Living on borrowed time? The changing frontiers of the NHS debate

The author of 'The Plot Against the NHS' discusses the political struggle over England's national health service and considers what those determined to save it can still do.

Colin Leys is an honorary professor of politics at Goldsmiths College London, who has worked in the UK, Africa and Canada, and whose latest book is The Plot Against the NHS (with Stewart Player). He spoke to New Left Project co-editors Alex Doherty and Ed Lewis about the political struggle over the NHS and considers what those determined to save it can still do.

Given the unpopularity of the Health and Social Care Bill some commentators have suggested that this might become a poll tax moment for the government. Is this a realistic assessment of the damage the bill may do to them and, if so, why do you think they are persisting with it?

The analogy with the poll tax is relevant but not exact. The poll tax was a very simple issue, and very plainly unjust. It also required citizens to do something – to pay the tax – and when enough of them felt angry enough, and when the anger was widespread enough, a significant minority decided to risk jail and refuse to pay, creating a serious crisis of legitimacy. In contrast, the Health Bill is hugely complex, its real meaning has been deliberately obscured, and it doesn’t require citizens to do anything. The poll tax was also introduced in Scotland first, aggravating Scottish resentment of all Thatcher’s policies, whereas the Health Bill only applies to England, where a social democratic culture is less strongly entrenched.

A further difference is that the poll tax was firmly identified with Thatcher personally, whereas Lansley, it is said, lacks strong support both in the parliamentary party and among the Conservative rank and file.

So on the one hand, while a large majority of voters now understand what the Bill really means, especially for the less well off, they don’t yet feel it, and so it doesn’t provoke a deep sense of outrage – so far. On the other hand if the hostility to it becomes sufficiently entrenched its author is not prime minister, as Thatcher was: Lansley can be dumped.

Cameron will do whatever it takes to save face, subject to retaining Clegg’s support, and Clegg will be influenced by how much damage he thinks the Lib Dems’ support for the bill will do to the party. Cameron sees abandoning the bill as a political defeat he can't afford, but he could perhaps go along with the idea of dropping the chapter on competition, as proposed by Shirley Williams, if that was the price the Lib Dem rank and file demanded for not revolting entirely.

An intriguing though distinctly outside possibility is that if he did that, the work needed to revise the rest of the bill to could outstrip the capacity of the legal draughtsmen in the Department of Health and lead to serious further delay. That could mean that there was not enough parliamentary time to reach a third reading in the House of Commons while also getting the government’s welfare legislation through. In that case the bill would lapse, and its abandonment would be blamed on the opposition of vested interests (the medical professions) and ‘scaremongering’ by far-left activists. The appearance of outright defeat on the issue would be averted. But some sort of cobbled-together compromise still looks more likely, the bill being pushed through with its essentials unchanged.

The government has spent a great deal of time courting the support of the various professional bodies, but have failed even to enlist those professionals who stand to gain most from the bill (such as GPs). Why do you think they have failed so dramatically in this regard?

I think they have failed because they don’t have a convincing case.  And they didn’t actually court the medical professions – they made the classic mistake of mistaking the leaderships of the BMA and the Royal College of GPs and the rest for the memberships of these bodies. Many of the leaderships were ready to fudge the fundamental issue and continue talking with the government about details, but in the end their members were not. Lansley also sets a lot of store in the power of spin, and it worked for a while with busy MPs – Labour nodded the bill through its committee stage in the House of Commons – and with most journalists. But the medical profession as a whole contains many people with a good grasp of health policy and when they finally faced up to what the bill meant they not only saw through the spin, they were also quite offended by it.

A small minority of GPs with longstanding links to the Conservatives – members of the National Association of Primary Care and the NHS Alliance – have consistently backed the bill, and have been regularly cited by Lansley as representing GP opinion. But when the Department of Health published its plans for private sector ‘support organisations’ to do the bulk of the work of the new Clinical Commissioning Groups, a number of GPs who had been a strong supporters of the bill resigned from their Groups’ boards of management. They now realised that instead of helping their patients they would be mired in administrative detail with no real control, and would get the blame for the rationing of care that limited budgets would lead to.

They also realised that they could lose the confidence of their patients, who would start wondering whether their doctors were recommending all the treatment they really needed, or were tacitly rationing it to save money. (Or, conversely, they might wonder if their doctor was suggesting that they should seek private care from some private company the doctor had a financial interest in – as a group of Yorkshire GPs were found to be already doing last year.) By January 2012 a poll conducted by the Royal College of GPs found that 98% supported the College’s call for the bill to be withdrawn.

But the decisive moment in the shift of opinion in the medical professions occurred at the beginning of October 2011 when a group of public health doctors drafted an open letter to the House of Lords, pointing out the bill’s real implications, and calling on the peers to oppose it. They hoped to get 200 signatures and got nearly 500, including no less than 40 directors of public health around the country. After that, in one Royal College after another, the membership began to demand that their leaders declare their opposition. In many cases, including the Faculty of Public Health, success required months of coordinated struggle, sometimes against leaders who were very reluctant to oppose the government openly. (This reluctance was not necessarily self-interested. The leaders were well aware that like its Labour predecessor, the government was liable to prove vindictive and use its power to punish those who opposed it.) But by early this year the great majority, including the Royal College of Nursing, the Royal College of GPs, and the BMA itself, had come out officially calling for the bill to be withdrawn.

The recognition by doctors and nurses that they had a professional responsibility to take a stand against the bill, and explain what it meant to the wider public, altered the political situation decisively. Activists who had been agitating locally and nationally now had allies who carried weight with the commentariat. The government’s spin now rang more and more hollow and editorial opinion moved against it. It became common ground among commentators left and right that Lansley would be dropped from the cabinet in the autumn, without this producing any strong denials from 10 Downing Street.

Finally, on February 10 this year, the editor of Conservative Home, the website most followed by Conservative activists, published a long article calling the bill a serious threat to the party’s long term election prospects, and alleging that three cabinet ministers had more or less commanded him to say so. Cameron reacted by immediately declaring that he and Lansley were ‘as one’, but the damage had been done. From then on it would be a question of how the damage could be limited. To abandon the bill would be derided as evidence of both incompetence and weakness, so the initial reaction was bound to be to persist with it. But finding a strategy to minimise the cost would from now on be the real name of the government’s game.

On February 4, Ed Miliband wrote a piece entitled 'We have just 3 months to save the NHS'. Of course, the current threat to the NHS (in the form of the health bill) did not materialise this month but has been present since 2010. What's your view of the Labour Party's response to the bill?

I think the NHS has been under threat of privatisation since the 1980s, when the far right first started seriously promoting the idea and financing think tanks to promote it. It is also a fact that from 1999 onwards, after Alan Milburn replaced Frank Dobson as Blair’s Secretary of State for Health, Labour became part of the threat. Under John Major the NHS had been organised into a set of quasi-businesses (NHS trusts). Under New Labour these began to be turned into self-standing financial operations (foundation trusts), dependent on selling treatments, with a price for each treatment, ready to operate in open competition with private providers of health care. It was also New Labour who first invited private providers, in the form of Independent Sector Treatment Centres, to compete with NHS providers. Labour health secretaries did their best to conceal the fact that this was the goal, but it was clear to anyone who followed it at all closely.

Ed Miliband’s first shadow health secretary, John Healey, was fully conscious of this, and not especially opposed to it. His position on Lansley’s bill was that Labour had wanted ‘managed competition’, not full competition of the sort that Lansley is after. This didn’t seem a very big point of principle on which to base opposition.  Conservatives jeered and Labour MPs – most of whom had been quite happy with the Blair-Brown policy – were just embarrassed. Andy Burnham, who served briefly as health secretary under Brown, is a more forceful critic of the bill, but his calls to rally against it also have a slightly hollow ring in the absence of equally categorical opposition from Miliband.

Miliband’s statement that ‘we’ have three months to save the bill would be more convincing if he had clearly renounced the privatisation trajectory pursued under New Labour. In the leadership contest he said that the days of New Labour were over, but he subsequently declared that Labour’s record on the NHS was good. He gives the impression that he thinks the bill will be unpopular enough to win the next election for Labour without his having to come out against privatisation in a forthright way and pay the price of immediately being attacked as Old Labour and in hock to the health unions.

If the popular movement against the bill grows even stronger I would expect Burnham and Miliband to become more outspoken in their criticism of it. But following public opinion rather than leading it could prove an electoral mistake. The scale of public opposition to the bill suggests that if Labour’s opposition is seen to be half-hearted, people whose votes Labour needs will be left feeling disappointed and disaffected.

How do you assess the resistance that has been posed to the Bill so far by the following groups: (i) the House of Lords (to the extent that they have resisted at all), (ii) trade unions and professional associations, and (iii) non-sectional activists and campaign groups?

The trouble with the House of Lords is that it has no democratic mandate. It can improve the detail of bills, but not change their fundamental purpose. A great deal of hype preceded the peers’ consideration of the health bill. It was said that they would give it a rough ride. But anyone attending their sittings expecting to see that happen would have been sadly disillusioned. Their lordships like to talk and often do so quite well, but the committee stage in the Lords is not where substantial issues get decided. The Labour peers moved a few amendments that would radically change the aims of the bill and were routinely defeated. Lib-Dem peers and some cross-benchers moved much less radical amendments, and then withdrew them when ministers promised to ‘consider’ them. This allowed the government to claim, just as it had after the famous ‘listening pause’ in the spring of 2011, that major concessions had been made. Most of the media initially accepted this without much question.

But by this time the doctors were getting mobilised and by December the reality was clear. The ‘listening pause’ in the spring of 2011 was conceived and manipulated to give the impression that the threat the bill poses to the NHS had been averted, thanks to the stout opposition of the Lib Dems, expressed at their March 2011 conference. This was soon seen to be false. Then it was said that the committee stage of the bill in the House of Lords would see it radically amended. This too proved illusory. Now, at the bill’s report stage in the Lords, Lib Dem peers are to move a new set of amendments which are supposed to involve major changes and secure rank and file support at the next Lib Dem conference in March. But the amendments are not major changes. The Lib Dem leadership will do its best to convince the party rank and file that they are, but by now the pretence has worn too thin. Even right wing newspaper editors have lost patience with it.

It is not clear that the Lords realise how far out of touch with public opinion they are, and how badly their reputations will suffer for having consistently fudged – with some honourable exceptions, most notably Lord Owen – the fundamental issue at stake.

As for the trade unions, their opposition to the bill has been hampered by the affiliation of most of them to the Labour Party, which as ‘the political wing of the labour movement’ ought to have been taking the lead, but hasn’t.  In the absence of strong, principled opposition to the bill by the Labour leadership, opposition by the unions is too easily labelled as merely reflecting their members’ interest in their jobs and terms of service, which certainly are threatened by the bill. The Coalition is indeed pursuing a broad attack on all aspects of the public sector, including public sector pensions.  This makes it hard for Unison and Unite and the other health unions to speak up for patients’ interests without being charged with really being more concerned for their members’ jobs – even though their concern for patients is entirely genuine, and their concern for their members’ jobs is entirely legitimate. When the Royal College of Nursing finally called for the bill to be withdrawn, Lansley immediately said this was just because of their concern for their pensions, which the government was proposing to cut. That said, these constraints are a constant, and don’t fully explain the unions’ lacklustre performance in defence of the NHS.

Other activists and campaign groups have also been handicapped by the passivity of the Labour Party. Keep Our NHS Public has done its best to act as a central information hub, supplying speakers to meetings and putting out leaflets and a newspaper, and rallying numbers for demonstrations. But resistance has remained fragmented. On the other hand local activists have probably done more than anyone to bring home the significance of the bill to ordinary people, writing letters to local papers and lobbying MPs and councillors. In the last analysis, in an age of lookalike parties and the deep penetration of the state by corporations – the Department of Health being a prime case in point – the only ultimate barrier to the privatisation of everything is public sentiment.

The main new element here is the impact of the new media, from Twitter and Facebook to 38 Degrees. The government is well aware of this and invests significantly in the blogosphere, but can’t dominate it. Each new revelation of the truth about the bill ricochets round the digital networks in the blink of an eye. On balance the internet has worked for the bill’s opponents. When Cameron’s aides complain that Lansley hasn’t been able to sell his ‘narrative’, this is probably a significant reason why.

What do you think those determined to save the NHS can do at this stage?

The important thing is not to let up. Everyone should just intensify what they are already doing. The time between now and the end of the parliamentary session is critical. People are tired, but so are the government. They are badly rattled. A good illustration of this was the ill-judged so-called summit with representatives of the medical professions called by Cameron on 20 February, to which only representatives of the few who support the bill were invited. This was so obvious that as a public relations exercise it proved seriously counter-productive. Government spokespeople were left lamely claiming that there would be other summits to which (they implied) those who had been excluded would be invited. The more people show that their opposition is deep and will be long-lasting, the more rattled the government will become.

The charade of the report stage in the Lords, which is about to begin, needs to be exposed. The media are already describing the new amendments as important when they are not. Pressure needs to be kept on the media, and not least the BBC, to show some objectivity and balance their coverage by inviting genuine expert critics of the bill to take part in their panel discussions of it.

It is important to focus on the Lib Dems. Lansley’s ham-fistedness has attracted most of the flak but the Lib Dem MPs and peers are providing him with cover by going through the motions of obtaining ‘concessions’ while in reality enabling the bill to be passed. The Lib Dem President, Tim Farron, has already blinked, calling for the competition chapter of the bill to be removed, while acknowledging that this may not go far enough for Lib Dem activists (it won’t). Delegates to the Lib Dem conference, and Lib Dem councillors standing in the forthcoming local elections, need to be heavily lobbied. Everyone should also write a letter to as many Lib Dem MPs and peers as they can, and get others to do the same.

The bill wasn’t in the Conservatives’ election manifesto, let alone in the Lib Dems’, nor was it in the coalition agreement. It has no electoral mandate. It is a private sector ramp, masterminded by McKinsey.  Lib Dems must be left under no illusions. They need to understand that if they allow the Conservatives’ bill to become law they are morally and electorally finished. 

This interview is co-published with New Left Project.