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21 April 2015

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.

By David Owen

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.

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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.


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