Politics, democracy and the NHS

In the early 1990s, my grandmother became seriously ill. She had a stroke; caused, it turned out, by a tumour in her brain. One morning she was taken by ambulance to a crowded NHS hospital in Liverpool. No beds were available. She was placed on a trolley in a corridor where she remained, untreated and undiagnosed, for the next eight hours. The tumour, we later discovered, was inoperable, and she died not long after, cared for by family and the excellent MacMillan Nurses.

This was what the NHS was like at the time. Chronically underfunded, under-resourced and terribly stretched, often past breaking point. Stories of people being left on trolleys for hours because of the shortage of beds were common. Nevertheless, things got better. Funding was increased, waiting times improved, and, within a decade, the service was unrecognisable to the one we encountered that day in Liverpool. Of course, the economy was doing well, but it is not always the case that when the economy improves so too do our public services. Most importantly, healthcare became a priority of public policy.

Of course, there remained occasional examples of truly appalling care, notably in Mid-Staffordshire, but these were very much exceptions. Yet while the crisis persisted, many commentators pointed to the NHS’s funding model: Yes, of course, we all love and value the NHS, they explained patiently, we all want it to remain as it is, free to all at the point of care with the same quality of care available no matter what your income, but it just isn’t affordable, I’m afraid. We have to change the funding model. Privately, politicians drew up plans for a private healthcare system in the UK.

Now, once again, the NHS is in crisis. As before, the background is cuts to funding and a lower than average (compared to comparable countries) spend on health and social care as a proportion of GDP. And, as before, the funding model is in question, with commentators pointedly wondering whether it is possible to have an adequately funded system in which access is unrestricted and the level of care universally good. Clearly, funding is a huge challenge. But before we throw away what is truly great about our healthcare system, we need to think hard about what we want it to be, who we want to be, as a society, and what our priorities really are. We should not just talk about the NHS as though it is a closed system, with a discrete funding stream on which decisions made elsewhere don’t impact. We need to think much bigger, taking into account issues such as poverty and wellbeing which place a strain on health services.

I do not want to say that the NHS is perfect or that it could not operate more efficiently and effectively. There are clearly things we could change, such as its focus on treatment rather than prevention. There are major cultural and educational issues too. And we need to be smarter when it comes to promoting active ageing, ensuring, in particular, that older people have opportunities to continue learning (a hugely important area which appears to have fallen out of fashion, even among its traditional advocates). But the NHS remains one of the most efficient health services in the world, despite its funding concerns, and the challenges it faces, principally demographic, while substantial, face every health service where populations are ageing. Furthermore, as the OECD has pointed out, ‘There is no health care system that performs systematically better in delivering cost-effective health care’. And general taxation remains an efficient way of raising funds, as the King’s Fund has pointed out.

Evidently, we will have to pay more in future but that is something most, I suspect, would be prepared to do. We should at least be aiming to match the EU average for health care spending. The argument that since other, different European healthcare systems are doing better in some respects, the NHS funding model doesn’t work, ignores the fact that these systems are better funded. There is, in other words, no prima facie case for abandoning the healthcare funding model we already have. The point I want to make is that, by all means, let us have a conversation but let us at least have an honest and open one in which all options are on the table.

The problem we face in the UK is that genuine choices, matters of our priorities as a society, are presented to the public as unavoidable outcomes of circumstances over which we have no real control. There just isn’t enough money to go around. Choices made by other countries, to better fund their health services or their education systems, are made to seem extreme, utterly unaffordable, the stuff of fantasy. Even the relatively modest proposals presented by the Labour Party in its last manifesto would ‘bankrupt the country’, we are told. Instead of the informed national conversation we so desperately need, we have a shouting match between those who supposedly think everything is affordable and those who think nothing is (or pretend to).

This is what I find so utterly discouraging about political debate in the UK. Not only do we lack a consensus as to the kind of society we want, or any meaningful sense of a social contract which might encompass all of us, we also have a media and political class which seem determined to prevent such a discussion taking place. When Jeremy Corbyn become leader of the Labour Party, promising a different, gentler style of politics, I hoped that he might be open to an inclusive debate within the party, to bring its different wings together – something that mirrored the kind of conversation we need to have as a country. Instead, the party now reflects its own divisions and those of the country more clearly than ever.

I don’t agree with those who believe that progressive policies can’t win at the ballot box. But I do think that meaningful, lasting change, needs inclusive politics that brings people out of their echo chambers and makes genuine debate possible. You cannot expect change to last if it is imposed on people who do not understand it and do not feel included in it. The British political landscape is a terribly divisive place right now, and there are far too few straws in the wind to make hope of change realistic. With Brexit looming ever closer, we are coming face to face with a reality which seems inevitable but which many people cannot bring themselves to accept, given the huge costs to the country it represents, and the damage it will do to people’s lives, particularly in places that are already struggling. The evidence on which people voted in the referendum is tainted, as are many of the people and organisations who campaigned on the leave side. Yet, even in these circumstances, there is hardly any mainstream political challenge to Brexit.

People feel unrepresented. In very many cases, they also feel desperate. Schools are struggling. The NHS is in crisis. Politics itself is in disarray. We are drifting into the future with no destination in mind and no map to guide us. Those who suggest we might pause a while to think about where we are going are pilloried in the press. How can we be dashing towards such radical change without any hint of a conversation about what kind of society we want to be? There is a gaping hole in the middle of British politics where just such a conversation should be taking place.

Politics is about choices. And democracy should mean we get to have a say about those choices. Any attempt to deny or limit those choices is, in effect, a subversion of democracy. There are many more options on the table than we are led to believe. We cannot have everything but we can have more and we can have different. We need to start being honest about who we are and what we want to be.