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

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Martin McGuinness's long game: why a united Ireland is now increasingly likely

McGuinness died with his ultimate goal of a united Ireland arguably closer to realisation than at any other time since the island’s partition in 1921.

In late 2011 Martin McGuinness stood as Sinn Fein’s candidate in Ireland’s presidential election, raising all sorts of intriguing possibilities.

Raised in a tiny terraced house in the Bogside, Derry, he would have ended up living in a 92-room presidential mansion in Dublin had he won. A former IRA commander, he would have become supreme commander of Ireland’s defence forces. Once banned from Britain under the Prevention of Terrorism Acts, he would have received the credentials of the next British ambassador to Dublin. Were he invited to pay a state visit to London, a man who had spent much of his youth shooting or bombing British soldiers would have found himself inspecting a guard of honour at Buckingham Palace.

McGuinness would certainly have shaken the hands of the English team before the Ireland-England rugby match at the Aviva Stadium in Dublin every other year. “I’d have no problem with that,” he told me, grinning, as he campaigned in the border county of Cavan one day that autumn. Though a staunch republican, he enjoyed the “Protestant” sports of rugby and cricket, just as he supported Manchester United and enjoyed BBC nature programmes and Last of the Summer Wine. He wrote poetry and loved fly-fishing, too. Unlike Gerry Adams, the coldest of cold fish, McGuinness was hard to dislike – provided you overlooked his brutal past.

In the event, McGuinness, weighed down by IRA baggage, came a distant third in that election but his story was astonishing enough in any case. He was the 15-year-old butcher’s assistant who rose to become the IRA chief of staff, responsible for numerous atrocities including Lord Mountbatten’s assassination and the Warrenpoint slaughter of 18 British soldiers in 1979.

Then, in 1981, an IRA prisoner named Bobby Sands won a parliamentary by-election while starving himself to death in the Maze Prison. McGuinness and Adams saw the mileage in pursuing a united Ireland via the ballot box as well as the bullet. Their long and tortuous conversion to democratic politics led to the Good Friday accord of 1998, with McGuinness using his stature and “street cred” to keep the provisional’s hard men on board. He became Northern Ireland’s improbable new education minister, and later served as its deputy first minister for a decade.

His journey from paramilitary pariah to peacemaker was punctuated by any number of astounding tableaux – visits to Downing Street and Chequers; the forging of a relationship with Ian Paisley, his erstwhile arch-enemy, so strong that they were dubbed the “Chuckle Brothers”; his denunciation of dissident republican militants as “traitors to the island of Ireland”; talks at the White House with Presidents Clinton, George W Bush and Obama; and, most remarkable of all, two meetings with the Queen as well as a state banquet at Windsor Castle at which he joined in the toast to the British head of state.

Following his death on 21 March, McGuinness received tributes from London that would have been unthinkable 20 years ago. Tony Blair said peace would not have happened “without Martin’s leadership, courage and quiet insistence that the past should not define the future”. Theresa May praised his “essential and historic contribution to the extraordinary journey of Northern Ireland from conflict to peace”.

What few noted was that McGuinness died with his ultimate goal of a united Ireland arguably closer to realisation – albeit by peaceful methods – than at any other time since the island’s partition in 1921.

The Brexit vote last June has changed political dynamics in Northern Ireland. The province voted by 56 per cent to 44 in favour of remaining in the European Union, and may suffer badly when Britain leaves. It fears the return of a “hard border” with the Republic of Ireland, and could lose £330m in EU subsidies.

Dismay at the Brexit vote helped to boost Sinn Fein’s performance in this month’s Stormont Assembly elections. The party came within 1,200 votes of overtaking the Democratic Unionist Party, which not only campaigned for Leave but used a legal loophole to funnel £425,000 in undeclared funds to the broader UK campaign. For the first time in Northern Ireland’s history, the combined unionist parties no longer have an overall majority. “The notion of a perpetual unionist majority has been demolished,” Gerry Adams declared.

Other factors are also working in Sinn Fein’s favour. The party is refusing to enter a new power-sharing agreement at Stormont unless the DUP agrees to terms more favourable to the Irish nationalists. Sinn Fein will win if the DUP agrees to this, but it will also win if there is no deal – and London further inflames nationalist sentiment by imposing direct rule.

McGuinness’s recent replacement as Sinn Fein’s leader in Northern Ireland by Michelle O’Neill, a personable, socially progressive 40-year-old unsullied by the Troubles, marks another significant step in the party’s move towards respectability. As Patrick Maguire recently wrote in the New Statesman, “the age of the IRA old boys at the top is over”.

More broadly, Scottish independence would make the notion of Northern Ireland leaving the UK seem less radical. The Irish republic’s economic recovery and the decline of the Roman Catholic Church have rendered the idea of Irish unity a little less anathema to moderate unionists. And all the time, the province’s Protestant majority is shrinking: just 48 per cent of the population identified itself as Protestant in the 2011 census and 45 per cent Catholic.

The Good Friday Agreement provides for a referendum if a majority appears to favour Irish unity. Sinn Fein is beginning to agitate for exactly that. When Adams and McGuinness turned from violence to constitutional politics back in the 1980s they opted for the long game. Unfortunately for McGuinness, it proved too long for him to see Irish nationalism victorious, but it is no longer inconceivable that his four grown-up children might. 

This article first appeared in the 23 March 2017 issue of the New Statesman, Trump's permanent revolution