Just a few months ago you could have turned on the TV on a Thursday night for Question Time and seen any one of Harriet Harman, Peter Hain, Hilary Benn, Alan Johnson or – most likely – Hazel Blears dutifully defending every aspect of the government’s NHS reforms. They would have lauded ‘choice’, defended competition, praised the private sector and dismissed the concerns of the unions.
Not so now – at least for most of them. Chasing the votes of Labour members and trade unionists in the contest to be Labour’s deputy leader, the likes of Hain and Harman have had a miraculous recovery of their senses, saying things that would have got them sacked a short while ago. All have been pulled sideways by the threat of John Cruddas – the only backbencher in the line-up – who has crowbarred open a political space to the left.
This collective self-criticism springs from a recognition that the government’s NHS market reforms have gone against the grain of Labour instincts and have not worked. Despite massive investment, polls suggest the Tories are now more trusted to run the health service.
Peter Hain describes this as ‘absolutely astonishing’. ‘We need to raise our game,’ he says in response to a Red Pepper/Keep Our NHS Public survey. ‘As a first step, we need a moratorium on structural change and reorganisation in the NHS. The health service doesn’t need to be in a state of permanent revolution in order to deliver. It’s time to let the health service settle down.’
The extent of private sector involvement in the NHS has been one of the clearest points of division in the race to be deputy. Taking the outside lane on the far right of the track, unswerving but somewhat lonely, is Hazel Blears. She defends the use of the private sector, saying, ‘We should have no ideological opposition to it.’ Running just inside her is Hilary Benn. Asked if private provision should be continued, he says: ‘What matters most is … doing what is best for people who are sick.’
On the centre-right of the circuit is Alan Johnson. He is following a more nuanced course, saying that Labour ‘has a responsibility to monitor the success of its changes, and if outsourced services do not perform, we must act’. He says that ‘many people have closely associated the trust debt difficulties with the outsourcing of services, and Labour must take care to treat the root of the problems’. But for Johnson it is not a point of principle, and he would be quite happy to see GPs and primary care trust (PCT) services outsourced.
Hugging the inside line on the left is John Cruddas. His approach is direct, calling for a moratorium on all new private contracts for NHS work. Early on, the distinctive course taken by Cruddas left a big area of empty track between him and the others. Harriet Harman and Peter Hain have steered into this space. Harman broke the previous orthodoxy when she told a hustings in Sheffield: ‘We should never, ever be saying we need the private sector to do the innovation because the public sector doesn’t innovate.’
She believes that independent sector treatment centres – the privately run clinics carrying out NHS operations – ‘have not always proved to be more efficient or innovative’. She criticises the contracting out of cleaners, caterers and healthcare assistants, saying it is ‘breaking up the NHS team’ – sentiments echoed by Hain, although neither have said a word against Gordon Brown’s pet private finance initiative (PFI) policy, which often requires the out-sourcing of these services.
Hain does believe, however, that the preference for private over public has been a mistake. ‘Where we have failed is in being clearer about what the scope and limits of private sector involvement should be,’ he says. ‘As a very basic general principle, I believe public services should be publicly provided unless there’s a very good reason why not.’
Hain believes Labour ‘needs to be prepared to admit when we have made mistakes’. This may extend to running the NHS as a market. Hain supported the introduction of ‘payments by results’ – the new NHS financial system – but he now says cryptically: ‘Clearly, we need to learn from experience, and only proceed with such reforms if the evidence shows that they are working.’
Even Gordon Brown, when he faced a potential challenge from Michael Meacher or John McDonnell, expressed doubt about the market model, telling the BBC: ‘Healthcare is quite different from any other area of the economy. You’ve got people who rely on doctors for advice … you’ve got hospitals that are effectively monopolies because you’re not going to find another A&E very close.’
This is a world away from the insistence of Blair that patients are consumers and that competition will result in better health outcomes – a view shot down by Cruddas, who told the Socialist Health Association that healthcare ‘cannot be left to the vagaries of the market – by its very nature it would mean different levels and standards of care for people, and some losing out altogether’. He argues that: ‘The current reforms of introducing competition and contestability into the health service, and the drive for PCTs to commission, rather than directly provide healthcare, threaten the universal ethos of the NHS.’
Back over on the right-hand side of the track, Hazel Blears has gone beyond being on-message to being über-message, saying: ‘I don’t accept that we’ve introduced free markets into public services.’
One of her fellow Blairites, Charles Clarke, recently proposed that the NHS should start charging for more treatments. Despite being ‘instinctively against’ charges, Blears told our survey she ‘would need to see the detail before saying “never”‘.
Indeed, before Blair’s resignation this seemed a fashionable idea. But all the other candidates, including Johnson and Benn, have voiced opposition. Peter Hain, for example, says the NHS ‘must remain free at the point of use, and I am opposed to any extension of charges for NHS services’. For Cruddas, charges are a consequence of ‘a system of multiple providers competing against each other for their income’.
After health secretary Patricia Hewitt was met with silence at Unison and boos at the Royal College of Nursing last spring, candidates have realised there needs to be what Hain calls ‘a new deal with NHS staff’. Unsurprisingly, given the electorate, on this issue the candidates are tripping over each other in the middle of the track.
Benn wants to involve unions in policy formation, instead of ‘handing down reform from on high’. Johnson agrees, and wants to see an increase in representation of the public sector unions on Labour’s National Policy Forum. At a hustings he said the government had ‘listened a bit too much to the British Medical Association and not enough to unions like Unison’ – possibly signalling a new divide-and-rule tactic, or more likely signalling that he is the Unison-backed candidate.
Cruddas goes a step further. The problem is ‘a top-down political structure with consultations over decisions already made and an adherence to a dogma that competition and markets always have the answers’. Instead, he wants policy to be ‘formed through the involvement of members and trade unionists at all levels’.
For Blears the issue is simply one of tone, not policy. She told the Guardian that staff were fed up with being told ‘You’ve got to reform because you’re not good enough.’ Everything would be hunky-dory if only the message was ‘Yes, we’ve got to reform, we’ve got to change, but we know you go to work wanting to do a good job, we want to help you do an even better job than that.’
Staff think Labour is telling them they’re not good enough partly because the government has placed such emphasis on ‘choice’ – almost selling the policy to patients as a chance to escape from the NHS into sparkly new private facilities. Campaigners have long suspected the rhetoric of choice as being a cover for privatisation. Cruddas has sympathy with this view, adding that choice will benefit those able to ‘work the system’.
Interestingly, even the more Blairite ministers are decidedly cool on choice. Johnson sees it as a secondary issue, saying: ‘Choice will only be valued if a good choice is on offer. The quality of healthcare per se is most important to the public, so the government must maintain its concentration on healthcare standards primarily.’ Benn prioritises ‘a good service and speedy treatment’, with patients being treated with respect. For him choice is merely ‘an important part of these aspirations’.
Whatever the fate of ‘choice’ in the NHS, choice within Labour is now in the hands of members and trade unionists. The deputy leadership race has highlighted the degree of unease over Blair’s NHS reforms. It remains to be seen if this will be reflected in real policies.
Keep Our NHS Public’s verdict: who is best for the NHS?
-# Jon Cruddas
-# Peter Hain
-# Harriet Harman
-# Alan Johnson
-# Hilary Benn
-# Hazel Blears
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