Jeremy Hunt speaks at the Conservative conference in Manchester last month. Photograph: Getty Images.
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Hunt wants to do for the NHS what Gove did to schools. How should Labour respond?

In a closely fought battle, when hospital wards face closure in marginal seats, there will be irresistible temptation for Labour to make promises that can’t be kept.

There is one simple Labour answer to the question of what is wrong with the NHS: nothing, apart from its misfortune in having fallen into Tory hands. Most opposition MPs know that is less than the whole truth but there are clear incentives not to complicate the picture.

The British public reveres the idea of the NHS even when it is disappointed by the reality. Voters also trust Labour much more than the Tories to share that reverence. The collective national memory is hazy on detail but the foundation of a free health service under a Labour government, its deterioration under Margaret Thatcher and rehabilitation under Tony Blair are folkloric.

That is why David Cameron made vows of love for the NHS the centrepiece of his campaign to “modernise” his party and why he must rue his televised pledges not to subject it to “pointless top-down reorganisations.” Labour would happily broadcast those clips on a loop as evidence that the Prime Minister’s pledges are bunk.

The Tory defence is that a budget crisis made drastic reform unavoidable. Change hurts, but the status quo was unsustainable. In other words, true belief in the NHS means willingness to confront long-term challenges. What Labour depicts as duplicitous vandalism, the Conservatives call visionary courage. (Besides, add ministers, the health budget has been ring-fenced to shield it from the ravages of austerity.)

Those arguments, while comforting to Tory ideologues, dissolve on contact with political reality. Cameron is on film saying one thing before doing the opposite. The moment when Prime Minister threw his weight behind a vast and, for most people, incomprehensible reconfiguration of health services, he evacuated his entire stock of trust as a guardian of the NHS. As headlines about staff shortages and waiting times in accident and emergency wards start colonising the front pages, Cameron will struggle to disentangle the mess he says he inherited from the last government from the one he patently made for himself.

Downing Street is braced for a difficult winter. The cold season always produces a spike in demand for the health service and it is already struggling to cope. Meanwhile, Cameron gets conflicting advice about how to respond. Earlier in the year he appeared to share the view of Tory grandees, including veteran health ministers, who counselled that Labour cannot be beaten on the NHS and that a Conservative’s best bet is always to aim for de-politicisation. According to this view, the Prime Minister should treat a winter crisis as a force of nature, appealing to the country’s stoicism and praising the fortitude of hospital workers, as he might do in the event of an earthquake. Labour’s constant partisan attacks might then be made to look tribal and opportunist. Andy Burnham, shadow health secretary, already risks coming across as the NHS doom-monger-in-chief.

The more aggressive approach, preferred by Lynton Crosby, Cameron’s campaign chief, and adopted by the Prime Minister over the summer, is to target Labour’s record. The Tories feel they have won an argument about reckless spending by the last government and want to deploy some of that political capital to insulate themselves from blame for health service misery. The charge is that problems were ignored when the money was flowing and that Burnham, as Labour’s last health secretary, is therefore disqualified from the debate about what to do now that the money has run out.

Jeremy Hunt, the current Health Secretary, has a third way. He aims to position himself as the champion of patients against an unresponsive health bureaucracy. He takes as his model Michael Gove’s approach to local authority schools, casting himself as the raiser of standards and the scourge of complacency in a system that embraces mediocrity and is fixated on only ever doing things the way they have always been done. “Jeremy is always going on about what Michael is doing at Education,” says a senior Department of Health insider. That is the impulse behind calls for more Ofsted-style regulation of hospitals and for GPs to offer more appointments outside normal office hours. Hunt would like to present the problems in the NHS as justification for reform. Labour responds that he is cynically dumping responsibility for the fiasco onto beleaguered doctors and nurses.

The Health Secretary’s strategy cannot repair the damage done by Cameron’s broken promises, although he has found the line the Tories probably ought to have taken in the first place. It is fair to point out that the health service is unprepared to deal with an ageing population whose clinical needs are getting more expensive and whose expectations of care and convenience are conditioned by the service culture of a 21st Century consumer-oriented market economy. Today’s patients are less patient than their forebears. Nor is it controversial to say the NHS budget will struggle to cope with those demands, regardless of who is in power.

Burnham has recognised that conundrum. His answer is an ambitious integration of health, social care and mental health services. In theory, this “whole-person care” mission saves money by deploying resources more wisely, intervening early to prevent solvable problems becoming chronic. It is a sensible long-term agenda but tricky for Labour to sell since it costs money up-front to implement and looks like another dreaded reorganisation.

The easy option would be to bury reform in the manifesto and campaign as if the glory days can be restored simply by freeing the health service from Cameron’s clutches. Labour front benchers insist the message will be more realistic and more nuanced than that. “We are not going to do a rehash of ‘they’ll cut the NHS, we’ll save it,’” one shadow cabinet minister tells me.

That is easy to say now. In a closely fought battle, when hospital wards face closure in marginal seats, there will be irresistible temptation to make promises that can’t be kept. There is an old pattern, followed at various times by all parties, of campaigning as if the NHS can be left alone, realising in office that it must change and then having to confront the anger of voters who feel duped. The Tories have committed that blunder on a colossal scale. The opposition’s advantage is clear. Less obvious is how Labour exploits the situation without making the same mistake.

Rafael Behr is political columnist at the Guardian and former political editor of the New Statesman

This article first appeared in the 13 November 2013 issue of the New Statesman, The New Exodus

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How to think about the EU result if you voted Remain

A belief in democracy means accepting the crowd is wiser than you are as an individual. 

I voted Remain, I feel sick about this result and its implications for what’s to come. But I’m a believer in democracy. This post is about how to reconcile those two things (it’s a bit unstructured because I’m working it out as I go, and I’m not sure I agree with all of it).

Democracy isn’t just fairer than other systems of governance, it’s smarter. It leads to better decisions and better outcomes, on average and over the long run, than countries that are run by autocrats or councils of wise men with jobs for life. It is simply the best way we have yet devised of solving complex problems involving many people. On that topic, if you’re not averse to some rather dense and technical prose, read this post or seek out this book. But the central argument is that democracy is the best way of harnessing ‘cognitive diversity’ — bringing to bear many different perspectives on a problem, each of which are very partial in themselves, but add up to something more than any one wise person.

I don’t think you can truly be a believer in democracy unless you accept that the people, collectively, are smarter than you are. That’s hard. It’s easy to say you believe in the popular will, right up until the popular will does something REALLY STUPID. The hard thing is not just to ‘accept the result’ but to accept that the majority who voted for that result know or understand something better than you. But they do. You are just one person, after all, and try as you might to expand your perspective with reading (and some try harder than others) you can’t see everything. So if a vote goes against you, you need to reflect on the possibility you got it wrong in some way. If I look at the results of past general elections and referendums, for instance, I now see they were all pretty much the right calls, including those where I voted the other way.

One way to think about the vote is that it has forced a slightly more equitable distribution of anxiety and alienation upon the country. After Thursday, I feel more insecure about my future, and that of my family. I also feel like a foreigner in my own country — that there’s this whole massive swathe of people out there who don’t think like me at all and probably don’t like me. I feel like a big decision about my life has been imposed on me by nameless people out there. But of course, this is exactly how many of those very people have been feeling for years, and at a much higher level of intensity. Democracy forces us to try on each other’s clothes. I could have carried on quite happily ignoring the unhappiness of much of the country but I can’t ignore this.

I’m seeing a lot of people on Twitter and in the press bemoaning how ill-informed people were, talking about a ‘post-factual democracy’. Well, maybe, though I think that requires further investigation - democracy has always been a dirty dishonest business. But surely the great thing about Thursday that so many people voted — including many, many people who might have felt disenfranchised from a system that hasn’t been serving them well. I’m not sure you’re truly a democrat if you don’t take at least a tiny bit of delight in seeing people so far from the centres of power tipping the polity upside down and giving it a shake. Would it have been better or worse for the country if Remain had won because only informed middle-class people voted? It might have felt better for people like me, it might actually have been better, economically, for everyone. But it would have indicated a deeper rot in our democracy than do the problems with our national information environment (which I accept are real).

I’m not quite saying ‘the people are always right’ — at least, I don’t think it was wrong to vote to stay in the EU. I still believe we should have Remained and I’m worried about what we’ve got ourselves into by getting out. But I am saying they may have been right to use this opportunity — the only one they were given — to send an unignorable signal to the powers-that-be that things aren’t working. You might say general elections are the place for that, but our particular system isn’t suited to change things on which there is a broad consensus between the two main parties.

Ian Leslie is a writer, author of CURIOUS: The Desire to Know and Why Your Future Depends On It, and writer/presenter of BBC R4's Before They Were Famous.