Tinker at your peril: we love the NHS more than any government

Many provisions in the English NHS reform plan will tilt the system in favour of private-sector prov

The Health and Social Care Bill is an impressive and visionary document. In its scope and ambition, it rivals any piece of legislation I can remember reading. Andrew Lansley, the Health Secretary, has stressed that these plans for the health service are not something he drew up on the back of an envelope; no, they have been a long time in the making. The bill redraws the operating system for the NHS in England: it
is a 180-degree reversal of Labour's approach, devolving power away from the direct, day-to-day responsibility of the secretary of state.

But that does not mean the plans are in any way democratic. The secretary of state will appoint most members of the NHS board to which his powers of management and oversight will be devolved - and he will be able to sack those whom he appoints. He will also have the power of veto over the appointment of the chief executive. This will be a highly political body. The elected local authorities will have charge only of public health, not medical, dental or ophthal­mic care. Most medical care will fall under the control of the new GP consortiums, overseen by the board and the regulator monitor.

Whether the vision of a democratic, locally accountable health service will be realised or will fade and die is in the hands of these GP consortiums. In theory, GPs will respond to informed and empowered patients to broaden the range of services on offer and improve care all round. Yet there are so many conflicting responsibilities and perverse incentives written into the proposed system that, in practice, the relationship between patient and GP - long the great strength of the health service - will come under extraordinary pressure.

Roll up, roll out

GP consortiums are answerable to the secretary of state, the board, the monitor and their patients. The push for greater plurality of providers will not come from patients. Patients are not sufficiently informed about what is in their best interests and survey after survey has shown that they are less interested in being given a choice about where they are treated than about how: in a clean hospital, with good pain control.

In the absence of any likely clamour from patients to open up the market, Lansley is busting it open. GPs will have to put contracts out to competitive tender. The bill even allows the secretary of state to tell consortiums what to put in their contracts (so much for independence) and to require them "to do such other things as the secretary of state considers necessary for the purposes of the health service".

In what looks like a direct contradiction of a promise in the Conservative manifesto to make every alternative provider compete on health service prices, providers will be allowed to tender at below cost price. This will tilt the market unfairly in favour of private-sector operators of "roll up, roll out" treatment centres, where those with less complicated problems can have same-day operations.

When complications do occur, these patients will be whisked off to the local NHS hospital, which will have all of that complex, inefficient, expensive care on standby. This is why an open market is unfair. NHS hospitals will not be competing on a level playing field: they must provide A&E and other high-cost specialisms. By allowing the private sector to undercut them, Lansley is setting up a system that will undermine their profitability. I wonder if patients will see the connection between having their hip operation contracted out to the nice, new private-sector treatment centre and the closure of their local hospital a few years down the line. Whom will they blame if they do?

The second invidious element of this bill is the offering of financial incentives to encourage GPs to play ball. If GPs provide good-quality care, in or under budget, they get paid extra for it. To quote the bill: "The board may, after the end of a financial year, make a payment to a commissioning consortium if, in the light of an assessment carried out under Section 14Z1, it considers that the consortium has performed well during that year . . . A commissioning consortium may distribute any payments received by it under this section among its members in such proportions as it considers appropriate." These payments will be made every year. There's no need to wait and see whether this system will damage care down the line. There is a clear financial incentive to do exactly as Lansley directs.

Power to the patient

So, from now on, patients will have to rely on advice from GPs whose independence is compromised; they will have to be very empowered to be able to challenge that. Yet consultation on the parts of the Lansley plan that are aimed at giving patients control closed weeks ago; the government had not even published its response before the second reading of the bill took place.

The Chartered Institute of Library and Information Professionals, in response to the "in­formation strategy", said: "Our main concern about the proposals in the consultation document is their partial nature. In our view, they do not cover information - most focus on the internal management of NHS data - and neither do they constitute a strategy." So much for the fig leaf of patient empowerment.

But it would be wrong to dismiss this bill as all bad. Stephen Dorrell, a former health secretary who is still highly respected in the NHS, said during the debate at the second reading that the bill only represents "an evolution of policy that has been consistently developed by every secretary of state with a single exception since 1990". He is right. It has the potential to be very creative.

That it also has the potential to be very destructive ought to alarm David Cameron more than it need alarm us. The NHS is a lot stronger than any government.

This article first appeared in the 07 February 2011 issue of the New Statesman, The New Arab Revolt

David Young
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The Tories are the zombie party: with an ageing, falling membership, still they stagger on to victory

One Labour MP in Brighton spotted a baby in a red Babygro and said to me: “There’s our next [Labour] prime minister.”

All football clubs have “ultras” – and, increasingly, political parties do, too: although, in the case of political parties, their loudest and angriest supporters are mostly found on the internet. The SNP got there first: in the early days of email, journalists at the Scotsman used to receive bilious missives complaining about its coverage – or, on occasion, lack of coverage – of what the Scottish National Party was up to. The rest soon followed, with Ukip, the Labour Party and even the crushed Liberal Democrats now boasting a furious electronic horde.

The exception is the Conservative Party. Britain’s table-topping team might have its first majority in 18 years and is widely expected in Westminster to remain in power for another decade. But it doesn’t have any fans. The party’s conference in Manchester, like Labour’s in Brighton, will be full to bursting. But where the Labour shindig is chock-full of members, trade unionists and hangers-on from the charitable sector, the Conservative gathering is a more corporate affair: at the fringes I attended last year, lobbyists outnumbered members by four to one. At one, the journalist Peter Oborne demanded to know how many people in the room were party members. It was standing room only – but just four people put their hands up.

During Grant Shapps’s stint at Conservative headquarters, serious attempts were made to revive membership. Shapps, a figure who is underrated because of his online blunders, and his co-chair Andrew Feldman were able to reverse some of the decline, but they were running just to stand still. Some of the biggest increases in membership came in urban centres where the Tories are not in contention to win a seat.

All this made the 2015 election win the triumph of a husk. A party with a membership in long-term and perhaps irreversible decline, which in many seats had no activists at all, delivered crushing defeats to its opponents across England and Wales.

Like José Mourinho’s sides, which, he once boasted, won “without the ball”, the Conservatives won without members. In Cumbria the party had no ground campaign and two paper candidates. But letters written by the Defence Secretary, Michael Fallon, were posted to every household where someone was employed making Trident submarines, warning that their jobs would be under threat under a Labour government. This helped the Tories come close to taking out both Labour MPs, John Woodcock in Barrow and Furness and Jamie Reed in Copeland. It was no small feat: Labour has held Barrow since 1992 and has won Copeland at every election it has fought.

The Tories have become the zombies of British politics: still moving though dead from the neck down. And not only moving, but thriving. One Labour MP in Brighton spotted a baby in a red Babygro and said to me: “There’s our next [Labour] prime minister.” His Conservative counterparts also believe that their rivals are out of power for at least a decade.

Yet there are more threats to the zombie Tories than commonly believed. The European referendum will cause endless trouble for their whips over the coming years. And for all there’s a spring in the Conservative step at the moment, the party has a majority of only 12 in the Commons. Parliamentary defeats could easily become commonplace. But now that Labour has elected Jeremy Corbyn – either a more consensual or a more chaotic leader than his predecessors, depending on your perspective – division within parties will become a feature, rather than a quirk, at Westminster. There will be “splits” aplenty on both sides of the House.

The bigger threat to Tory hegemony is the spending cuts to come, and the still vulnerable state of the British economy. In the last parliament, George Osborne’s cuts fell predominantly on the poorest and those working in the public sector. They were accompanied by an extravagant outlay to affluent retirees. As my colleague Helen Lewis wrote last week, over the next five years, cuts will fall on the sharp-elbowed middle classes, not just the vulnerable. Reductions in tax credits, so popular among voters in the abstract, may prove just as toxic as the poll tax and the abolition of the 10p bottom income-tax rate – both of which were popular until they were actually implemented.

Added to that, the British economy has what the economist Stephen King calls “the Titanic problem”: a surplus of icebergs, a deficit of lifeboats. Many of the levers used by Gordon Brown and Mervyn King in the last recession are not available to David Cameron and the chief of the Bank of England, Mark Carney: debt-funded fiscal stimulus is off the table because the public finances are already in the red. Interest rates are already at rock bottom.

Yet against that grim backdrop, the Conservatives retain the two trump cards that allowed them to win in May: questions about Labour’s economic competence, and the personal allure of David Cameron. The public is still convinced that the cuts are the result of “the mess” left by Labour, however unfair that charge may be. If a second crisis strikes, it could still be the Tories who feel the benefit, if they can convince voters that the poor state of the finances is still the result of New Labour excess rather than Cameroon failure.

As for Cameron, in 2015 it was his lead over Ed Miliband as Britons’ preferred prime minister that helped the Conservatives over the line. This time, it is his withdrawal from politics which could hand the Tories a victory even if the economy tanks or cuts become widely unpopular. He could absorb the hatred for the failures and the U-turns, and then hand over to a fresher face. Nicky Morgan or a Sajid Javid, say, could yet repeat John Major’s trick in 1992, breathing life into a seemingly doomed Conservative project. For Labour, the Tory zombie remains frustratingly lively. 

Stephen Bush is editor of the Staggers, the New Statesman’s political blog.

This article first appeared in the 01 October 2015 issue of the New Statesman, The Tory tide