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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This Ada Lovelace Day, let’s celebrate women in tech while confronting its sexist culture

In an industry where men hold most of the jobs and write most of the code, celebrating women's contributions on one day a year isn't enough. 

Ada Lovelace wrote the world’s first computer program. In the 1840s Charles Babbage, now known as the “father of the computer”, designed (though never built) the “Analytical Engine”, a machine which could accurately and reproducibly calculate the answers to maths problems. While translating an article by an Italian mathematician about the machine, Lovelace included a written algorithm for which would allow the engine to calculate a sequence of Bernoulli numbers.

Around 170 years later, Whitney Wolfe, one of the founders of dating app Tinder, was allegedly forced to resign from the company. According to a lawsuit she later filed against the app and its parent company, she had her co-founder title removed because, the male founders argued, it would look “slutty”, and because “Facebook and Snapchat don’t have girl founders. It just makes it look like Tinder was some accident". (They settled out of court.)

Today, 13 October, is Ada Lovelace day – an international celebration of inspirational women in science, technology, engineering and mathematics (STEM). It’s lucky we have this day of remembrance, because, as Wolfe’s story demonstrates, we also spend a lot of time forgetting and sidelining women in tech. In the wash of pale male founders of the tech giants that rule the industry,we don't often think about the women that shaped its foundations: Judith Estrin, one of the designers of TCP/IP, for example, or Radia Perlman, inventor of the spanning-tree protocol. Both inventions sound complicated, and they are – they’re some of the vital building blocks that allow the internet to function. 

And yet David Streitfield, a Pulitzer-prize winning journalist, someow felt it accurate to write in 2012: “Men invented the internet. And not just any men. Men with pocket protectors. Men who idolised Mr Spock and cried when Steve Jobs died.”

Perhaps we forget about tech's founding women because the needle has swung so far into the other direction. A huge proportion – perhaps even 90 per cent - of the world’s code is written by men. At Google, women fill 17 per cent of technical roles. At Facebook, 15 per cent. Over 90 per cent of the code respositories on Github, an online service used throughout the industry, are owned by men. Yet it's also hard to believe that this erasure of women's role in tech is completely accidental. As Elissa Shevinsky writes in the introduction to a collection of essays on gender in tech, Lean Out: “This myth of the nerdy male founder has been perpetuated by men who found this story favourable."

Does it matter? It’s hard to believe that it doesn’t. Our society is increasingly defined and delineated by code and the things it builds. Small slip-ups, like the lack of a period tracker on the original Apple Watch, or fitness trackers too big for some women’s wrists, gesture to the fact that these technologies are built by male-dominated teams, for a male audience.

In Lean Out, one essay written by a Twitter-based “start-up dinosaur” (don’t ask) explains how dangerous it is to allow one small segment of society to built the future for the rest of us:

If you let someone else build tomorrow, tomorrow will belong to someone else. They will build a better tomorrow for everyone like them… For tomorrow to be for everyone, everyone needs to be the one [sic] that build it.

So where did all the women go? How did we get from a rash of female inventors to a situation where the major female presence at an Apple iPhone launch is a model’s face projected onto a screen and photoshopped into a smile by a male demonstrator? 

Photo: Apple.

The toxic culture of many tech workplaces could be a cause or an effect of the lack of women in the industry, but it certainly can’t make make it easy to stay. Behaviours range from the ignorant - Martha Lane-Fox, founder of, often asked “what happens if you get pregnant?” at investors' meetings - to the much more sinister. An essay in Lean Out by Katy Levinson details her experiences of sexual harassment while working in tech: 

I have had interviewers attempt to solicit sexual favors from me mid-interview and discuss in significant detail precisely what they would like to do. All of these things have happened either in Silicon Valley working in tech, in an educational institution to get me there, or in a technical internship.

Others featured in the book joined in with the low-level sexism and racism  of their male colleagues in order to "fit in" and deflect negative attention. Erica Joy writes that while working in IT at the University of Alaska as the only woman (and only black person) on her team, she laughed at colleagues' "terribly racist and sexist jokes" and "co-opted their negative attitudes”. 

The casual culture and allegedly meritocratic hierarchies of tech companies may actually be encouraging this discriminatory atmosphere. HR and the strict reporting procedures of large corporates at least give those suffering from discrimination a place to go. A casual office environment can discourage reporting or calling out prejudiced humour or remarks. Brook Shelley, a woman who transitioned while working in tech, notes: "No one wants to be the office mother". So instead, you join in and hope for the best. 

And, of course, there's no reason why people working in tech would have fewer issues with discrimination than those in other industries. A childhood spent as a "nerd" can also spawn its own brand of misogyny - Katherine Cross writes in Lean Out that “to many of these men [working in these fields] is all too easy to subconciously confound women who say ‘this is sexist’ with the young girls who said… ‘You’re gross and a creep and I’ll never date you'". During GamerGate, Anita Sarkeesian was often called a "prom queen" by trolls. 

When I spoke to Alexa Clay, entrepreneur and co-author of the Misfit Economy, she confirmed that there's a strange, low-lurking sexism in the start-up economy: “They have all very open and free, but underneath it there's still something really patriarchal.” Start-ups, after all, are a culture which celebrates risk-taking, something which women are societally discouraged from doing. As Clay says, 

“Men are allowed to fail in tech. You have these young guys who these old guys adopt and mentor. If his app doesn’t work, the mentor just shrugs it off. I would not be able ot get away with that, and I think women and minorities aren't allowed to take the same amount of risks, particularly in these communities. If you fail, no one's saying that's fine.

The conclusion of Lean Out, and of women in tech I have spoken to, isn’t that more women, over time, will enter these industries and seamlessly integrate – it’s that tech culture needs to change, or its lack of diversity will become even more severe. Shevinsky writes:

The reason why we don't have more women in tech is not because of a lack of STEM education. It's because too many high profile and influential individuals and subcultures within the tech industry have ignored or outright mistreated women applicants and employees. To be succinct—the problem isn't women, it's tech culture.

Software engineer Kate Heddleston has a wonderful and chilling metaphor about the way we treat women in STEM. Women are, she writes, the “canary in the coal mine”. If one dies, surely you should take that as a sign that the mine is uninhabitable – that there’s something toxic in the air. “Instead, the industry is looking at the canary, wondering why it can’t breathe, saying ‘Lean in, canary, lean in!’. When one canary dies they get a new one because getting more canaries is how you fix the lack of canaries, right? Except the problem is that there isn't enough oxygen in the coal mine, not that there are too few canaries.” We need more women in STEM, and, I’d argue, in tech in particular, but we need to make sure the air is breatheable first. 

Barbara Speed is a technology and digital culture writer at the New Statesman and a staff writer at CityMetric.