coast is a disaster far beyond 2010. Our vote was concentrated ever more heavily in the seats we already held: above all in places where young, liberal, urban communities live cheek by jowl with large ethnic minority communities – places like Hackney, Islington, and Walthamstow. I make no criticism of Labour's pre-election organisational focus on trying to win seats quite unlike those, which might have given us a Labour government had we won them. It was our political failing that we had a message, a leader, and a set of policies which proved totally inadequate to winning over a plurality of the British people. We are still desperately far from changing that today: a recent poll had us no fewer than eighteen points behind the Tories. Sometimes it seems almost unbelievable that less than a decade ago there were Labour governments in London and Edinburgh as well as Cardiff.

How did all this come to pass? Alastair Campbell's latest volume of diaries offers a powerful reminder of both the strengths and achievements of Labour in government, and the mistakes or missed opportunities that all governments come to rue. Reading Gordon Brown’s remark from February 2005 that “we have not changed the country as much as we could or should” and his prescient observation about media obsessions - “how easy it is for the Tories to make immigration the issue, and we help them” - made me reflect on quite how much has changed and how insightful those observations remain, despite all the water that has flowed under the bridge since that spring almost twelve years ago when last we won power. It seems an age ago now. It is striking quite how little we have done in that time to address those changes; how little we have done to engage with the changing world since then and to shape our wider political discourse. The social and cultural background to how we seek support and contest elections, never mind the shape and structure of our economy, has altered beyond recognition.

Perhaps we should cast our minds back further, to the end of our last prolonged electoral malaise, and ponder how different that world was. I remember the Britain of 1997: I joined Labour as a teenager not long after, watching as Tony Blair changed our party and our country. It was a world where along with most other people, I didn't have an email address. It was a world without social media. It was a world where mobile phones were largely a novelty and you communicated with relatives and ordered items with letters and cheques and stamps. The newspapers were in black and white and had mass readerships, and there were just four channels on most people’s televisions. The concept of a national conversation had a degree of reality it has now almost certainly lost.

It was a world where everyone of pensionable age, and plenty who were younger, remembered the Second World War. I grew up listening to my grandfather's experiences of serving in that war and how it shaped the beliefs of those fortunate enough to return home. There remained a strong belief in the notion of personal sacrifices for a greater collective future and plenty of people whose experience of those sacrifices had been all too real. Much of that was still true even in 2005, the last time we won an election. The social media echo chamber didn’t exist. We couldn’t avoid listening to the electorate, no-one expressed their outrage on Twitter, or was reassured by Facebook that their friends all felt the same way; and the touchscreen smartphone in my hand and the tablet on which I'm writing this article were only glints in Steve Jobs’ eye.

That world has gone forever. As well as having lost manufacturing industries from town after town, ours is now a much more culturally fragmented society, with fewer people listening to what passes for any form of national conversation. Social media echo chambers are both symptom and cause of that change. More people now spend more time talking and listening to voices with which they agree, less exposed to opinions at variance with their own, less aware of their differences with others and less tolerant of political differences, even as they become in many respects more socially tolerant. The changes in the economic basis of our society have also driven that steady push towards a disintegrating polity.  The period since 1997 has seen slowly falling trade union membership, an ongoing decline in skilled manufacturing jobs, and the coming revolution (of which the long march has only begun) whereby skilled “white collar” jobs are lost to automation and smartphone technology. To a degree that worries me, the industrial and economic foundations of our collectivist traditions – the successful Labour and trade union politics of the last two centuries, from the Tolpuddle Martyrs to Tony Blair – seems to be giving way very fast to a different economy for which we are politically ill-prepared.

Earlier this year, Faisal Islam remarked that the Labour Party was a coalition between Hull and Hampstead, and that that coalition was breaking. I think that captures our problem really well, and I think the causes of that fracture lie in the economic and cultural changes since last we won power. To understand how we might address these changes requires an analysis of both what the people of Hull (or Sunderland, or Stoke, or the Rhondda) and Hampstead (or Islington, or Cambridge) have in common, and also what separates them.

At root, what people in Hull and Hampstead have in common – or had in common – and what unites both those areas in returning Labour MPs, is that a plurality of the electorate believes in a more equal society. They want decent public services, high quality schools for all children, and a first-rate health service. They accept and welcome a role for collective action – for government – in creating that fairer society. The electorate in those places also trusts Labour to deliver that agenda with competence, as every Labour government over the last century has done.

No matter how much we might wish it otherwise, the continuum stretching from left to right is an inadequate description of the political dynamics in our country at the moment. If we didn’t already know it, the referendum was a pretty clear message. My own home city of Sunderland, where I grew up and which I have had the privilege of representing for six years, sent three Labour MPs to Westminster last year, re-elected its Labour council in May, and delivered a resounding ‘Leave’ vote in June. The same story was repeated in many Labour strongholds across Britain. By contrast, almost every borough in London voted to stay and inner-city Labour strongholds like Camden and Lambeth did so by thumping margins. What is going on? How is economic and cultural change driving this divide?

It is worth mentioning at this juncture that Britain is not exactly alone in facing these challenges, nor is the British left the only movement dealing with this sort of tension within the existing party system. Donald Trump’s victory in the U.S. presidential election would appear in part down to the failure of the Democratic Party to motivate its traditional base in crucial swing states like Ohio, Wisconsin, Michigan and Pennsylvania. A quick look at every one of the major economies in Europe does not reveal a continent with electorally successful social democratic parties maintaining commanding poll leads. While we do well to examine ourselves to understand our problems, we should also be informed by what has happened elsewhere and – equally pertinently – what has not. So while Gordon Brown might have had a fair point that we had not done as much to transform Britain as we could have done, we should not beat ourselves up too much. This was, sadly, a general failing of social democracy in Europe and the United States. Even where our sister parties continue to govern, as in France, the polls do not give hope that situation will long continue. Similar to the outcome of the EU referendum in this country, the situation in the rest of Europe gives us a clear view of the difficulty that is tearing our support, if not yet our Party, apart. It is hard not to look at the rise of the FN in France, the AfD in Germany, or even of Podemos in Spain or Syriza in Greece, without seeing patterns across our continent.

One of the best assessments I have read recently on what is happening to our politics is an article on the bifurcation of our politics that Will Jennings and Gerry Stoker published in the Political Quarterly in March this year. Using terminology I find a little objectionable but with characteristics I can recognise, they identify two ‘Englands’: one that is (in their words not mine) “inward-looking, relatively illiberal, negative about the EU and immigration, nostalgic and more English in its identity”, and another which is (again their words not mine) “global in outlook, liberal and more plural in its sense of identity”.

To me, their key insight is that in both these Englands there is a battle between right and left for electoral success, and that in that first England, the Labour Party lost far too much ground to the Tories and UKIP in 2015. Ever since, we have made ourselves more and more a party at home on the left side of the second England rather than in both. The former Labour voters who live in that first England – the people who are sometimes described as the “left behind” – are the voters for whom we need to have a strong set of messages and to whose concerns we must be most alive. They are the people for whom we must craft a message that also carries the Labour vote in the second England, thereby forging and sustaining a governing majority to take us back to power and keep us there. As Jennings & Stoker put it: “In majoritarian systems such as the UK’s, the challenge for party elites is to build an electoral coalition that straddles the divides created by the bifurcation of politics.” I should also say that though they talk about England, I think a lot of their analysis is true for Wales as well. Scotland, as ever, poses a very different set of challenges.

My view is that the bifurcation has been driven by the rapid hollowing out of our economic model that has sustained social democratic movements since the coming of the industrial revolution. Too many cities like Sunderland have lost most of their manufacturing industries, with too little hope of the large numbers of jobs they provided ever returning. At the same time London, Edinburgh and other cities built on less tangible industries thrive and attract migrants from across the world. That is great, but it also opens up a sharp gap between places where being an economy open to Europe and the world is obviously a good idea, and places where that advantage is rather less apparent to people. A combination of free trade and automation means the sorts of work that once employed miners, dockers, millworkers and shipbuilders in my constituency and in every major city in Britain haven't just moved to China, Malaysia or wherever, they've also moved from people to machines. They aren't ever coming back, because lots of them aren’t done by people in Malaysia either, but by robots. Let us not forget, all that said, that many of those jobs were hard and dangerous. The reality that my son will probably never work down a coalmine, and that my daughter will probably not leave school to work in a textile mill at fifteen is one I welcome, even as I worry about what jobs there will be and what their future will hold.

I am repeatedly struck by the startling lack of serious thought in the wider Labour Party about how we engage with these changes, and with the people left behind by them. We lack as a movement a clear picture of how we frame our politics and present our values for an age where the economy is transforming and the social and political divides are shifting. That’s not to say there haven’t been efforts to understand this process, but too often they have been woefully inadequate. We've seen various manifestations of communitarian reinvention, from ‘community organising’ to 'Blue Labour' – all variations on a common premise that it is possible to deal with cultural and industrial change by wishing it hadn’t happened, an effort to pass off nostalgia as political strategy. Elegiac lyricism about a vanished world of large unionised workplaces full of men doing semiskilled jobs, shared cultural experiences, shared religious affiliation, and tight community links does not amount to a plausible programme for government. That world has gone, it isn't coming back, and hankering for the past isn't what any of us were elected to do. And to go back to that horrible morning of 8 May 2015, no evidence I have ever seen suggests that nostalgia is the route to victory in Nuneaton.

We shouldn’t be surprised by that. Thirty-five years ago, Lord Dahrendorf famously pilloried the SDP for offering “a better yesterday”. That is what too much of our offer has been in recent years, and what almost all of it has been in recent months. We will repeal Tory legislation – excellent, but what will go in its place? We will restore manufacturing industry as a larger component of a rebalanced British economy – how, when governments of all sorts have been wrestling with this for decades? We will, according to some colleagues, reduce immigration sharply – and what will that do to the economy? We are still offering the electors of Nuneaton nothing but the slogans and solutions of times long past.

We've also seen an extraordinary fascination among Labour colleagues with talking about “Englishness”. It is true that many of the people in the so-called “left behind” group are people who would probably describe themselves as English rather than British, but I am wholly unconvinced that the way to reconnect with these voters is to talk about Englishness all the time. To diagnose a political problem, or to point to a feature of its manifestation, is not in any sense to identify the means by which to resolve it. Talking about the Chartists or fiddling with our Rulebook is not the high road to the New Jerusalem, and I am completely unconvinced that simply wrapping ourselves in the Cross of St George will get us very far in Nuneaton either.

Another blind alley is electoral reform. First, it isn’t going to happen – at least not in a way that helps us for as long as there’s a Tory government – so let’s not waste our time calling for it. We need to face up to the fact that we lost the general election. Fiddling with the electoral system so that losers become winners is pathetic, looks pathetic, and distracts us from the changes we need to achieve. Every moment that the British people hear us talking about electoral reform is a moment we are not heard talking about the things that matter to voters and their families: the economy, jobs, the NHS, schools. We clearly failed to cut through to electors on these issues last May. Let’s not make it harder for ourselves by banging on self-indulgently about AV and STV, d’Hondt and MMP, when we could be talking about issues that most people have actually heard of.

Partly perhaps because power in Parliament seems so far away, we’ve also seen a new embrace of devolution and the concept of localism. Localism is too often a trap for anyone who calls themselves a socialist or a social democrat. In the US the same movement is called “states’ rights”, and everyone knows why certain states want certain rights returned to them rather than controlled centrally. In the US, few of a leftish persuasion would find convincing the idea that power is always best exercised and controlled locally, closest to the citizen. They have seen where that leads. Here in Britain the trap can be set because the pitfalls are less obvious and our history less scarred, but they remain pitfalls all the same. Most obviously, localism too often means devolving responsibility without power.

Metro mayors and combined authorities provide an excellent illustration of that trap. The Tories are now devolving power over the NHS in Greater Manchester to the local Combined Authority and its directly elected mayor. It is my strong suspicion that George Osborne knew exactly what he was doing when he invented this constitutional novelty: he was doing over the Labour Party. I have sat through enough Health Questions in the Commons where every criticism of the government is deflected with an answer along the lines of “In Wales…”. The Tories are going to create a small Labour-controlled NHS in the heart of England, run separately from the rest of the country. Responsibility for administering it will rest with the Labour Party, yet decisions on the overall level of funding from general taxation will continue to rest with the Conservative Party in Westminster. So Labour will endure responsibility without power, and the Tories will enjoy power without responsibility. What could possibly go wrong? I wish Andy Burnham every success, but I fear the Tories have not merely set him up to fail, they have set up that failure to be a fable for all England.

There is another and more insidious set of traps in localism. A powerful government in Whitehall can take on major companies that seek to defraud the people, can build a National Health Service, can reform our schools. Take these powers away from the centre and they may be more local, but they are also lesser. For one thing, they are easier to chip away at. Yvette Cooper led a brave if doomed fight this time last year to resist the devolution and fragmentation of the legal framework for abortion rights within Britain. As she said at the time: “We are stronger if we stand together to defend them against those who want to turn back the clock, rather than leaving each other to face the heat of the campaign alone.” The powers that Labour councils seek to take from the central state are – as they see it – about improving services locally. But you can bet that any number of Tory councils would love there to be regional or even council-specific Minimum Wages, not a National Minimum Wage. On occasions when HMRC bothers investigating rather than excusing tax evasion, they at least have the resources to do a decent job of it. If further elements of taxation are devolved to local level, don’t bet on that always being the case. If you care about effective, equitable and efficient public services, cutting them into council-sized chunks is not the obvious way to achieve economies of scale, let alone to ensure their responsiveness to democratically elected governments.

There’s also a politics to all this which we shouldn’t forget. If people in places where we are never going to control the council locally are going to vote Labour at Westminster elections, we need to give them a reason to do so. If we want people to vote Labour, we should not be advocating for an incoming Labour government to relinquish at once the remaining levers it has to make everyone’s lives better. A Labour government should not be limiting its ambitions for improvement to the lives of people who happen to have a Labour council or a Labour combined authority. Political power is there to be used to achieve positive change, not to be handed back to local Tories on a misguided point of principle, not least because – as we all know – the notion that people only vote in local elections on local issues and never as a way of kicking the incumbent government is at best optimistic.

If none of these arguments persuade you that promising to devolve power to local government is simply another electoral blind alley for us, I recommend looking at what the voters think. The TUC commissioned one such study immediately after the election, and their website allows you to compare the interests of swing voters who considered voting Labour and ended up voting Tory with the interests of the broader electorate. The people we need to win over to form a government again – people who voted Tory having thought about voting Labour – are even less interested in what we say about devolution than the population in general.

Not one of these approaches to our travails is remotely good enough. None of them acknowledge the world in which we currently live, let alone that which we will live in after Brexit – whatever that ends up meaning – or ask what a Labour government is for in such a world. Let me take immigration as an example, as much as anything else because most political arguments seem to these days.

Given the city in which I grew up, perhaps it’s inevitable that my political analysis is shaped by the fortunes of the manufacturing industry. But this also means that I am extremely reluctant to endorse solutions to our problems that might sound popular but which I believe would bring economic ruin to my constituents. We are lucky – we still have manufacturing industries. The Nissan plant has a productivity record which is the envy of the sector and of which everyone in Sunderland, and indeed the wider region, is rightly proud. So solutions which might win elections but destroy industries and livelihoods thereafter are no solutions at all. Nowhere has this been clearer to me of late than the issue of free movement and immigration. Nissan is one of the north-east’s iconic employers, a huge manufacturing plant supporting supply chains across the region. Access to the single market has been central to the success of the automotive sector in a Sunderland and across our country, yet it is already all too clear that Europe isn't going allow us free movement of goods without free movement of people. I wholeheartedly welcome Nissan’s recent decision to continue investing in Sunderland, but we shouldn't imagine the issues have gone away. Any form of Brexit that imperils single market access puts at risk the livelihoods of thousands of the people I represent.

Movement across continents and the world is now extremely straightforward. The real terms cost of getting on a plane to Spain or Italy, never mind Poland, Hungary or Egypt, has gone through the floor. Migration is here to stay. Across swathes of the world, war and unrest creates wave after wave of refugees, making their way to the relative safety of Europe. The destructive and long-running civil war in Syria, which is sliding slowly towards a proxy war between Russia, Iran, and the West, is only the beginning. Yet the refusal of almost every European country to either intervene effectively in Syria or to admit refugees in adequate numbers – not even economic migrants but people fleeing for their lives – has hampered EU decision-making to a degree to which those who wish Europe and its institutions ill could only have dreamed. What is more, it has changed the conversation about free movement across the continent. Today, migration has a salience and unpopularity that has hardly been known for generations.

I take the view that the right decisions for Britain’s future are not invariably the ones that are immediately and universally popular. If they were, all politicians would be redundant. Sometimes things that are true are deeply unpopular, and sometimes things that are popular would be catastrophic as policy choices. That to me is why we are a representative democracy rather than one governed by referendum after referendum. I also believe that as politicians we have a moral responsibility to tell the truth. On immigration, the facts – as Jonathan Portes of the NIESR frequently and untiringly points out – are clear. Free movement of people within the EU is, overall, good for Britain. Not because it widens our cultural experience, although it undoubtedly does and that is a good thing. Not because it is a price worth paying for single market access, although it may well be and for my constituency single market access is very important. Not because I don't care about the transitional effects when suddenly more people are living in an area than existing public services can support, because I do, very much. But because immigration into Britain has boosted our economy year after year and thus raised the standard of living for people in this country. It makes people in our country and in my constituency wealthier on average than they would otherwise be, and it makes working people – for whom Labour was founded and exists – better off. We should have no compunction about telling those simple truths.

If we pretend things that are true aren’t so, and pretend that seductively popular options which would actually damage us are without downsides, we deserve to get in trouble. The fastest way to lose trust is to be found out in deceit, and once we lose that trust, we will then find it very hard to gain the support we need to change what can and should be changed. It’s easy for those who don’t believe in government: they have nothing to lose from a diminution of faith in politics and politicians. As Labour politicians we have everything to lose: we have a double responsibility.

So to the point: the ‘lump of labour’, the notion that there are a finite number of jobs to go round, is a long-known fallacy. Those who pretend otherwise or deny that finding should be treated with the same bemused contempt as Douglas Carswell when he claimed the tides were driven mainly by the sun. The problems we face in Britain today do not result from the inadequacy of immigration controls. The reason it's difficult to get a GP appointment in Sunderland is because the government has wrecked the health service through chaotic reorganisations and haven't trained nearly enough family doctors. It is not because there are tens of thousands of recent arrivals in Sunderland from central Europe who are disproportionately unhealthy, because that simply isn't true. The reason Hetton School in my constituency has spent most of the last few years falling down is because the Tories cancelled the rebuilding in 2010, not because Hungarian workers were able to claim benefits when they fell ill from the day they started working here a decade ago. There is something horribly un-socialist about blaming people for the consequences of political decisions of a right wing government. That is the politics of populism not socialism, the politics of easy answers rather than right answers.

It is also, to return the concern I expressed earlier, the politics of shredding apart the left-wing coalition of the two Englands. If you want an issue on which Labour voters in Hull and in Hampstead probably don’t agree, it’s immigration. Simple political common sense – as Gordon Brown observed all those years ago – tells us that we should not be banging on about an issue which divides our own potential support in two, nor encouraging and enabling others to do so. The more we ourselves frame our politics in a way which divides our support, the less surprised we should be when we are almost twenty points behind in the polls. At the last election, half of Labour’s possible support was horrified that we were selling mugs branded “Controls on immigration”, while the other half simply did not believe that, if immigration was a major issue, Ed Miliband was the answer. In truth, both sides had a point, and experience elsewhere in Europe tells us that social democratic parties that make a point of talking about immigration while in opposition do not by and large spring back into power. The lesson is clear: if the divide in our politics is indeed between the two Englands, and we have put ourselves on the side of one of them, then the Referendum result tells us who is going to win. If the divide in politics is twofold – both the two Englands and left-right, then we cannot be restricted to one corner. We have to win for the left and centre in both Englands. Repeatedly reminding the electorate of issues which split Hull from Hampstead even within the core Labour coalition is completely counterproductive, not least because there are plenty of people willing to move onto patches of what was once our political territory. The obvious one has been UKIP, but Theresa May’s conference pitch on the power of government to do good was an audacious bid to park a lot of tanks on a very poorly defended lawn.

Since there are various blind alleys, and since I don’t think emulating Ukip’s stances on immigration would be either right or expedient, what should we do, and what should we emphasise? Part of that is, or should be, an empirical question. Nigel Stanley at the TUC wrote a fascinating article a few years ago on George Lakoff’s work on framing, and how the polling that the TUC had conducted could and should inform the choice of language we use about the welfare state in Britain. The results themselves are extremely interesting – for example, we should talk about “national insurance” instead of “benefits” or “social security” – but actually the work in itself is just as important. This is interesting on three levels. First, because despite how cheap polling now is, public discussion on the left of how we should frame our language is too often sorely lacking in empirical content, making up with moral indignation and baseless assertion what it lacks in demonstrable truth. Second, because the polling they carried out also looked at how best to change the way people saw these issues so as to make them more likely to support the sort of policies Labour would be likely to advocate. Finally, because the results were usable, although whether Labour actually used them to inform our messaging ahead of 2015 I do not know. I do know that the further work the TUC did following the 2015 election, to which I referred earlier, on what swing electors thought about the issues that matter, is both fascinating and chastening. Too much of our debate is trapped in an arrogant belief that what we think matters to swing voters, or what we find interesting to talk about, is what actually matters to them, even when the data disproving that stares us in the face. One thing that this data does tell us is that “having decent messages for people on middle incomes” and “being trusted to run the economy” mattered noticeably more to those who considered voting for us but in the end chose not to than they did for the rest of the population. Englishness, not so much.

Another large part is necessarily less empirical, but still needs to be grounded in the reality of where we are. It is about engaging with the world as it will be when we are next on the threshold of power, and not as we dimly remember it from the 1980s or even the 2000s. Tom Watson’s speech at conference was excellent, and in particular his commission on the future of work is really important. Done properly, their work could inform much of how we move Labour politics to look – as we said  in 2005 – forward not back. As a party, we have a habit of determined navel-gazing, focusing on internal organisational issues in which the electorate has no interest. What was so refreshing about Tom’s speech was his determination to move past that and straight back onto the territory of government. I’d add schools and the NHS as two issues where in the last few years we have simply not had a coherent policy that properly engages with where we will be by the time of the next election. Solemn vows to repeal the Health and Social Care Act cheer up the delegates at Conference, but repealing legislation that by 2020 will be almost a decade old and the basis for how the NHS operates is a recipe for total chaos, not sustained improvement. We also need to be more serious about reviewing how the health service works. Do we spend enough on preventative care and on public health? If we targeted that work better, could we save money more quickly? Does the government make proper use of the vast quantities of health data that it collects to drive improvements in NHS operation and resource allocation? How do we connect up the budgets so that managers of acute services for preventable ill-health find it in their interests to fund prevention work? If we want to reduce the role of the private sector in the NHS, what are the criteria by which we should go about doing that? There was remarkably little about any of this at Conference this year, and yet the NHS is an issue which – handled well – could mobilise and unite the left of both Englands.

On transport, to take another issue, we must reach beyond a comfort zone commitment to rail renationalisation – which is good, but won't in itself solve very much – to address questions about what the purpose of renationalising will be, and how we would balance funding transport improvements. And what of those voters, including in my own constituency, who don't enjoy easy access to rail services and rarely get on a train?

As for schools, the catastrophically stupid Tory policy of bringing back grammar schools has distracted us from having a coherent position on the wider situation. The reality is that well over half of state secondary schools are now academies outside local authority control. Tristram Hunt did some good work in the run up to 2015 on how we could put in place a new framework for driving up standards and intervening, but we should engage with the probability that the vast majority of schools by 2020 will be outside the power of local authorities, with governing bodies that are smaller, less representative, and – for good or ill – much more professionalised. That creates opportunities as well as problems. It’s worth remembering that the Dedicated Schools Grant was introduced by the last Labour government to stop Tory councils siphoning off money we wanted spent on schools to pay for their own pet projects. If school funding is now more directly driven by central government than it was twenty years ago that means greater power for an incoming Labour government to effect change fast. What should schools be teaching that they aren’t now? What sorts of skills might we want people to learn at school that we don’t now? The current fads for coding and (to a lesser extent) Mandarin don’t seem to reflect a serious consideration of how best we can use limited hours in the school day to give our people either a better education or a competitive edge in the trading world of the future. What can we learn from the success of The London Challenge to improve schools across the county? Again, talking about schools – as with talking about the need to improve all public services delivered by the state – is a way of uniting the left of both Englands: shared concerns about the distribution of social goods that unite us, rather than opening cultural gaps that divide us. We need to show both a degree of intellectual seriousness about the issues, and a laser-like focus on how we shape and refine our language to turn those issues into victory.

To me, therefore, what the next few months and years need to show from Labour isn’t simply or necessarily about supporting Jeremy or maintaining a semblance of unity or a particular policy platform. What we need to do is to look as forensically as we can at the changes that have actually happened in Britain since we last won a general election in 2005 – a time before Twitter, iPhones, Brexit, same sex marriage, the Trade Union Act, the rise of the Scottish National Party – and decide what a Labour government might do differently when it returns to power. We need to formulate a policy agenda that is more practical and more redistributive of power, wealth and opportunity than simply “repeal Tory legislation”. This could allow us to frame the debate again as one between collective action and its absence, not between the two Englands of Jennings and Stoker. And having formulated that clear sense of how the Britain of 2020 would be run differently between 2020 and 2025 by Labour, we need to work out how to persuade the electorate of that – to work out exactly how we should communicate our promises. Mass rallies of the true believers and shared content from The Canary or the Independent are definitely not the answer, even if it turns out that can be part of winning a leadership election. The question is one on that should be driven by evidence: what framing and what language best allows us to present our messages? What beliefs do the electorate already have about us that need defusing, or at least acknowledging before we can say our piece? What parts of what the Tories say about us are things the electors believe, or at least find plausible, and also think are damaging?

All of these questions have answers we find by commissioning research, by talking to electors on the phone and on the doorstep, and not by introspection. We would do well to encourage those who have funds, and will spend them on helping the Labour Party even if not on supporting the leadership, to look at a whole host of questions on how we frame issues and what language we use. We need to understand how and where that can actually be effective from opposition, and where we are pushing uselessly at firmly closed doors. We need to understand on which issues we can make the best progress in taking votes off the right in both Hampstead and in Hull, and how we can hold together Hampstead and Hull when different forces try to take each away from us. It is time for Labour’s debate on our future to move from self-indulgence, arm waving, and affirmation to discipline, analysis, and evidence. We’re only going to get one shot at winning the next general election and securing the Labour government that Britain needs, and we need – need desperately – to get it right.

Bridget Phillipson is Labour MP for Houghton and Sunderland South.