Monday, May 16, 2011

The Tories and the NHS

The NHS has always been a vulnerable point for the Tories. They neither like nor trust what it stands for, how it works, but cannot assemble a viable coalition in favour of its destruction. Today, David Cameron has attempted to justify the present government's privatizing measures by claiming that they are the only way to meet a funding crisis that will hit the service in the next few years. That is, they intend to underfund the system by at least £20bn by 2015, and claim that the dire effects of this can only be avoided through their 'reforms'. But note what they're not saying. This is David Cameron's explanation:

"If we stay as we are, the NHS will need £130bn a year by 2015 – meaning a potential funding gap of £20bn.

"The question is, what are we going to do about that? Ignore it? No – because we'd see a crisis of funding in the NHS, over-crowded wards and fewer treatments. Borrow more so we can chuck more money at it? No – because we can't afford to.

"Ask people to start paying at the point of delivery for it? No – because, as I said, the NHS must always be free to those who need it. There's only one option we've got, and that is to change and modernise the NHS to make it more efficient and more effective and, above all, more focused on prevention, on health not just sickness.

...when I think about what our NHS will look like in five years' time, I don't picture some space age institution, a million miles away from what we have now. Let me make clear: there will be no privatisation, there will be no cherry-picking from private providers, there will be no new up front costs people have to pay to get care."

This is obviously disingenuous. There will be privatization, and it will not make the service more efficient, either in terms of cost or patient outcomes. And the claim that this new system will look anything like the one we have now is a ham-fisted insult to reason. But the Tories are not seriously attacking the 'common sense' of the NHS. At the level of discourse, they are not making any inroads whatever into the principle of a taxpayer-funded, free national healthcare system. They dare not even try. Instead, they depend on a manouevre pioneered by Thatcher, that of exploiting a crisis of underfunding to argue for the reforms they want to see, which are then coded in apparently neutral, anaesthetizing phrases: not privatization - good heavens no! - efficiency. This is Stuart Hall writing back in 1988:

Mrs Thatcher has personally taken charge of the crisis - always an ominous sign. 'The impression which the prime minister was trying to create was that she was pleased that talk of crisis by the opposition and health professionals had opened up the NHS to her radicalism. Her spokesmen countered the impression of government panic by stressing that she was "seizing the tide of public perception"' (The Guardian Jan 27). The talk is now exclusively about 'alternative ways of funding' (which every post-Thatcherite child of nine knows is a code-phrase for the massive expansion of private medicine and privatisation within the NHS) and 'breaking the barriers to greater efficiency' (which we know is a codephrase for destroying COHSE and NUPE).


the balance of ideological advantage slowly turns Thatcherism's way, because the specific issue of the NHS is secured for the Right by a deeper set of articulations which the Left has not begun to shift. These include such propositions as: the public sector is bureaucratic and inefficient; the private sector is efficient and gives 'value-for-money'; efficiency is inextricably linked with 'competition' and 'market forces'; the 'dependency culture' makes growing demands on the state - unless ruthlessly disciplined - a 'bottomless pit' (the spectre of the endlessly desiring consumer); public sector institutions, protected by public sector unions, are always 'overmanned' (sic).; 'freedom' would be enhanced by giving the money back to the punters and letting them choose the form and level of health care they want; if there is money to spare, it is the direct result of Thatcherite 'prosperity'; and so on.


We may have to acknowledge that there is often a rational core to Thatcherism's critique, which reflects some real substantive issues, which Thatcherism did not create but addresses in its own way. And since, in this sense, we both inhabit the same world, the Left will have to address them too. However, squaring up to them means confronting some extremely awkward issues. One example is the fiscal crisis of the welfare state - the ever-rising relative costs in the NHS as the average age of the population rises, medical technology leaps ahead, health needs diversify, the awareness of environmental factors and preventive medicine deepens and the patterns of disease shift. The fiscal crisis of the welfare state is not simply a Thatcherite plot, though of course Thatcherism exaggerates it for its own political ends.

The Left's answer is that there is more to spend if we choose; and this is certainly correct, given Britain's pitiful comparative showing in terms of the proportion of GDP spent on health amongst the industrialised countries. But only up to a point. At the end of this road, there are limits, which are not those set by Thatcherism's artificial 'cap' on spending but those limits set by the productivity of the economy itself. What the Right argues is that, once this limit is reached (even at the USA's 10.7% rather than the UK's miserable 5.9%) there is then not much to choose between rationing by price (which they would prefer) and rationing by queue (which is what has been going on in the NHS for decades). Naturally, they prefer rationing by price, since it increases the incentive to the patient to save on costs and puts pressure on the 'health market' to become more efficient.


simply 'spending more on the NHS' comes up against the barrier of the failure of the Left so far to elaborate a strategy for an expanding economy. On the other hand, where it hits the road block of the unpopularity of higher taxation in the form of that entrenched figure (which, at the moment, belongs exclusively to the Right) - the 'sovereign taxpayer'. Thatcherism is also held in place by this ideological figure of 'economic man', the measure of all things, who only understands cash-in-hand, readies-in-the-pocket, and who apparently never gets ill, doesn't need his streets cleaned or his children educated or to breathe oxygen occasionally. Clearly, the NHS issue cannot be won in terms of the NHS alone. If Thatcherism wins the argument about 'wealth creation', 'prosperity' and 'taxpayer freedom', it will, sooner or later, win the argument about privatising the NHS.

Now, it so happens that Hall exaggerated the popular appeal of Thatcherism, and over-estimated their ability to erode public support for socialised health care - but discount for it and the same issue looms before us. Look at that last sentence from Hall again. If the Tories win the wider argument about austerity, they may not win the argument for privatising the NHS, but they will certainly make their case for this vandalism more plausible. The austerity narrative says that the state has over-extended itself and must contract to a more manageable scale; that the productive capacities of the economy are being over-burdened by the high taxation needed to support the welfare state; that prosperity can only be restored if business is allowed to get on with investing under relaxed conditions (albeit with some safety barriers built in to the financial sector in a vain attempt to protect the system from its instability). Naturally, therefore, "we can't afford" to pay for the NHS. The obvious lessons are that the Left, to counter this, has to have an alternative growth strategy, and; this has to be elaborated in an unabashedly ideological way, because what is at stake isn't just a bureaucratic-managerial matter of efficiency but rather of the priorities and direction of the whole society. I think there may be some in the Labour leadership who understand this, but they are no more able to act on this understanding than Gordon Brown was capable of being the 'secret socialist' of reactionary nightmare and centre-left masturbation fantasy.

I select the NHS to focus on because, apart from the fact that Cameron has made this intervention today, it's the Tories' weakest point, the issue on which we can assemble the broadest social forces. The middle class suburbs are up in arms about what's being done to healthcare every bit as much as working class boroughs. The Tories have already had to retreat on this, and the issue divides the coalition somewhat. We have them beating a tactical retreat before a serious shot has been fired. Yet, if what Hall referred to as the "political-ideological thematics of Thatcherism", which today are concentrated in the politics of austerity, remain in place, then they will be able to continue to come back for more. Even if the Tories do not succeed in getting all that they want, they will gradually get some more of what they want; and more importantly, they will find that their occupancy in power is not disturbed by their losing an election. New Labour, operating within a broadly Thatcherite mode, took the logic of privatization and marketization in the health service further, faster, than the Tories had been able to. Labour's leaders today cannot think or articulate a politics outside of austerity, which leave us with a desperate need for a counter-hegemonic campaign to do just that.