Healthy Scepticism: thoughts on Andy Burnham's #lab14 speech, Labour and the NHS
Labour are going to make the 2015 General Election as much about the NHS as they can. They say they intend to make the election effectively a referendum on which party should manage the NHS, even a 'Day of Reckoning'.
Retweet if u agree with Andy Burnham that Election Day will be a day of reckoning for Cameron for privatising our NHS pic.twitter.com/s2xa03Y2wQ
— Dr Éoin Clarke (@LabourEoin)
As is obvious from the above tweet, one reason for this is it enables them to connect with their base and soft supporters far better than Ed Ball's economic policy of a "root and branch review of every pound the government spends from the bottom up" aka austerity-max.
I'll leave it to others to critique Labour's austerity economics, but it is worth raising them early, as they do of course have implications for the party's NHS policy. Here, I offer a strong dose of scepticism to anyone inclined to listen to Labour's words on the NHS.
Until recently, Labour have been criticised for not really having any policies. A criticism that retains some validity. But Andy Burnham's speech to the 2014 Labour Party Conference (#lab14) does flesh out a few things, so it's worth dissecting.
The speech begins with Burnham requesting delegates to "please show your appreciation for the Darlo mums and the People’s March for the NHS". Burnham has been attempting to align himself with the extra-parliamentary movement to defend the NHS for some time. I'll note two examples here - first, I reacted grumpily to the way he presented the campaign to Save Lewisham Hospital. That campaign was dealing with problems arising from PFI contracts expanded massively under the previously Labour government, of which Burnham was not only a part but at one point Health Minister. At no point, to my knowledge, has Burnham apologised for the past government's obsession with PFI, the best he could do being to describe the £300bn+ cost as 'poor value for money'.
Closer to my personal experience, Andy Burham and Diane Abbott were invited by my local Labour Party to join a public meeting Stroud Against the Cuts had organised in the aftermath of a settlement in the High Court. The settlement was between a local patient and Gloucestershire PCT (precursor of CCGs) and it proved to be crucial in our ultimately successful campaign to stop Gloucestershire Community health services being privatised - giving us the staff and public consultation that had previously been avoided - and the time to mobilise a preference of 91% of the public and 96% of staff to remain in the NHS). No doubt Burnham wanted to turn up at what at a point could be mistaken for being the end of the campaign and soak up some positive vibes for the Labour Party, at at time when the Health & Social Care Act was going through parliament, as he was later to do with the Lewisham campaign (in neither case did he stick around when it became clear it wasn't the end of the campaign).
The trouble was, the privatisation of local NHS services we were fighting was the result of policy introduced as part of the previous Labour government's privatisation of the NHS (specifically, the 'right to request' transfer of services to social enterprise - which was a) nothing but 'friendlier' privatisation through 'social enterprises' and b) routinely abused by management, resulting in what were effectively management buy-outs, rather than the 'staff takeovers' the rhetoric implied. More on this later)
As a result, a fraught SATC meeting left local Labour Party members frustrated at the attitude of others to Mr Burnham, who cancelled (it was claimed he was busy working on opposition to the H&SC Act, but it is widely assumed he was warned of a negative reception and stayed away). The local parliamentary candidate and Chair of the local Constituency Labour Party, left SATC following the public meeting, citing the attention on the non-appearance of Mr Burnham and the possible reasons for this as their reasons for leaving (it was probably more to do with the obvious drift of the Labour Party away from an anti-austerity position).
Why does this anecdote matter? Well, for all that the Labour Party is banging on about how they are bravely standing up to fight for the NHS, they certainly pick and choose the battles they want to join (or, less charitably, they're interested in co-option for their own ends).
I'm also convinced that the Labour Party's policy on privatisation/competition within the NHS remains not dissimilar to that under the previous Labour government - ie, there will be some, though it will often be dressed up as 'social enterprise' or 'mutual' or 'staff-led'.
Let's have a look at what Burnham says in the speech to indicate this:
"People look to Labour to change these things and that is what we will do. You know the Tories will never do it. They put profits before people - always - it’s in their DNA.
Their answer is to let the market that has ripped through social care carry on ripping through the NHS.
Conference, we will do the precise opposite.
I am clearer about this than anything in my life - the market is not the answer to 21st century health and care."
So - Burnham sets up the Tories as privatisers par excellence (which is basically fair) and then claims Labour are the opposite. The last part of his quote is, to anyone with either an understanding of health as a public good or an anti-capitalist approach, a welcome statement:
"the market is not the answer to 21st century health and care."
It's troubling then, that 5 sentences later, Burnham is spelling out what the Labour Party policy actually is:
"We will ask hospitals to collaborate once again and reinstate the NHS as our preferred provider."
Look at these words carefully. First, "ask"-ing hospitals to collaborate is different to "enabling" this. More importantly, a "preferred provider" implies continuing the system of commissioning (competition between different providers to be selected to provide services, through winning eg. 5-year contracts), and in turn a commitment to retain the fragmented, marketised system we in the UK now have (thanks to both the current govt and the previous Labour one).
This is not surprising. It's what Burnham has been saying for some time, and plenty of people have been calling him out on it. Indeed, he was heckled just before the conference on this very issue.
You may also notice a similarity with other Labour Party policies - "An incomprehensible policy on our fragmented, rip-off, publicly subsidised privatised railway is offered, even though a clear-cut commitment to renationalisation is backed by a large majority" (as Owen Jones has it). Their education policy, as I noted last year, is similar too. "The comprehensive ideal, within a mixed economy of schools", said Stephen Twigg, then Shadow Education Minister. "There will be no bias for or against a school type"... "A school should not have to change its status to earn the permission to innovate…if a freedom is afforded to an academy and it drives up standards, that freedom should be available to all schools"..."Academies can choose to buy in tailored support that better meets their needs, so should maintained schools…We’ll give all schools, not just some, the option to shop around"..."I pay tribute to the excellent work of many chains, like ARK and United Learning".
Burnham might not be saying things quite so explicitly, perhaps because he's smarter, but probably just because it would be spotted by Labour's core support as unacceptable in a way that isn't quite as true for education, and (adopting the very charitable view those on the Labour Left take) because he may disagree with these elements of the policy himself. But the implication of the preferred provider policy is that Labour will continue to treat the market as part of the answer to 21st century health and social care.
My hunch is that the preferred provider policy is also loose and that, as with rail, Labour will make 'social enterprises' and 'mutuals' preferred providers, as well as publicly owned NHS Trusts (to be fair, by 2015, most NHS Trusts will be Foundation Trusts / 'Mutuals', which are effectively private companies anyway). Why do I suspect this? Because they've said next to nothing about the utter sham that is Francis Maude's plan to mutualise the NHS, and because they say they will "legislate to make private and third sector providers subject to the Freedom Of Information Act". While it's good to do this, I suspect it implies less opposition to those private and 'third sector' providers currently delivering NHS services (it's worth stating unequivocally here to a naive anarchists, that 'mutualising the NHS' is not a great working class gain even if it superficially looks a bit like 'anarcho-sydicalisation of the NHS'. While were living within capitalism, taking apart the welfare state just makes it harder for us all to survive - harder for us to undertake activity).
Finally on the preferred provider policy, and as the Tory Health twitter account wasted no time in pointing out, Burnham's preferred provider policy is probably illegal:
Official guidance issued by the Labour govt to NHS commissioners stated that Burnham’s preferred provider policy was illegal. What’s changed
— ToryHealth (@Toryhealth)
This of course gives any future Labour government a handy post-election get out clause. EU competition law prevents services where commissioning takes place from favouring particular companies. It was by utilising this that SATC was able to stop Gloucestershire PCT handing Gloucestershire's community health services to it's 'preferred provider', a 'social enterprise'. There hadn't been a tender. There - at that point at least - was only one way to hand services to a chosen provider without a tender and that was to give them to an NHS Trust (a process at that time exempted from competition law because of health's status as a public good, essentially. The H&SC Act has changed this).
The Labour Party is not offering renationalisation of the NHS, despite the impression it is attempting to give to supporters and activists.
This is as true of funding/cuts as it is of privatisation. Miliband made much out of finding £2.5bn for the NHS from a Mansion Tax and a Tobacco levy, but a) the details are unclear (whether this is a one-off or annual increase), b) it's not the sensible option of using higher income taxes for higher earners and c) it's not actually that much money (like Miliband's derisory £8/ph National Minimum Wage policy).
[I'll hyperlink the following up a little, but basically, health spending as a proportion of GDP is well below what it is in other countries in the UK. This is partly because the NHS is more efficient than other, more marketised/privatised systems - achieving the same or better outcomes for less money - but partly because it has been massively underfunded for decades. While the Tories crow about increasing NHS spending since 2010, it has basically flatlined - they're increasing it just enough to claim it's rising - and is falling per person, as a percentage of GDP, and - particularly when combined with the social care budget (which is s sensible way to look at things because people not treated by social care end up being treated by the NHS) is unable to cope with demand. What Labour is offering is insufficient to meet the ~£30-60bn gap that's been identified. Sometimes this gap is exaggerated to make the case for payments - beloved of both the Kings Fund and Reform, for example,, but it's certainly bigger than Miliband's £2.5bn]
Speaking of the links between health and social care, let's come to what Burnham considers his key task as future Health Minister:
"Just as Nye Bevan wrote to every household to introduce his new NHS, so I will write again in 2015 to explain what people can expect from our national health and care service."
Many people might consider it arrogant to try to align yourself so blatantly with Nye Bevan (who actually had some rarely publicised views on housing crises not dissimilar to Newham's shitweasel Mayor Robin Wales and his fellow councillors), but Burnham knows this will go down well with Labour's core vote. And to most people, it sounds great. It's been dissected well elsewhere, however. The key issues are:
1) You know how they means-test access to social care? Not something we want in the NHS, is it?
2) ‘Merging two bankrupt outfits – the NHS and social care – will not magic up one solvent service.’ (as even Polly Toynbee is capable of noticing)
3) There's loads of guff about people being treated 'at home' or 'in the community' which is really just coded language for 'we can save money by closing hospitals'. This gets dressed up as being very modern (hospitals being very 20th century, dontchaknow) but is basically a load of fatuous bollocks designed to appeal to private companies who like avoiding the expense of buildings and prefer you to work from your car (externalisation of costs, basically). There's no reason why we can't maximise the benefits of a network of hospitals in a thoroughly 'modern' way, given sufficient funding. This guff often overlaps even more fatuous bollocks about extending 'choice' by giving people 'Personal Health Budgets' or, as Thatcher had it, 'vouchers', so you have to do all the work of deciding how your healthcare should be delivered (more externalisation of costs) and conveniently can also be blamed for not spending your vouchers on the right types of healthcare. Personal Health Budgets also rather conveniently make it easier to cut budgets without people noticing, and with fewer opportunities for collective action by either patients or workers. At it's extreme, the two piece of fatuous bollocks combine to create policy so utterly idiotic the swearwords necessary to introduce it just don't exist, like Essex Council's 'Treat your own Dementia'.
The best bit of Andy Burnham's speech, for me, is the bit where he says:
"will we have mental health nurses and therapists at the heart of this team, no longer the poor relation on the fringes of the system but making parity a reality."
Anyone who has experienced mental health provision will know how desperately this is needed. Even those with relatively minor issues face interminable delays, limited options (a heavy preference for drugs - which are easy, or CBT - which is cheap), and a woeful lack of provision (the services are underfunded, fragmented, and suffering from the privatisation and marketisation that has occurred already, basically - we should demand more, but I think these things can be done better within the NHS framework than by expanding privatisation).
HOWEVER, as it stands "The only 'parity' for mental health is that it is being cut and privatised as well". Based on the above comments regarding Labour's actual policies on funding and privatisation, I'm not inclined to give them the benefit of the doubt.
The worst bit of Andy Burnham's speech is probably his failure to mention the Transatlantic Trade and Investment Treaty. Well, that or his failure to apologise for PFI and make clear they'll be none of it in the future. Perhaps he just "forgot to mention it", eh? More likely that's because Labour don't have a decent policy on TTIP, and are bound to use PFI (or variants of it like Social Impact Bonds) to keep borrowing off central government books again.
Running these sins of omission a close second is this sin of comission:
"But, with the best will in the world, the NHS won’t be able to do it all."
This, I'm sure, is coded language for "all that stuff I said about a National Health & Care Service. Doesn't mean what you think it does. I reserve the right to ration and exclude in accordance with what Mr Balls will let me pay for. Which is not much"
There are two more quotes I want to mention from Burnham's speech:
"Help the party that founded the NHS give it a new beginning."
The Labour Party will make hay with this slogan, and they have some excuse. But this version of events neglects to mention the fact that Nye Bevan resigned over the Labour Party's 1951 decision to limit free prescriptions and spend the money on war instead (his resignation speech is well worth a read. It includes the suggestion to "Take economic planning away from the Treasury. They know nothing about it").(1) Here's the key quote from Bevan:
"The Chancellor of the Exchequer in this year’s Budget proposes to reduce the Health expenditure by £13 million—only £13 million out of £4,000 million... If he finds it necessary to mutilate, or begin to mutilate, the Health Services for £13 million out of £4,000 million, what will he do next year? Or are you next year going to take your stand on the upper denture? The lower half apparently does not matter, but the top half is sacrosanct. Is that right? ...
The Chancellor of the Exchequer is putting a financial ceiling on the Health Service. With rising prices the Health Service is squeezed between that artificial figure and rising prices. What is to be squeezed out next year? Is it the upper half? When that has been squeezed out and the same principle holds good, what do you squeeze out the year after? Prescriptions? Hospital charges? Where do you stop? ... The Health Service will be like Lavinia—all the limbs cut off and eventually her tongue cut out, too."
I don't doubt that Bevan would like to be making the same speech today. I suspect that were he elected as a backbench MP for Labour in 2015, he'd be saying much the same thing in 2016.
Burnham closes his speech with a rousing section to inspire the Labour faithful. It includes the following:
"Make no mistake - this coming election is a battle for the soul of the NHS. The fight of our lives."
I agree with Burnham that defending the NHS is (one of) the fight(s) of our lives. I agree that the coming general election will feature it as a key issue - hence giving us an opportunity to intervene in this debate. I do not believe that voting Labour, still less campaigning for them on the basis of their NHS policies, is the best way to defend the NHS. Indeed, supporting Labour is not only a misdirection of effort, but a tacit approval of their shitty offer (it will only encourage them to think they can get away with even more egregious bullshit). There are plenty of alternatives - you might pick another party (the Green Party and National Health Action Party certainly have better policies on the NHS) - or you might choose to support the upcoming strike action by 500,000 NHS workers (not mutually exclusive, obviously).
Personally, I consider the NHS a key concession that followed collective action and class struggle undertaken in the first half of the 20th Century (though it should also be seen as part of a range of reforms motivated more by the desire to keep workers healthy enough to maintain capitalist profitability). Though the NHS is now a shadow of what was an imperfect system even when it was founded (from an anarcho-syndicalist point of view), it remains worth defending. It is collective action and class struggle that will be most effective in defending it. I am opposed to working through political parties not only as a matter of 'ends', but because I believe that even in the most pragmatic sense, a more effective 'means' to pressure the parties of government is determined action which terrifies them from outside, rather than pleading for compromises on the inside.
Please support the upcoming strikes for pay increases. If you want to do more, assist health workers in acting collectively across union and workplace boundaries and with patients and other members of the public. Time your use of different campaigning tools (including the use legal cases where it buys you time to organise) is, to my mind, better than restricting yourself dogmatically to particular forms of action. More important still is designing campaigns to leave room to escalate. This is how I believe we can defend the NHS. It's also how I believe we can build a basis on which to demand provision of health and care on the basis of need, not profit. Both things, I think, will contribute to our ability to prefigure a future society that enables us to live the longest and highest quality lives possible.
1) Anyone with a genuine interest in the record of the halcyon 1945-51 Labour Government (and certainly those with either a a healthy scepticism or Loach-level of enthusiasm) really ought to read "How Labour Governed 1945-51" (link is to a pdf) - a pamphlet produced by an earlier incarnation of the Solidarity Federation.
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