Labour steps cautiously up to difficult truths about the NHS

At last, a shadow minister says budgets would be tight and reform essential regardless of who was in power.

We know Labour loves the NHS. All British political parties are obliged to profess their undying devotion to the health service at routine intervals, but Labour, as the party that oversaw the creation of the NHS (and has, in recent memory, invested the most money in it) claims a special protective monopoly. Voters seem to recognise this and regularly award Ed Miliband’s party robust leads on questions of who is most trusted on the issue.

That advantage is sure to be extended as the government’s NHS reforms, combined with an unprecedented budget squeeze, reinforce the impression that the Tories inevitably succumb to vandalistic urges towards the health service.

Even without the Lansley reforms (now to be implemented by Jeremy Hunt, who has never knowingly inspired confidence in anyone apart, it seems, from the Prime Minister) the NHS would be causing headaches for the coalition.  The health budget may be “ring-fenced” but anything other than a real terms rise in spending feels, over time, like a nasty cut, given inflation in the cost of treatments and the growing demands of caring for an ageing population.

That would be a problem for Labour in government too although you don’t often hear opposition MPs advertise the fact. Why would they? Slamming David Cameron for trashing the NHS is an open goal for Ed Miliband; it would just complicate the goal-scoring manoeuvre to add mealy-mouthed acknowledgements of the immovable budget obstacles on the horizon. That, at least, is one argument and it has generally prevailed at the top of the Labour party.

There is another view, which is that the public are not fools and will, as an election approaches, expect to hear something about the opposition’s intentions towards the NHS other than “we wouldn’t be the Tories”. As I’ve argued (ad nauseam) in the past, a necessary step on Labour’s journey to governing credibility, especially with regard to fiscal responsibility, is being seen and heard to talk about innovation and reform of public services. This doesn’t have to be a macho breast-beating display of willingness to wield the axe. It just means demonstrating, by the deployment of some policy imagination, that Labour recognises the long-term obligation to find ways of getting more for less.

With that in mind, I was heartened to come across a speech yesterday given by Liz Kendall, shadow minister for social care. Not many people spend their weekends catching up on policy interventions by junior ranking shadow cabinet figures, so I suspect you may not have yet got round to reading this particular example of the genre. It is not the Gettysburg address, nor is it a complete exposition of Labour’s policy towards reforming the health service. As with everything else in Labour's agenda for government (with good reason, given the time still to run before an election) health policy is a work in progress.

Nonetheless, for those of us who try to decrypt dull Labour announcements, scouring the formless surface of cosy One Nation reassurance for signs of something that looks like progress towards a governing position, Kendall’s speech is a find.

She states, for example that:

The truth is that far more fundamental reform is vital if we’re going to meet the challenges of demographic and social change.

And that:

.. Whichever party is in Government and however much growth we get back into the economy, we’ve got to get far more out of the billions of pounds spent in the NHS into the foreseeable future.

Obviously true, and a few grades below rocket science, but refreshing to hear said aloud by a shadow cabinet minister.

Kendall clarifies, up to a point, Labour’s view on what would happen to the new NHS architecture currently being put in place by the coalition if Ed Miliband were prime minister.

If Labour wins the next election we will repeal the 2012 Health and Social Care Act but we will not force the NHS through another major re-organisation.

We don’t need new NHS organisations, we’ll simply ask those we inherit to work differently.

We’ll keep Clinical Commissioning Groups and Health and Wellbeing Boards, but ensure they work within a properly accountable national health service.

And what about this for a realistic account of how the opposition should behave towards hospital  reconfigurations (a euphemism for the movement of services out of hospitals, into the community, usually involving ward closures, demonstrations, angry public meetings, bad headlines etc.):

Whilst changes to local hospital services will always be difficult, Labour will not have a policy of blanket opposition to hospital reconfigurations like the Conservatives did at the last election.

That might be easy politics. But it wouldn’t be right in principle or in practice.

We will judge every proposal on its merits: whether it saves more lives, reduces disabilities, and improves the quality of care. The clinical case must be made and supported by the evidence, if the public as well as local MPs are to be convinced.

In other words, yes, sometimes wards and even hospitals will have to close if we’re serious about finding the most effective and efficient way to deliver modern health services. That is because vast old district general hospitals are a desperately outmoded way of looking after people, many of whom have chronic conditions that should be treated not in hospital beds but at home or at local clinics. Better still, such conditions should prevented or kept in check by lifestyle changes. It’s what nearly everyone who has looked at the long-term implications of health policy decides in the end, but you rarely hear opposition politicians say it because joining in the anti-closure demo is so much more rewarding in the political short term.

Kendall even talks about “innovation” in the health service and the need to take a non-dogmatic view of the role of private and voluntary sector providers:

For all the criticism you hear, there’s actually a huge desire and talent for innovation amongst NHS staff.

What they need is the encouragement, freedom and space to innovate. They need backing to experiment and take sensible risks, not rigid performance management from on high.

The private and voluntary sectors also have a vital role to play in bringing innovation and challenge into the system.

Of course private and voluntary providers must be effectively commissioned and regulated, within a properly managed system - not the free market, free-for-all that this Government is putting in place.

But it would be a real mistake to slip back into old ways of thinking, and attempt to block rather than encourage the benefits these services can bring.

To most people who think about the challenge of running a decent public sector on limited budgets, that is all perfectly sensible. It is also, however, by the standards of recent Labour party caution in the discussion of public sector reform and given the reactionary mood in some corners of the wider labour movement, quite a departure. Brave, even. A modest burst of level-headed realism from a shadow minister about the challenge of running services in straightened times, acknowledging the need for innovation and reform that might not always be popular at first - I wonder if it will catch on.

The Olympic opening ceremony celebrating the NHS. Source: Getty Images

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

A woman in an Indian surrogacy hostel. Photo: Getty
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The Handmaid's Tale has already come true - just not for white western women

Why, if the fate of the fictional Offred is so horrifying, is the fate of real-life women in surrogacy hostels causing so little outrage?

When anti-choice Republican Justin Humphrey referred to pregnant women as “hosts”, I found myself wondering, not for the first time, whether everything had got “a bit Handmaid’s Tale.”

I’m not alone in having had this thought. Since Donald Trump won the US election, sales of Margaret Atwood’s dystopian novel have spiked and we’ve seen a plethora of articles telling us how “eerily relevant [it] is to our current political landscape.” In an interview during Cuba’s international book fair, Atwood herself said she believes the recent “bubbling up” of regressive attitudes towards women is linked to The Handmaid’s Tale’s current success: “It’s back to 17th-century puritan values of New England at that time in which women were pretty low on the hierarchy … you can think you are being a liberal democracy but then — bang — you’re Hitler’s Germany.”

Scary stuff. Still, at least most present-day readers can reassure themselves that they’ve not arrived in the Republic of Gilead just yet.

For those who have not yet read it, The Handmaid’s Tale tells the story of Offred, who lives under a theocratic dictatorship in what used to be the United States of America. White, middle-class and college-educated, Offred once enjoyed a significant degree of privilege, but now belongs to a class of women whose sole purpose is to gestate offspring for high-status couples. Much of the shock value of the story comes from the contrast between Offred’s former life – in which she had a name of her own - and her present-day existence. If this can happen to someone like Offred, it is suggested, surely it can happen to any of us.

Or so that is what a white, middle-class reader – a reader like me – might tell herself. Recently I’ve started to wonder whether that’s strictly true. It can be reassuring to stick to one narrative, one type of baddie – the religious puritan, the pussy-grabbing president, the woman-hating Right. But what if it’s more complicated than that? There’s something about the current wallowing in Atwood’s vision that strikes me as, if not self-indulgent, then at the very least naive.

In 1985, the same year The Handmaid’s Tale was published, Gina Correa published The Mother Machine. This was not a work of dystopian fiction, but a feminist analysis of the impact of reproductive technologies on women’s liberties. Even so, there are times when it sounds positively Handmaid’s Tale-esque:

“Once embryo transfer technology is developed, the surrogate industry could look for breeders – not only in poverty-stricken parts of the United States, but in the Third World as well. There, perhaps, one tenth of the current fee could be paid to women”

Perhaps, at the time her book was written, Correa’s imaginings sounded every bit as dark and outlandish as Atwood’s. And yet she has been proved right. Today there are parts of the world in which renting the womb of a poor woman is indeed ten times cheaper than in the US. The choice of wealthy white couples to implant embryos in the bodies of brown women is seen, not as colonialist exploitation, but as a neutral consumer choice. I can’t help wondering why, if the fate of the fictional Offred is so horrifying to western feminists today, the fate of real-life women in surrogacy hostels is causing so little outrage.

I suppose the main argument of these feminists would be that real-life women choose to be surrogates, whereas Offred does not. But is the distinction so clear? If Offred refuses to work as a handmaid, she may be sent to the Colonies, where life expectancy is short. Yet even this is a choice of sorts. As she herself notes, “nothing is going on here that I haven't signed up for. There wasn't a lot of choice but there was some, and this is what I chose.” In the real world, grinding poverty drives women of colour to gestate the babies of the wealthy. As one Indian surrogate tells interviewer Seemi Pasha, “Why would I be a surrogate for someone else if I don't need the money? Why would I make myself go through this pain?"

None of the feminists who expressed shock at Justin Humphrey referring to pregnant women as “hosts” have, as far as I am aware, expressed the same horror at surrogacy agencies using the exact same term. As Dorothy Roberts wrote in Killing The Black Body, the notion of reproductive liberty remains “primarily concerned with the interests of white, middle-class women” and  “focused on the right to abortion.” The right not just to decide if and when to have children, but to have children of one’s own – something women of colour have frequently been denied – can be of little interest of those who have never really feared losing it (hence the cloth-eared response of many white women to Beyoncè’s Grammy performance).

As Roberts notes, “reproductive liberty must encompass more than the protection of an individual woman’s choice to end her pregnancy”:

“It must encompass the full range of procreative activities, including the ability to bear a child, and it must acknowledge that we make reproductive decisions within a social context, including inequalities of wealth and power. Reproductive freedom is a matter of social justice, not individual choice.”

It’s easy to mock the pretensions to pro-life piety of a pussy-grabbing president. But what about the white liberal left’s insistence that criticising the global trade in sexual and gestational services is “telling a women what she can and cannot do with her body” and as such is illiberal and wrong? “Individual choice” can be every bit as much of a false, woman-hating god as the one worshipped by the likes of Humphrey and Trump.

One of the most distressing scenes in The Handmaid’s Tale takes place when Janine/Ofwarren has just given birth and has her child taken from her:

“We stand between Janine and the bed, so she won’t have to see this. Someone gives her a drink of grape juice. I hope there’s wine in it, she’s still having the pains, for the afterbirth, she’s crying helplessly, burnt-out miserable tears.”

Right now there are women suffering in just this way. Only they’re probably not white, nor middle-class, nor sitting in a twee white bedroom in Middle America. Oh, and they’re not fictional, either.

The dystopian predictions of 1985 have already come true. It’s just that women like me didn’t notice until we started to be called “hosts”, too.

Glosswitch is a feminist mother of three who works in publishing.