Brothers in arms: Ed Balls and Jim Murphy on the campaign trail. Photo:Getty
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The coming election will decide the future of the NHS, and with it, the United Kingdom

The National Health Service will be on the ballot paper in May, and its continued survival is vital to the preservation of the Union.

In September 2014 the Scottish independence referendum brought the United Kingdom perilously close to splitting apart. From that moment on those elements that we share, that help create a sense of common purpose need to become ever more precious as we try to unify our nation.

As always, constitutional change should be evolutionary and never more so than for that complex and flexible instrument of our democracy, the House of Commons. It must also, even in the shadow of the referendum in Scotland, go with the grain of English nature. I detect no wish for a separate English parliament, nor for regional government in England. But there is an English dimension which those of us whose origins are from other parts of the UK must respect. The tragedy of today is that our Prime Minister, David Cameron, cannot seem to embrace the broadminded generosity of spirit that almost all of his predecessors have been able to summon up.

Ours is at this moment in our history a hesitant and fragile Union. We all need to respect and value, whatever political parties we support, those elements which bind the citizens of the UK together. David Cameron needs to understand that to play the ‘English card’ on Scottish devolution in the way he did outside 10 Downing Street on the day after the Scottish referendum vote was a grave mistake which has already had far-reaching constitutional consequences.

He has started to do this again in his depiction of the SNP MPs likely to be elected in large numbers to the House of Commons as an illegitimate force merely because they advocate separation through the democratic mechanism of another referendum. The former Conservative Secretary of State for Scotland, Michael Forsyth, taking a different angle was correct to warn David Cameron against bolstering the SNP chances over Labour as "a short-term and dangerous view." These issues are too serious for ‘Flashman’ politics and Ed Miliband is wise to adopt a longer term and steadier view.

The closest analogy I can find to such irresponsible behaviour on the Constitution is when David Lloyd George on 5 December 1921 infamously threatened “war within three days”, if all the members of the Irish delegation did not sign the Anglo-Irish Treaty. It was, as it turned out, a very dangerous bluff. At 2.20 a.m. the treaty was signed but not by all. Lord Birkenhead in the British government delegation commented, ‘I may have signed my political death warrant,’ to which Michael Collins, leading the Irish delegation, perceptively replied, ‘I may have signed my actual death warrant.’ Lloyd George’s intervention when revealed to the Dáil damaged Collins and though the vote went through it was despite of not because of it. Collins was at that stage despite Éamon de Valera’s opposition recognised as a brave farsighted man. Weakening him was weakening the Union.  Cameron should learn this lesson from history: holding the UK together is still a task that requires courage, holding to the long view.

We need elements other than the most obvious one of the defence of the realm to bind the UK together and even on defence in relation to Trident, there are deep differences that need addressing. The aftermath of the referendum in Scotland has not lifted the threat of separation but given the UK a little more time to achieve the correct balance between its constituent parts.

David Cameron, as Prime Minister, must also take the main responsibility for deceiving the people over the Health and Social Care Act 2012 and the incompetent implementation of that legislation.

Cameron told NHS audiences – the royal colleges of surgeons, nurses and pathologists among others – throughout 2009 that “there will be no more of these pointless re-organisations that aim for change but instead bring chaos”. Or that “we will not persist with the top-down restructures and reorganisations of the NHS that have dominated the last decade in the NHS”, causing “terrible disruption, demoralisation and waste”. Vain attempts have been made since to claim the 2012 legislation as being “bottom up” but these were soon shown to be demonstrably false.

The major consequence of the 2012 Health and Social Care Act has been how it views health care in England as a business rather than a service. Along with Scotland, Wales and Northern Ireland have retained an undoubtedly recognisable NHS, albeit in slightly different forms. Only in England does the threat exist that the NHS will be unrecognisable by 2020 if the 2012 legislation is not repealed in substance after the May 2015 general election. This has profound implications for the UK for the underlying reasons that make the original concept of the NHS worth fighting for are clear, but not often stated, perhaps because they go to the ethical and moral basis of the way many UK citizens wish to live their lives.

In this general election there is a settled wish emerging from the great bulk of voters for the original NHS to be available in all parts of the UK in a recognisable form. It would be a unifying theme for the next UK government to reinstate the NHS, at a time when the UK needs to revive a sense of unity.

There is another aspect to the Scottish referendum, the wish it has inspired for England to devolve more decisions to its bigger cities: London, Birmingham, Manchester, Leeds, Liverpool and Newcastle. In part this follows the success story of the gradual introduction of powerful mayors. There is a strong case for considering a strategic health and caring role for such cities. It would need to be introduced carefully on the basis of proven experience, not all happening at once, and would stem from a well-considered proposal from a city put to the Secretary of State for Health, who would have the enabling power to introduce it.

Constitutional changes in a democracy usually are the result of political trade-offs and changes for Scotland impact on Wales and Northern Ireland and of course by far the largest component of the UK, England.

Two other vital reforms could reinforce the structure of UK unity. First, an elected Senate representing the four elements of the UK. The House of Lords has become an absurdity in size and composition. It reeks of patronage.

The second reform comes from the McKay Commission on the consequences of devolution published in March 2013.  They propose that “decisions at the United Kingdom level with a separate and distinct effect for England (or for England and Wales) should normally be taken only with the consent of a majority of MPs for constituencies in England (or England and Wales)” while ensuring that “the right of the House of Commons as a whole to make the final decision should remain”. They have carved out a mechanism allowing that some English legislation would not have to be part of the normal procedure on all occasions. The commissioners assert: “We would expect departures from the norm to occur only rarely in practice” and “The apparent fragility of the declaratory resolution approach can also be seen as flexibility. A government, after consideration, may decide that it is necessary in the interests of the UK as a whole, or an affected part of it, to invoke the exception implicit in the word ‘normally”.

The report preserves the present position in the House of Commons that there should not be two different kinds of MPs, so all MPs would vote on whether to grant a second reading for all Bills and finally whether a Bill should become law with a single vote on third reading. If some English legislation has from time to time so great an implication for the UK as a whole that it does not fit with only English MPs amending it at committee and report stages, then Parliament can decide to make it UK legislation.           

NHS reinstatement legislation in 2015 will be a classic case of the sort of legislative exception that the McKay commissioners had in mind. Ed Miliband should indicate in advance during this election that he would so regard it. He should also indicate that he would not endorse legislation for another referendum as Prime Minister of the UK in the lifetime of the next Parliament.

The social history of the NHS makes clear that it would be ‘an error to regard the NHS as a spontaneous creation’. The cumbersome National Health Insurance (NHI) administration established in 1911 supplied minimum financial relief during sickness and a ‘panel doctor’ service for the low paid on the basis of weekly deductions of income for the so-called health stamp. But many were not covered by this insurance. There was nothing for those excluded other than the charity of the doctor or a hospital. The Dawson report of 1920 pointed the way but many slum dwellers had totally inadequate healthcare, if any, and lived in conditions of Dickensian squalor. The Second World War brought the Emergency Medical Service, the Beveridge report and the 1944 White Paper outlining the provisions of the projected NHS: a resolve emerged in wartime within the British people that when peace came there would be a different and better system of healthcare for everyone.

At the heart of all marketisation and commercialisation of the NHS, David Marquand has written, lies the “totemic term “choice”: free choice by unconnected individuals, satisfying individual wants through market competition”. Healthcare, whether public or private, in a very real sense is infinite: money can be – and in many countries is – poured into healthcare by those who can afford it. Money for the NHS is a public choice, but it is all relative to what we choose to spend on education, housing, welfare, defence, all legitimate demands.

Healthcare, if publicly provided, inevitably has to be constrained. That rationing process within the NHS is flexible, professional and democratically accountable. It is decided by Parliament through the Chancellor of the Exchequer, the Secretary of State for Health and Cabinet. By democratic choice it is not done by a market or by insurance premiums or an appointed QUANGO like NHS England.

Voters could have chosen a different system – they exist in many parts of the world – but no major political party has ever felt brave or foolish enough to put that choice to them. It was not a choice put to the electorate in 2010 by either the Conservatives or Liberal Democrats. Both parties are fudging this choice again in 2015 though at least now the Liberal Democrats have admitted some changes are needed to the existing legislation. 

Politics cannot be an ideology-free zone but it should not resound with zealotry. No one should be Prime Minister for England alone. We saw in the Scottish referendum how powerful a vote swinger the NHS became in the closing stages of the campaign. Despite the fact that health is fully devolved to the Scottish Parliament, the spectre of an English-controlled Treasury being able to use financial allocations to bring marketisation to Scotland's NHS carried sufficient weight with voters that the ‘yes’ campaign exploited it and the ‘no’ campaign feared it. It also served to remind some voters, not just in Scotland, that the NHS as we have known it since 1948 was under threat. The English voters in this General Election are becoming evermore aware of this threat in England.

Before 7 May 2015 many MPs and candidates – Conservative, Labour, Liberal Democrat, Ukip, Green, SNP, Plaid Cymru – will be systematically challenged to indicate whether they will support the NHS Reinstatement Bill in England. In Scotland, Wales and Northern Ireland, candidates are being urged to commit to vote, if elected as an MP, for reinstatement of the NHS in England. Allow marketisation and commercialisation to continue in England and it will not be long before it affects the NHS throughout the United Kingdom. The NHS in one part of the UK means the NHS in all of the UK. They will never be exactly the same for they are part of devolved government but they need to be inextricably linked in a truly united UK.

The end of the NHS as we have known and understood it in England will take place before 2020 if whichever party or parties that win the 2015 general election does not change the 2012 NHS legislation. Social historians may not be agreed as to when the exact moment of its passing will be. As endings go, it will be, in the words of T. S. Eliot, “not with a bang but a whimper” and around that moment the issue of Scottish independence will be back on the political agenda with a vengeance. The two are linked in more ways than have yet been fully recognised.  The NHS is not a religion, as it has been likened to, nor is it the preserve of one political party, nor one country within our United Kingdom. It belongs to all of us.


Lord Owen was Foreign Secretary 1977-79, a founder-member of the SDP and is now a crossbench peer.

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"Labour are as pro-Brexit as the Tories": what do Sinn Fein's MPs really want from Westminster?

Its seven MPs are much less sympathetic to Corbyn's party than popularly imagined, and won't ever take their seats.

Should the Conservative minority government fall, what is Jeremy Corbyn’s route to power? The counterfactual as popularly understood goes like this: Corbyn would pick up the phone to his old pal Gerry Adams and convince Sinn Fein’s seven MPs to abandon the habit of a century and take their seats.

There are countless reasons why this would never happen, most of them obvious. One is more surprising. Despite Corbyn’s longstanding links with the republican cause, the Labour party is not all that popular among a new intake, which is preoccupied with one thing above all else: Brexit.

No wonder. Sinn Fein’s long game is an all-Ireland one, and the party believe the UK’s departure from the EU will hasten reunification. In the meantime, however, its priority is a Brexit deal that gives Northern Ireland – where 56 per cent of voters backed remain – designated status within the EU.

Pioneered by the moderate nationalist Social Democratic and Labour Party as an antidote to Brexit, designated status would allow the six counties in the North to continue to enjoy the EU’s four freedoms. But the idea is anathema to unionists and the UK government, and Sinn Fein sees little evidence that the Westminster establishment will make it work – not even Labour.

“They are as pro-Brexit as the Conservatives are,” says Mid Ulster MP Francie Molloy. “We’re anti-Brexit. We want to see the right of the people in the North who voted to remain in Europe respected.”

Simmering resentment over what the party perceives to have been broken promises on Tony Blair’s part – especially over legal protection for the Irish language, a key stumbling block obstructing the resumption of power-sharing – makes the already implausible deal even less likely.

“The Irish language act was something that Blair agreed to,” says Molloy. “So when people talk about us taking our seats, they don’t realise we would be backing a Labour government that wouldn’t be living up to its commitments either, and would be just as pro-Brexit as the Conservatives are."

That criticism may well surprise a lay audience whose working assumption is that Adams and Corbyn work hand in glove. But it is perhaps the best illustration of Sinn Fein’s parliamentary priorities: its seven MPs will not in any circumstances take their seats but use their Westminster presence to lobby ministers and MPs of all stripes while running constituency offices at home (they are unsalaried, but claim expenses).

Crucially, its MPs believe abstentionism strengthens, rather than weakens their negotiating hand: by their logic other parties need not and do not fear them given the fact they do not have voting power.

They will use their leverage to agitate for special status above all else. “Special status is the biggest issue that we are lobbying for,” says Molloy. “We feel that is the best way of securing and retaining EU membership. But if we get a referendum on Irish unity and the people vote for that, then the North will automatically join the EU.”

But that wasn’t always the received wisdom. That assurance was in fact secured by Mark Durkan, the former deputy first minister and SDLP MP beaten by Sinn Fein last week, after an exchange with Brexit secretary David Davis at the leaving the EU select committee. The defeat of the three SDLP MPs – two of them by Sinn Fein – means there will be no Irish nationalist voice in the commons while Brexit is negotiated.

Surely that’s bad news for Northern Irish voters? “I don’t think it is,” says Molloy. “The fact we took two seats off the SDLP this time proves abstentionism works. It shows they didn’t deliver by attending. We have a mandate for abstentionism. The people have now rejected attendance at Westminster, and rejected Westminster itself. We’ve never been tempted to take our seats at all. It is very important we live by our mandate.”

If they did, however, they would cut the Conservatives’ and Democratic Unionist Party’s working majority from 13 to a much more precarious six. But Molloy believes any alliance will be a fundamentally weak one and that all his party need do is wait. “I think it’ll be short-lived,” he says. “Every past arrangement between the British government and unionist parties has always ended in tears.”

But if the DUP get its way – the party has signed a confidence and supply deal which delivers extra cash for Northern Ireland – then it need not. Arlene Foster has spoken of her party’s desire to secure a good deal for the entire country. Unsurprisingly, however, Sinn Fein does not buy the conciliatory rhetoric.

“They’ve never really tried to get a good deal for everybody,” says Michelle Gildernew, who won the hyper-marginal of Fermanagh and South Tyrone back from the Ulster Unionists last week. “The assembly and executive [which Sinn Fein and the DUP ran together] weren’t working for a lot of groups – whether that was the LGBT community, the Irish language community, or women...they might say they’re going to work for everybody, but we’ll judge them by their actions, not their words.”

Molloy agrees, and expresses concern that local politicians won’t be able to scrutinise new spending. “The executive needs to be up and running to implement that, and to ensure a fair distribution. If there’s new money coming into the North, we welcome that, but it has to be done through the executive.”

On current evidence, the call for local ministers to scrutinise the Conservatives’ deal with the DUP is wishful thinking – Northern Ireland has been without an executive since February, when the late Martin McGuinness resigned as deputy first minister and triggered a snap election.

The talks since have been defined by intransigence and sluggishness. James Brokenshire, the Northern Ireland secretary, has had to postpone the talks deadline on four separate occasions, and has been criticised by nationalists for his perceived closeness to the DUP.

The final deadline for the restoration of an executive is 29 June 2017. Sinn Fein has called for Brokenshire to recuse himself in favour of a neutral chair. “His hands are tied now, completely,” says Molloy. “The Conservative party were always questionable on where they stood – they’ve always been unionists. The issue now is whether they can act neutrally as a guarantor to the Good Friday Agreement.”

He believes that question is already settled. “Legally, they have to act to ensure that nothing happens to damage that agreement – but we’ve already breached it through Brexit. There was no consultation. The people of the North voted to remain and it hasn’t been recognised. It totally undermines the consent principle.”

Just how they and Brokenshire interpret that principle – the part of the Good Friday Agreement that specifies the constitutional status of the North can only change by consent of its people – will be key to whether they can achieve their ultimate goal: Irish unity.

Molloy and Gildernew say the fact that 11 of Northern Ireland’s 18 constituencies voted to remain in the EU is enough for Brokenshire to call one within the next five years (though polling consistently shows that a clear majority of the province’s electorate, including a substantial minority of nationalists, would vote to stay in the UK). They are confident they can win, though, failing that, Molloy envisages it as the first in several referenda on unification.

But beneath the optimism lies the knowledge that the British government are unlikely to heed their calls. And, willingly absent from the Westminster chamber, they say the UK government’s discussions about Brexit are illegitimate. They see their real powerbase as elsewhere: in Dublin’s Dail Eireann, where Sinn Fein is the third largest party, and the chancelleries of Europe.

“That’s where most of the negotiation will actually happen,” says Molloy. “The EU27 will make the decisions. They won’t be made in Westminster, because the British have already set out what they’re doing: they’re leaving.”

But with seven MPs already lobbying ministers and a united Ireland unlikely to happen in the immediate future, Sinn Fein itself won’t be disappearing anytime soon.

Patrick Maguire writes about politics and is the 2016 winner of the Anthony Howard Award.

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