Thursday 13 August 2009

So let's have a sensible debate about health

I was surprised to hear that Graeme Archer twitter that he felt that the rather effective and inspiring #welovethenhs Twitter 'uprising' involved facile bullying from the left.

Graeme is a rather personable Conservative interested in engaging in genuine political debate. He has explained on ConservativeHome that he feels the pro-NHS campaign is an attempt to close down public debate about health in Britain - arguing that

If #welovethenhs is the end of the debate, what, really, is the point of politics?

This is something of a straw man attack. I am not aware that anybody has said this should be the end of the debate.

And I think the charge misreads not just the campaign itself - but indeed the nature of politics too.

#welovethenhsseemed to me a very positive campaign. It seems to have been a spontaneous idea from a creator of Father Ted, irked by the ludicrous nonsense being spouted about the NHS by opponents of Obama's health reforms in America.

Claims that Stephen Hawking would never have been allowed to live had he been British (!) may have been the last straw.

So the campaign took off, because people wanted to defend the NHS. After all, it has a good claim to be the most popular institution in Britain, though I don't think anybody thinks it perfect. (If there was a "we salute the army" or a "we love the BBC" campaign, people can choose to join or not join in any public debates about these institutions on any terms which they wish).

The most effective tweets were the personal testimonies thanking the NHS for the support it has given us or our families at difficult times. Several Labour, LibDem and Green voices contributed alongside those of no obvious political views. Health ministers have now got in on the act too. But it wasn't a left-wing front, which may be a shame as, if it were then The Sun would be back in the big tent!.

When one LibDem (@jamesgraham) pointed out to myself and Tim Montgomerie that he had not yet seen any Conservatives take part, I tweeted this:

NHS is a national institution. Nye may have created it, but I would welcome some Conservatives speaking up too #welovetheNHS

This seems to have irked Graeme. But I don't agree I was looking for an artificial "dividing line"; more the opposite. Indeed, my argument was that it would be useful for American observers to see how marginal Dan Hannan's views are, including on the centre-right of politics, as I hope that they are.

Could it really have been a "gotcha" attempt when David Cameron has gone so far as to say this:

"The Conservative Party has an historic opportunity: to replace Labour as the party of the NHS. That's quite an aspiration – but I believe it is our duty to live up to it. To be the party of the NHS is an honour that must be earned. So I pledge today that I and my Party will work tirelessly this year to earn that honour to deserve the trust of the patients and staff of the NHS and to be what I believe we should be: the party of the NHS".

Not, intriguingly, to claim that no party should try to claim to be "the party of the NHS" but that Labour currently has that honour and that the Conservatives should be audacious in taking it from them.

So I would prefer that the existence of the NHS was not contested in the mainstream of party politics. That has been the norm for most of post-war politics - that there has not been a dividing line about the principle of the NHS itself.

So doesn't that, then, close down debate? I don't think it can be said do so illegitimately. This depends on every party. A consensus on any issue can only be established or maintained because different parties choose to be part of it.

Indeed, this is part of how political change happens, and is entrenched or is challenged. It helps to explain why there is currently a rather broader consensus about climate change in the UK, but not in the US, for example. Clement Attlee set the contours of thirty years of politics by establishing the contours of the Beveridge settlement; Margaret Thatcher overturned much of that - and so had an influence long after she left office. But she was always prepared to acknowledge that the NHS - "safe in our hands" - was beyond her grasp.

So Stephen Fry tweeted in favour of a pro-NHS consensus too.

Republicans know this. Even the most right wing British politician wouldn't think of dismantling our NHS

Yet Fry is not quite right about that. Dan Hannan MEP is keen to establish a profile with his repeated attacks on the NHS as a "mistake", "Marxist" and something "he would not wish on anyone". He is entitled to his views, but it is part of politics and free expression that he should expect them to be challenged and tested.

Hannan always exudes confidence yet is very shaky on his health facts.

Many people will think it rude as well as politically unwise for Hannan to help some of the nuttier people on the US right to spread stupid myths about the NHS as part of a US domestic political debate if he won't even bother to engage seriously with the evidence.

But Hannan knows what he is doing. This is what he thinks the point of politics is.

He knows that the Conservative leadership has and will make clear they do not agree. But I imagine he would take inspiration from how Keith Joseph acted as John the Baptist for Margaret Thatcher. So Hannan is unabashed about having a long-term political strategy to ensure he keeps open a political argument for parts of his general Hayekian libertarianism which are currently politically inconvenient for his own party.

Since Hannan's project is to act as an ideological standard-bearer within this party, it is quite legitimate to ask how strong the support for the Hannanite agenda is among the grassroots.

Hannan is clearly personally popular on the right - either because of his views, or in spite of them. It seems to me that, on Europe, he has shifted arguments in his direction, without (yet) winning the war. On the NHS, he has a much tougher job, and can not hope to carry the day while Cameron is leader. However, he may take some hope from their being relatively few opinion formers in the party think-tanks and in the media who take an unambigiously Cameroonian line on these issues, other than as a tactical matter of political positioning.

And I don't think Graeme establishes a particularly strong case that expressing public support for the principle of the NHS closes down arguments about how the NHS might change. It is often claimed that the status of the NHS as a secular religion prevents reform. But there has been a dizzying amount of health reform, and many think rather too much, so it clearly can't block everything.

There are many areas where we could do with a better health reform debate than we currently have. I doubt any party are saints - but the fault does not lie only with Labour.

No doubt every opposition party is prone to opportunism to some extent - but I can not see any other policy area where the Conservatives have been quite as opportunist and populist (and often contradictory) as on health. That is a point that has been made from their right, left and centre.

The Fabians long argued for a more open debate about taxation and spending, proposing a hypothecated health tax. This influenced New Labour's (popular) national insurance increase. At the time, many Conservatives were sceptical about the need for more money. Most think too much money has been spent. Rebalancing public finances is a major public issue - and Conservatives challenge the Labour government on this.

Yet, the Tory leadership now also seeks to outflank Labour on the pro-spending side of the health spending debate, certainly if one listens to Andrew Lansley, though ConservativeHome surveys suggest broader opposition in the party to ring-fencing health spending entirely.

Many Conservatives think less money would be needed, if there was more reform. But most Conservative health campaigning often goes in the other direction.Conservatives have also called for a moratorium on all local NHS reconfigurations, campaigning under the slogan "Stop Brown's NHS cuts"; campaigning against polyclinics, though the evidence for these as a good use of resources seem to me strong.

The pro-NHS Fabian Society and ippr have published a good deal on NHS reform, particularly on how to make a more public health focused and preventive NHS possible, with Howard Stoate addressing the political challenges of arguing for fewer hospitals. The Kaiser Permanente model of integrated care from California has certainly influenced the government's agenda and the health reform debate on the left: that is not inconsistent with NHS principles, and support for universal coverage.

Meanwhile, many on the right fear that Andrew Lansley risks "producer capture" in his attempt to curry favour with the BMA and the nurses. Again, this seems more likely to slow reform than to speed it up. And, just last week, we had the pro-localism Grant Shapps arguing for a uniform national standard on IVF to avoid postcode lotteries.

None of these issues - funding, prevention, localism - have an easy solution. But the Conservatives have not shown much interest in acknowledging their complexity.

Whether Conservatives want to be as unabashed in their admiration for the NHS as David Cameron is a matter for them.

Some clearly feel that - despite the political advantages - there is too high an ideological price to pay.

The argument that they should both support the NHS and promote wide-ranging reform - stressing that this does not mean they are hostile to the principle of the NHS - is perfectly legitimate. But it would be useful to have some more coherent idea of what that reform agenda is about.

Meanwhile, several right-of-centre commentators or think-tankers - might argue that public support for the NHS is often sentimental and misplaced. That would mean resisting the idea of campaigns which celebrate the NHS as a great national institution. This view would not "love" the NHS - but rather tolerate it - though few go as far as Dan Hannan in arguing that the NHS is a Marxist institution which Conservative should oppose, so that one day they can replace it with something which reflects different values of their own.

And I assume Hannan is trying to cause offence when he derides the NHS as "Marxist". But his argument that what saves the NHS from abolition is that its employees form an electoral bloc is nonsense. 1 million people can't do that: there were 13 million trade unionists in 1979, and that did not prevent Thatcher's trade union legislation. The bloc to Hannanism on health is that the vast majority of those not working in the NHS value it, while only 1% share his view that it was a mistake from the very start. Because he won't admit this, Hannan accuses NHS staff of selfishly protecting their jobs and self-interest at the price of a much worse health system for us all. He won't win that argument while being so unwilling to engage seriously with the evidence or with opposing views.

So let's have a sensible debate about health. We might even find out what our would-be next government will do about the NHS in practice. That would be rather more interesting than Dan Hannan spouting yet more nonsense on Fox News.

1 comment:

Soho Politico said...

Wonderful analysis. This passage, in particular, nails it on Hannan's overarching approach to politics, IMO:

"Many people will think it rude as well as politically unwise for Hannan to help some of the nuttier people on the US right to spread stupid myths about the NHS as part of a US domestic political debate if he won't even bother to engage seriously with the evidence.

But Hannan knows what he is doing. This is what he thinks the point of politics is."