Health Secretary Jeremy Hunt delivers a speech during his visit to the Evelina London Children's Hospital on July 5, 2013. Photograph: Getty Images.
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NHS privatisation isn't working, it’s time for a more mutual solution

Mutuals are best placed to initiate a system of healthcare that delivers personalised, holistic care in a cost-effective manner.

As much as many of us would like to ignore the fact, our National Health Service is at the most critical juncture in its long history. An ever-ageing population, together with the stark rise in prevalence of those suffering from lifestyle diseases, both place our healthcare system on a financially unsustainable footing. Indeed, long-term conditions, such as obesity and diabetes, will alone bankrupt the NHS within a decade, with a £19bn funding gap expected if these conditions are not managed properly.

Yet from government there seems to be a lack of good ideas on how to ensure that NHS remains viable as an institution free at the point of use. Many of the arguments surrounding health reform suggest that the solution to this financial crisis is a laughably simple one – more liberalisation. The trend towards NHS liberalisation, which started with Margaret Thatcher and continued with the Health and Social Care Bill, has been at the heart of health reform over recent decades. This trend is based upon the proposition that is all that is needed to improve NHS services is to open up the system to private sector providers. Then competitive forces will, as if by magic, improve patient quality whilst making the necessary savings.

But although competition in certain cases is to be welcomed, it is alone insufficient to tackle the health systems incoming problems. The complex conditions of the future will require a different type of healthcare, delivered by a different healthcare system. The NHS of the past, which was designed to combat acute diseases like polio and tuberculosis, is simply not configured to treat the chronic diseases associated with ageing and flawed lifestyle choices. These conditions require more integrated forms of service delivery that provide holistic, whole-person care.

It has long been known that integrated care is the holy grail of NHS reform. Yet the coalition government has failed to make this a top priority, and the cancellation of the £3.8bn Better Care Fund is clear evidence of this. In fact, instead of choosing the harder path towards better healthcare integration, the government has opted for and prioritised yet more liberalisation in the form of the Any Qualified Provider programme.

This initiative is intended to open up services and improve patient choice. Under this scheme, private providers are allowed to deliver basic NHS services. At a first glance, by the government’s standards the programme seems to have been a success, with 105 firms singed up to the scheme. But instead of opening up the service to smaller providers, as was first intended, the process has been criticised for prioritising the larger providers. A study of AQP found that 24 of the 105 firms were large companies with at least 250 members of full-time staff.

AQP is not the answer to integrated care, as it merely atomises and fragments care by multiplying the number of bodies delivering healthcare. In this way, it simply destabilises existing services and damages care pathways. It cannot, therefore, deliver the whole-person care we need. Because of this, we at ResPublica ask that the government seriously consider scrapping the Any Qualified Provider scheme. Competition and choice are to be welcomed, but they should not come at the price of collaboration and holistic care. We would instead argue for a different approach.

In our latest report, Power to the People: The mutual future of our National Health Service, we argue that mutuals are best placed to initiate a system of healthcare that delivers personalised, holistic care in a cost-effective manner. Mutual organisations are, by their very nature, democratic and benevolent institutions. As such, they are perfectly placed to integrate the needs of patients with the capabilities of clinicians in an inclusive fashion.

Such a proposal is not an odd suggestion. Mutuals already have a firm foothold in the NHS. Foundation Trusts, which operate on a mutual model, are now the standard composition for hospitals, and mutual NHS spin-outs are raising standards across the sector. One type of mutual organisation that has often been ignored, but could perhaps perform such a vital role, is the friendly society.

Before the advent of the NHS, most healthcare was provided through friendly societies. Just before the onset of the Great War, there were 26,877 friendly societies operating in England and six million members. The democratic and inclusive characteristics of these organisations would make them ideal candidates for performing an integrator role that would connect disparate elements of the NHS to deliver the holistic care our older people need.

As the report makes clear, the financial benefits of this model could be vast. By integrating care, we estimate that the NHS could save £4.5bn by 2020. Embracing mutualism would not only integrate care and deliver better outcomes, it would have significant financial benefits as well. Clearly, if we are to have the integrated care that so many of us need, then policy makers will have to ditch their fixation with ever increasing liberalisation and assess the benefits more mutualism could bring to the NHS.

Adam Wildman is research manager at ResPublica 

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Is defeat in Stoke the beginning of the end for Paul Nuttall?

The Ukip leader was his party's unity candidate. But after his defeat in Stoke, the old divisions are beginning to show again

In a speech to Ukip’s spring conference in Bolton on February 17, the party’s once and probably future leader Nigel Farage laid down the gauntlet for his successor, Paul Nuttall. Stoke’s by-election was “fundamental” to the future of the party – and Nuttall had to win.
 
One week on, Nuttall has failed that test miserably and thrown the fundamental questions hanging over Ukip’s future into harsh relief. 

For all his bullish talk of supplanting Labour in its industrial heartlands, the Ukip leader only managed to increase the party’s vote share by 2.2 percentage points on 2015. This paltry increase came despite Stoke’s 70 per cent Brexit majority, and a media narrative that was, until the revelations around Nuttall and Hillsborough, talking the party’s chances up.
 
So what now for Nuttall? There is, for the time being, little chance of him resigning – and, in truth, few inside Ukip expected him to win. Nuttall was relying on two well-rehearsed lines as get-out-of-jail free cards very early on in the campaign. 

The first was that the seat was a lowly 72 on Ukip’s target list. The second was that he had been leader of party whose image had been tarnished by infighting both figurative and literal for all of 12 weeks – the real work of his project had yet to begin. 

The chances of that project ever succeeding were modest at the very best. After yesterday’s defeat, it looks even more unlikely. Nuttall had originally stated his intention to run in the likely by-election in Leigh, Greater Manchester, when Andy Burnham wins the Greater Manchester metro mayoralty as is expected in May (Wigan, the borough of which Leigh is part, voted 64 per cent for Brexit).

If he goes ahead and stands – which he may well do – he will have to overturn a Labour majority of over 14,000. That, even before the unedifying row over the veracity of his Hillsborough recollections, was always going to be a big challenge. If he goes for it and loses, his leadership – predicated as it is on his supposed ability to win votes in the north - will be dead in the water. 

Nuttall is not entirely to blame, but he is a big part of Ukip’s problem. I visited Stoke the day before The Guardian published its initial report on Nuttall’s Hillsborough claims, and even then Nuttall’s campaign manager admitted that he was unlikely to convince the “hard core” of Conservative voters to back him. 

There are manifold reasons for this, but chief among them is that Nuttall, despite his newfound love of tweed, is no Nigel Farage. Not only does he lack his name recognition and box office appeal, but the sad truth is that the Tory voters Ukip need to attract are much less likely to vote for a party led by a Scouser whose platform consists of reassuring working-class voters their NHS and benefits are safe.
 
It is Farage and his allies – most notably the party’s main donor Arron Banks – who hold the most power over Nuttall’s future. Banks, who Nuttall publicly disowned as a non-member after he said he was “sick to death” of people “milking” the Hillsborough disaster, said on the eve of the Stoke poll that Ukip had to “remain radical” if it wanted to keep receiving his money. Farage himself has said the party’s campaign ought to have been “clearer” on immigration. 

Senior party figures are already briefing against Nuttall and his team in the Telegraph, whose proprietors are chummy with the beer-swilling Farage-Banks axis. They deride him for his efforts to turn Ukip into “NiceKip” or “Nukip” in order to appeal to more women voters, and for the heavy-handedness of his pitch to Labour voters (“There were times when I wondered whether I’ve got a purple rosette or a red one on”, one told the paper). 

It is Nuttall’s policy advisers - the anti-Farage awkward squad of Suzanne Evans, MEP Patrick O’Flynn (who famously branded Farage "snarling, thin-skinned and aggressive") and former leadership candidate Lisa Duffy – come in for the harshest criticism. Herein lies the leader's almost impossible task. Despite having pitched to members as a unity candidate, the two sides’ visions for Ukip are irreconcilable – one urges him to emulate Trump (who Nuttall says he would not have voted for), and the other urges a more moderate tack. 

Endorsing his leader on Question Time last night, Ukip’s sole MP Douglas Carswell blamed the legacy of the party’s Tea Party-inspired 2015 general election campaign, which saw Farage complain about foreigners with HIV using the NHS in ITV’s leaders debate, for the party’s poor performance in Stoke. Others, such as MEP Bill Etheridge, say precisely the opposite – that Nuttall must be more like Farage. 

Neither side has yet called for Nuttall’s head. He insists he is “not going anywhere”. With his febrile party no stranger to abortive coup and counter-coup, he is unlikely to be the one who has the final say.