A protest in support of the NHS at last year's Labour conference. Source: Getty
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NHS funding is a taboo topic for all parties

The Tories blew their chance to be trusted on health and Labour doesn't want to talk about where the money will come from.

It is hard to think of a policy that Labour is less likely to adopt for its 2015 manifesto than the flat rate £10-per-month “membership fee” for the NHS proposed by Lord Warner, a Blair-era health minister now sitting in the Lords. Jamie Reed MP, shadow health minister has said “this is not something Labour would ever consider.” He might have added re-introduction of small pox as a health policy  closer to Ed Miliband’s preferred general election offer.

When Labour has a vast lead over the Tories as the party to be trusted with the health service, anything that sounds as if it undermines the founding principle of universal access free at the point of use is out of the question. The problem is that Labour has signed up to tight spending constraint if it forms a government and under those circumstances NHS funding is certain to become a volatile issue. People are living longer, suffering from chronic conditions that are expensive to treat – especially if they result in prolonged hospital stays – and costs in medicine tend to rise faster than inflation. Even without the ongoing fiscal crunch, this would be an issue of existential urgency for the system as it is currently configured.

MPs in all parties know this but it has become hard to say so aloud for fear of facing the follow-up question – what would you do about it? In theory, health spending this parliament has been “ring-fenced” but it doesn’t feel that way in the context of local authority cuts, which have severe consequences for social care, and “efficiency savings” that amount to real terms cuts when imposed in a climate of rising costs. GPs say privately that a growing part of what they do amounts to managing patient expectations downward and rationing.

This model of service erosion is no-one’s preferred policy but it is the inevitable consequence of persistent failure of political courage on all sides. The Tories had their moment to bring public opinion with them in a conversation about reform and they blew it with a vast restructuring that alienated pretty much everyone apart from private healthcare providers. The Lib Dems are desperate to scrub away as much trace of complicity with the Tories’ mangled reforms as they can before polling day, although Nick Clegg was a prominent co-mangler.

Labour, meanwhile, does have a plan to transform the provision of health services – the “whole person care” idea developed by Andy Burnham. This puts the emphasis on public health and investment in prevention to save costs down the line. It also envisages the merger of health and social care.

There are obstacles. First, even if the numbers can be made to add up over the long-term, it looks like a hefty up-front expense and yet another epic re-organisation to boot. Second, Ed Miliband’s office is deeply suspicious of Burnham, believing him to be building a support base in the party machine and manoeuvring into a position to be ready for a leadership contest in the event that Labour loses the next election. With an eye on those ambitions, neither Miliband nor Ed Balls seems in a massive hurry to give the shadow Health Secretary the kind of boost that would come from the adoption of his health plans as a flagship reform proposal going into the general election.

Finally, there is a feeling among some Labour MPs and activists that owning up to the imminent cost crunch in the health service and offering a complicated reform agenda to address it just confuses the message, when all the voters need to know between now and May 2015 is that “you can’t trust the Tories with the NHS.” This school of opposition would gladly build an entire campaign around the anti-Conservative message played on a loop alongside pictures of David Cameron and George Obsorne looking smug interspersed with reminders of their “tax cut for millionaires.”

The reality is that Labour expected problems with the NHS to be more extreme and more salient in political debate than they have proved to be so far. (That isn't meant as a denial of the severity of the problem, only as an observation that they haven't blasted other matters off the front pages.) It is an issue where the opposition has a huge potential advantage but only if voters think it is a matter of such urgency as to trump other questions when weighing up who to vote for – the economy; immigration; crime; education etc. Labour’s dilemma is that the obvious way to make more political noise around the health service is to talk about the funding crisis but doing so invites scrutiny of the opposition’s proposed solution. And that is a conversation the party is not yet ready to have.

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

Photo: Getty
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The future of the left: The path ahead is full of challenges

Be in no doubt: the left faces a struggle for survival.

There are plenty of grounds for pessimism about the left’s prospects and they are well rehearsed.  Across Europe, social democrats are out of power and when they do manage to enter government, it is under the skirts of dominant centre-right parties or at the helm of fragile coalitions. Ageing western societies have become more conservative, immigration has driven a cultural wedge into the cross-class coalitions that once undergirded centre-left voting blocs, and austerity has ushered in a politics of security, not reform. Only those who have borne the brunt of the financial crisis and its aftermath, like the unemployed youth and evicted homeowners of Southern Europe, have swung decisively to the left, joined by relatively protected but angry older middle class liberals of Northern Europe. Even in Latin America, where the left swept the board at the turn of the century, politics is shifting to the right. Bright spots, such as municipal experimentalism in Spanish cities, or energetic liberalism in Canada and Italy, illuminate the gloom. But mostly, darkness is visible.

Is this condition terminal? Inequality, stagnant living standards and the turbulence of global capitalism generate profound political discontent. They give oxygen to progressive protest movements as well as populist reactionaries, as the convulsions in US politics show. But only a facile determinism reads off political progress from economic crisis. There is nothing to guarantee that revulsion at political and economic elites will give birth to a new egalitarianism. The left needs a clearer headed view of the political terrain that it will face in the 2020s.

Demographic change is a given. Advanced democracies like Britain will get older and the weight of older voters in elections will increase, not diminish. The gap in turnout rates between young and old is unlikely to close, tilting politics even further towards the cultural concerns and economic interests of the over fifties. Leadership credentials and economic competence matter for these voters more than abstract appeals to equality. But a generation of young people will also enter middle age in the 2020s having endured the worst of the age of austerity, with lower wages, stymied home ownership aspirations and stunted career progression to show for it. So just as 20th century catch-all parties built cross-class electoral alliances, successful political movements in the coming decades will need to secure inter-generational voting blocs. Stitching these together will foreground the politics of family and focus policy attention on transfers of wealth and opportunity across multiple generations. 

Ageing will also ratchet up fiscal pressures on the state, as costs mount for the NHS, care of the elderly and pensions. But Britain’s tax base has been weakened by low productivity, corporate tax avoidance and expensive personal allowance giveaways. In the 2020s, this crunch will loom large over fiscal policy and force hard choices over priorities. Just as in the 1990s, we can expect public disquiet at the run-down of investment in public services to mount, but this time there won’t be the same spending headroom to respond to it. The political debate currently underway in Scotland about raising income tax is therefore a harbinger of the future for the rest of the UK.

Fiscal constraints will also force the left to take seriously the agenda of economic reform opened up under the ungainly title of “pre-distribution”. Without an account of how to generate and share prosperity more equitably within the market economy, social democracy is purposeless. But it will need a far more robust and plausible political strategy for achieving these ambitions than anything that has been on offer hitherto. Technological change will not usher in a new economy of its own accord, and without the solid base of an organised working class to ground its politics, the left needs to be open to a wide set of alliances with businesses, big and small. Combining economic radicalism with credibility and popular appeal, particularly to voters who still blame it for the financial crisis, is the hardest challenge the left faces, but there is no getting away from it.

On a note of optimism, the left is currently strong in cities, from which it can build out. Diversity is a strength in major urban centres, not a weakness, and powerful city leaders endow progressive politics with governing authority. Cities are the places where new social movements are most active and much of the energy of contemporary politics can be found, even if elections are fought on wider terrain. The task is to combine a propensity to decentralise and devolve with clear national political direction. The same holds with party reform: the mass political parties of the 20th century are dead, but networks can’t fight elections, so combining openness and democratic engagement, with discipline and national purpose, is vital. 

Nick Pearce is the director of the Institute for Public Policy Research.