National Health Service or national myth? Why UK Uncut’s ‘Block the Bridge’ protest is an empty gesture

In Norway, after the horrendous massacres carried out by Anders Breivik in July of this year, acts of remembrance were organised throughout the country in which people held aloft red roses: the symbol of Norway’s governing Labour Party, and once the symbol of Britain’s. By contrast, no red roses will be carried by the followers of UK Uncut, which is organising a ‘Block the Bridge’ protest this coming Sunday: a blockade of Westminster Bridge, just opposite the Houses of Parliament, to urge the Lords to throw out the government’s NHS Bill – the last chance of its being defeated or modified.

No, the red rose – international symbol of socialism, and incidentally also an iconic symbol for England in the form of the Tudor Rose – will not be in evidence. This is despite the fact that the protesters ostensibly wish to defend the socialist principles and legacy of the ‘British’ NHS, founded in the wake of the Second World War by Attlee’s Labour government. Instead, the plan is apparently to deck the bridge out in the blue and white colours of the NHS brand, or at least the NHS brand in England, which uses a lighter blue colour than the logos for NHS Scotland and NHS Wales, and a darker blue than the branding for Health and Social Care in Northern Ireland – the equivalent of the NHS in the Province.

The NHS (the one in England)

Darker blue for Scotland

Nice Celtic image and dark-blue font for GIG Cymru

‘NHS’ vanished altogether in this sky-blue logo for Northern Ireland

As these logos neatly illustrate, the ‘British’ NHS that UK Uncut’s valiant brigades will be standing up for is not the British NHS at all but the English NHS; and the Union government’s NHS Bill does not constitute a dismantling of the British NHS but a reorganisation of the English NHS along market principles. The British NHS as such was in fact dismantled by the last Labour government’s lop-sided implementation of devolution, which created four separate health services for each of the UK’s established nations (for the purposes of this discussion, Cornwall being assimilated to England). And it was that same Labour government that began the further dismantling of the English NHS that UK Uncut and its supporters are demonstrating against, as it was Labour that began the marketisation of the NHS that the Tory-Lib Dem coalition is finishing off. And of course, Labour’s marketisation was based on the support of its Scottish and Welsh MPs, with whose help the introduction of Foundation Hospitals – in England only – would not have been passed.

So it is perhaps no wonder that those Blocking the Bridge on Sunday will not be sporting socialist red roses. Maybe the protesters realise deep down that it was Labour that first sold out the founding principles of the NHS: that it was to be both a state-run and -owned service, and a national service, available free at the point of use to all in Britain in a uniform, consistent way. And perhaps they realise that the NHS is already neither of those things and will be even less so – in England, that is – if the Bill goes through.

But try telling UK Uncut that the NHS Bill relates only to the NHS in England – and believe me, I have tried this week, via tweets and email – and you might as well be threatening to try and march the massed ranks of the English Defence League across Westminster Bridge on Sunday: stunning silence and a complete lack of engagement with the critique of UK Uncut’s discourse, which refers constantly to ‘Britain’ and the ‘UK’ in relation to this and many other England-specific issues, and never to ‘England’. Nothing. In fact, one imagines that UK Uncut would view demonstrators bringing banners displaying the Tudor Red Rose and flags of St. George on to the Bridge on Sunday more as potential reincarnations of Anders Breivik himself – whose somewhat tenuous Facebook links with some EDL members were joyfully paraded about in some parts of the media and blogosphere in the wake of July’s massacres – rather than as being like the noble Norwegian public standing up for a national institution and values that are under threat, and mourning its young.

Indeed, Sunday’s demonstration really has more of the character of an act of mourning for an NHS that no longer exists than a political campaign that stands a realistic chance of influencing the government and bringing about meaningful change. In this sense, the absence of socialist and English symbols betrays the lack of any coherent blueprint – to continue the logo theme – for how a truly nationally owned and accountable NHS might be organised and funded in England now that it is no longer possible to go back to the Bevanite British NHS. Because that’s what the protesters will be defending on Sunday: the founding principles of the British NHS, not the actual one in England that the NHS Bill relates to, or the potential for a better English NHS, run by an English government, that puts the needs of English people first.

In this sense, it seems to me that the UK Uncut protesters are more interested in engaging in political myth than practical reality. The NHS – the idea of a unified, UK-wide health service free at the point of use to all UK citizens – is still widely proclaimed as one of Britain’s great national institutions. Indeed, it is one of the things, alongside the BBC, that symbolises Britain itself: its national unity and values. But if people finally wake up to the truth that the British NHS no longer exists, it might also dawn on them that a unitary Britain no longer exists. UK Uncut’s failure to engage with these realities is therefore an expression of its, and many other people’s, profound inability to emotionally separate themselves from a British nation that is no more.

For my part, UK Uncut doesn’t cut it. Maybe the almost inevitable passing of the NHS Bill, for all the doubtless harm it will do to universal health-care provision in England, will finally convince people that the old Britain is dead and only an English politics, accountable to the English people, will put their interests before those of UK plc. I won’t be helping to Block the Bridge on Sunday, because I’d rather stand up for an English future than be stuck in futile mourning for the British past.

England: The Unspoken Other

“What we cannot speak of we must be silent about”. Ludwig Wittgenstein

I’ve received a reply from the BBC to my complaint about their failure to point out anywhere in their coverage that the Conservatives’ draft manifesto on health care related to England only. Here’s what they said:

Dear Mr Rickard

Thank you for your e-mail regarding a Radio 4 news broadcast on 2 January. Please accept our apologies for the delay in replying. We know our correspondents appreciate a quick response and are sorry you’ve had to wait on this occasion.

I understand you were unhappy with a report on the Conservatives’ manifesto for the National Health Service (NHS) and that you felt it failed to make it clear it related to England only. I note that you feel this was another example of an issue presented as relating to the whole of the UK and that it is a practice you continue to dislike.

We are aware that a report that is of great interest to one part of our audience may be of little interest to another. This issue of national and regional news is of great importance to BBC News and requires a balance which we are always striving to get just right.

While certain news items may be specific to one part of the country, and often reserved for coverage by our regional news, we also have to acknowledge and cater to the many listeners and viewers who express a clear interest in knowing what is happening in other parts of the UK. It is also the case that certain stories which at first appear geographically limited can ultimately have a wider impact on the country as a whole. [My emphasis.]

You may be interest in the following entry on The Editors blog by Mark Byford, the deputy director general, who looks at this issue and the recent review of the merits and challenges facing BBC News regionally and nationally by the BBC Trust. The Editors blog is availabe here:

http://www.bbc.co.uk/blogs/theeditors/2008/06/uk_news_coverage.html

I would also like to assure you that we’ve registered your comments on our audience log for the benefit of the news teams and senior management. The audience logs are important documents that can help shape future decisions about content and ensure that your points, and all other comments we receive, are circulated and considered across the BBC.

Thanks again for contacting us.

Regards

Stuart Webb
BBC Complaints
__________________________________________
www.bbc.co.uk/complaints

There’s something profoundly unsatisfactory about this response, over and above the plain fact that Mr Webb failed to address the substance of the complaint, which was that the BBC had failed in its duty to report on the news accurately and impartially. In this case, this would involve simply letting people know that the Tories’ proposed policies would be implemented only in England. Rather an important detail, one might think.

But let’s analyse what Mr Webb is saying here. I’m particularly interested in the section I’ve highlighted in italics. Mr Webb is comparing the coverage of the Tories’ draft NHS manifesto to the way ‘regional’ stories are reported on. In essence, he’s saying:

1. The story in question did relate to just one ‘part of the country’ [a circumlocution for 'England': notice how, after the initial reference to my email, he can't bring himself to use the 'E' word] but was nonetheless of interest to listeners outside of that ‘region’, and so was legitimately broadcast as a ‘national’ news story
2. ‘Geographically limited’ [i.e. English] stories can have a significant impact on ‘the country as a whole’ [i.e. the UK], which thereby sets up a second reason why this particular story should have been broadcast on the national news: it’s not just ‘of interest to’ the whole of the UK (appealing to people who take an interest in current affairs), but it also affects the ‘interests’ of everyone in the UK. In other words, the Tories’ policies on the NHS could affect everyone in the UK materially in some way. Hence, though this was on one level just an ‘English matter’, it also matters to everyone in the UK – in both senses.

Well, yes, that’s all true: policy and expenditure decisions about the NHS in England are indeed of interest to many UK citizens living outside of England; and they do have a knock-on effect on the NHS’s outside of England, in that an overall increase or decrease in England-specific expenditure results in proportionally higher rises or cuts in expenditure in the other countries via the workings of the Barnett Formula.

But the relationship between spending in England and in the devolved countries is not straightforward or transparent. In this instance, Tory pledges not to cut the English NHS budget in real terms do not mean that the NHS budget won’t be cut in Scotland or Wales. If English spending declines overall despite the NHS budget being ring-fenced, then the Scottish and Welsh block grants will be smaller, and NHS spending in those countries may well have to be reduced. In order to understand how the Tories’ NHS policies will affect their interests – in the sense of ‘benefits’ – it is vital that Scottish and Welsh listeners understand the true relationship between England-specific policies and the corresponding policies in their own countries. And they can hardly come to this understanding if they’re not informed that the Tories’ policies are in fact only intended for England. To use Mr Webb’s analogy, this may have been a ‘regional’ story, relating to just one ‘part’ of the UK (England); but then, when genuine regional stories are covered at a ‘national’ level, the BBC does tend to take the trouble to spell out which region the story directly relates to.

So Mr Webb’s regional analogy completely falls over: a ‘regional’ story (e.g. one about Scottish politics or, say, an innovative private-public partnership being pioneered by a hospital Foundation Trust in one part of England) can well become a ‘national’ story (covered in the national news bulletins) if lots of people throughout the UK are interested in it and could be affected by it in some way. But that doesn’t make it a national story in the other sense: directly concerning the whole of the UK. But that’s precisely how the NHS story was covered: no attempt was made to make clear to listeners that it did relate just to one – albeit a highly influential – part of the UK. The word ‘England’ (the actual name for that ‘part’) simply wasn’t mentioned by the British Broadcasting Corporation; just as it was not referred to anywhere in the Tories draft NHS manifesto itself.

This illustrates a common observation: that while England is indeed formally ‘a part’ of the whole (Britain, the UK), it is generally referred to and thought of in British political discourse as if it were the whole (the UK) itself. In fact, there are two kinds of ‘parts’ of Britain from this point of view:

1. England, which is a ‘geographically limited part’ of the UK but, as such, is politically and existentially (in terms of its official identity) indistinct from the UK and subsumed within it
2. The ‘nations and regions’, both of which are really in effect thought of as regions of the UK / Britain (the ‘country’), the only difference being that three of those ‘regions’ have a distinct national character as recognised in the devolution settlement.

Such a structure does not reserve any place for England, which is where Mr Webb’s comparison of the Tory NHS story to a regional item is so disingenuous. On this model of the UK, the UK / Britain is ‘the country’ or ‘the nation’; and the nation is sub-divided into regions, three of which have their devolved, ‘nation-like’ systems of partial self-government. England (or ‘the regions’), on the other hand, is simply none other than the UK; just as Andalusia or Castile are regions of Spain (and are thereby also Spain), whereas the Basque Country, Catalonia and Galicia are national regions of Spain (and are by that token also still Spanish). On this analogy, England has become a ‘convenient’ (actually, inconvenient) name for the non-national regions of the UK; while Scotland, Wales and N. Ireland are the UK’s ‘national’ regions.

According to this understanding of the UK, then, England as such – as a nation – does not exist. This is a hard ‘truth’ whose implications are only beginning to dawn on me, despite the fact that I’ve voiced similar thoughts and discussed similar models for the relationship between England and the UK in numerous previous posts. In particular, thinking of things in these terms allows one to come to a deeper understanding of why the BBC won’t and can’t engage properly with complaints that they present ‘English’ stories as if they were British ones; and why the mainstream political parties resolutely persist in avoiding any reference to England when setting out their England-specific policies.

On an obvious level, this is of course done for political advantage: ultimately, because it maintains the whole British establishment and system of power, in and through which both the BBC and the parties seek to exercise their influence and prosper. But beyond these considerations of ‘interest’, the establishment won’t say ‘England’ because it can’t: how can you speak the name of something that does not exist? Both aspects are in play here:

1. Because the establishment doesn’t want England to exist, in case this undermines its self-ascribed right to govern as Britain, it does not speak the name of England and thereby, in a sense, makes England not exist, at least within the formal discourse and self-understanding of British politics: ‘the Nation is Britain, and the parts of Britain are its nations and regions’. That’s it: no need to invoke an ‘England’ that is just not a distinct part of this whole.
2. And because the word and name of England does not exist within the ‘politically correct’ language, it then becomes both inappropriate and irrelevant to mention it: language deals with things that exist, or that we believe to exist, not with what does not exist. ‘England’ has ceased to refer to anything in the present: it’s off the map of the British establishment’s mind, just as it’s off the physical map of the nations and regions. ‘England’, then, is a word that has served its time and is now redundant.

The BBC and the mainstream parties therefore do not say ‘England’, not just because they’d rather suppress all thought of England but because they’ve actually succeeded in removing the thought of it from the official and publicly ‘acceptable’ language of the British polity. They won’t say England because they can’t say England; and they can’t say England, not only because England officially doesn’t exist (it doesn’t refer to anything tangible within the polity) but because they actually don’t believe it exists any more, and they don’t know what ‘England’ means or should mean. In short, they’ve not only suppressed England from the apparatus of British governance, but they’ve repressed ‘England’ from their conscious minds and language.

This is the reason for my allusion to Wittgenstein at the start of this post: a foundational figure in what used to be referred to as the ‘English’, or at least ‘Anglo-Saxon’, school of analytical philosophy. The quote I used is my own translation from the original German that seeks to capture its ambiguity better than the classic translation: “Whereof one cannot speak, thereof one must be silent”. For me, my version (“What we cannot speak of we must be silent about”) perfectly encapsulates the combination of psychological repression and conceptual incapacity that characterises the British establishment’s silence with respect to ‘England’. First, out of political considerations of power, England was suppressed, both as a distinct national focus of politics and identity, and as something whose name – and in whose name – our political representatives could thereby speak. But then, once suppressed from the language, ‘England’ has become suppressed from the minds and understanding of reality of British politicians and media. England was first deliberately suppressed from political language and influence out of pure political motives; but now that language genuinely does not know it – so better not talk about it.

So on this view, England is no more. England is none other than the UK. And yet, England, as that which has been eliminated from British-political language, thinking and institutions – and as that which, in part for that reason, is beyond their reach and understanding – is also the Other of Britain. In psychological terms, if an individual represses a part of themselves and their history that they think of as unacceptable and inappropriate to express openly and socially, that part doesn’t in fact cease to exist, even if the individual’s conscious mind has succeeded in erasing all trace of it, and can no longer access the reality of that suppressed experience through deliberate thought and language. That part of themselves thereby becomes their ‘Other’: their repressed, unconscious selves that the conscious mind won’t and can’t recognise but sees as alien and unreal. The Other is the part of the individual that they have to suppress in order to think of themselves and to function as who they think they ‘are’. But in reality, those individuals cannot be whole persons until they are able to come to an understanding of and reconnect to the hidden parts of their selves and their histories.

So it is with England. The British establishment has suppressed its own deep roots in English identity and history because it projected onto England all the bad aspects of its own society, politics and history; and because it acted in the interests of redistributing power in a way that appeared more equitable than the England-dominated past, even while in fact continuing to exercise the same sovereign power that it previously wielded in England’s name. In other words, England had to die in order to be resurrected as Britain – but a Britain that, in order to be Britain, refuses and is incapable of acknowledging the England it still profoundly contains within it.

So England is Britain’s Other, whose name it cannot speak for fear that it might recognise itself in it. England is indeed both a ‘part’ and the whole of Britain: the part that in reality it needs to reaffirm as part of itself in order to be whole again. Otherwise, if the voice and identity of England cannot find expression within a Britain that would rather pass over it in silence, they will find expression in ways that could destroy the cohesion and survival of Britain itself as a political entity – just as, in an individual, unwanted traits and experiences end up being acted out in a more self-destructive manner if they are repressed indefinitely.

Well, this is a nice analytical model; but where does it leave us in practical terms? In particular, I’m wondering whether I should bother continuing to send off my complaint emails to the BBC every time they flagrantly ignore the England-specific nature of a story or policy announcement. If I do carry on, I certainly shouldn’t expect them to see reason, in the sense that, in my view, it is a simple case of reporting things in such a way that the public in different ‘parts’ of the UK know whether and how a story affects them. That’s what an ‘impartial’ public broadcaster is supposed to do, isn’t it?

But the responses I’ve received, as exemplified by Mr Webb’s email, reveal that the BBC appears not to see it that way. Perhaps they actually believe they’re carrying out their remit to report a story impartially by not making a point of saying ‘the Conservatives’ draft manifesto for the NHS in England’ or the ‘Liberal Democrats’ policy for childcare and education in England’ if the parties themselves choose not to spell this out.

More fundamentally, though, the BBC doesn’t see this as a serious enough issue, in my view, because they are a prime embodiment and propagator of the new Britain-centric political discourse and vision of the ‘nation’ that I’ve been describing. Despite Mr Webb’s comparison of the English-NHS story with an item of ‘regional’ news, the Corporation didn’t feel it was necessary to point out that the Tories’ proposals affected England only because they saw it as not just a ‘national’ story but a British story: about one of the national-British parties’ policies at the UK election for the ‘British NHS’, which were therefore of interest and relevance to the ‘whole country’. OK, ‘they’ – or some members of the various editorial teams involved – may have been dimly aware that, in fact, the policies related to England alone. But this fact would have been regarded as almost tangential and not worthy of being mentioned. The reason for this is that, for the BBC and the political establishment, there are really no such things as ‘English stories’ or ‘English politics’, but only British stories that happen, in some instances, to affect England only because of devolution but which are ‘British’ nonetheless because the nation itself is called ‘Britain’ and there is no such thing, officially, as ‘England’. These are, in short, ‘British’ policies that apply to a territory sometime known as ‘England’, and not ‘English policies’.

So the hard truth that I feel I’m perceiving more clearly now is that, for the British political and media establishment, the nation is Britain, and England does not exist: for them, England is merely the historic name for a part of Britain and a (British) cultural identity to which some remain sentimentally attached. England, in sum, is not present: neither ‘real’ in any objective, meaningful sense; nor ‘in the present’ (because it’s part of (British) history); nor represented in national politics (nor needing to be); nor requiring a mention when presenting ‘national’ policies.

Hitherto, my response to what I’ve called in this blog the establishment’s ‘Britology’ (the fabrication of a new British Nation as a sort of fiction: a creation of official and politically sanctioned discourse, language and symbolism) has preceded from the assumption that the ‘real’ nation that the fiction was intended to obfuscate and suppress was England, and that the establishment knew, more or less, what it was doing: a deliberate, politically led suppression of English national identity and pride. I’ve assumed that people generally knew that it was a lie, that they could see through it, and that the embargo of silence imposed on the word ‘England’ was really a conspiracy of silence maintained by all those who stood to gain from it: the established media and political parties.

But now I’m beginning to think that the establishment genuinely believes its own myths: that it’s not so much a case of collusion in the denial of England but shared delusion that England doesn’t exist. I think this is what we’re up against: not just the full weight of British political power but the power of a sort of collective psychosis. That may be too extreme a word to use. But really, I think there’s no alternative other than to conclude that powerful psychological forces such as repression (relegating unpalatable truths to the unconscious mind) are at work here if you are to really understand the systematic way in which all references to England are occulted from official documents, party-political pronouncements and media reports that relate to England alone; and the way that, when challenged, representatives of the organisations in question simply don’t get it: they genuinely don’t appreciate the significance and relevance of the omission of references to England.

Let’s put it this way: those of us who do love and value England, and see ourselves as English, of course think of England as a real nation. Therefore, when we notice that news stories and policies relating to England are presented as if they related to (the whole of) Britain, we think a mistake is being made: a deliberate mistake, intended to mislead, by the parties; and, if we’re being charitable, we think this is an oversight or error of omission on the part of the media for not picking the parties up on it. But if you try to get inside the mindset and assumptions of the Britological establishment, then you realise that they think England isn’t real and doesn’t exist; so that, for them, there are only British policies and stories at ‘national’ level. So saying that some of them relate to ‘England’ isn’t just a slightly irrelevant nicety but actually a non-sequitur: how can policies affect a non-existent country? For them, all policies are ‘British’ and relate only to ‘Britain’.

Devolution, as understood from this position, works like this: ‘all policies of the UK government relate to “Britain”; it’s just that some parts of Britain make their own policies in certain areas’. So ‘Britain’ is the name and identity of the nation, whether you’re talking just of the part (which we like to call England) or the whole. From this point of view, it isn’t deceitful to present policies affecting England only as ‘British’, because there is only Britain.

So I think we’re up against a government and establishment that not only refuses to recognise the right of the English nation to determine its own form of government, but which both refuses and – more profoundly – is incapable of recognising the very existence of an English nation. The new unofficial official map of the United Kingdom, for them, is one of a single, united Nation (‘Britain / the UK’), three parts of which are partially self-governing regions with a distinct national character: Scotland, Wales and Northern Ireland. England simply isn’t in the picture.

English nationalists are therefore inevitably not just campaigning for an English parliament but for recognition of England as a nation. Optimistically, you might say that the latter will flow from the former: if we manage to secure an English parliament, this will automatically entail official recognition that England is a distinct nation. But I would tend to put it the other way: we have first to win recognition of England as a nation for an English parliament even to be a realistic option on the table. If the establishment can’t even engage with relatively trivial and obvious complaints about omission of references to England in England-only policies and news reports, how can they be expected to seriously entertain calls for an English parliament? How can you have a parliament for a nation that doesn’t exist?

Maybe things are shifting more than I’m suggesting. It’s just that the wave of recent pre-election policy statements, in which the failure by the parties and media to mention their England-only character has been so gross, has depressed me a bit and made me wonder whether the powers that be will ever change. But it’s possible that change is nonetheless proceeding among the population as a whole and that, despite its inability to engage with any sort of English question, the establishment is getting increasingly isolated in its views from the people, who do think of themselves as English and want a government that cares about England and its needs. Maybe this is indeed the unspoken truth about the outbreak of disaffection towards the political class that was sparked off by the parliamentary-expenses scandal last year: that it reflects not just the ‘British public’s’ demand for a more accountable politics but the outrage of the English people at a British establishment that is pursuing its own agenda and interests without regard to the priorities, values and identity of the English nation. Perhaps England was the unspoken Other of this story, yet again.

So what do we do about the silence towards England that the establishment politicians and media would like to use to consign England to the dustbin of history? Well, the one thing we don’t do, even if tempted to, is fall silent ourselves. We have to keep on speaking out against it and asserting the right of England to be named, and so to exist. Keep on chipping away at the establishment armour – it might prove to be made of fragile porcelain rather than hardened steel.

As for me, I will keep complaining about unjustified omissions of ‘England’ where it should be mentioned, although I might vary the tactics a bit: not just write off to the BBC but consider other avenues, and also just ask them straight out why they chose not to mention that the policies or story in question related only to England? We’ve got to keep on gnawing away at their conscience and inserting ‘England’ into their consciousness, from which they’d rather relegate it.

Remember, apartheid South Africa and the Soviet dominion in Eastern Europe both collapsed at lightening speed after previously seeming as immovable as rocks. And that’s because the rot had set in from within: both systems were predicated on lies and on the denial of people’s right to freedom, democracy and national self-determination. Similarly, if the people continue moving away from the British establishment edifice by identifying as English and demanding a true national-English democracy, then that edifice may prove to be built on foundations of sand, not rock.

I for one, then, will not let England be an unspoken Other.

A good day for burying references to England

The Conservatives published their draft manifesto for the English NHS yesterday, which failed to mention the only country it concerns – England – once. Yes, not once.

You can suggest questions on the policies, to be put to David Cameron in a webcast on Friday of this week, here. You can also vote on the existing questions regarding the omission of ‘England’. Please do so, as this will help ensure that at least one of them gets put to the Conservative leader. Mine is as follows:

“Do the Conservatives plan to reverse devolution in the area of health care? If not, I was wondering why your manifesto proposes policies for the NHS (i.e. that of Britain / the UK) rather than just the NHS in England? Why not mention England?”

Meanwhile, BBC Radio 4′s news output scarcely did any better yesterday, failing to indicate to listeners that the Tories’ proposals related to England only – eliciting the following complaint email from yours truly:

“Why did the news broadcasts on Radio 4 yesterday fail to mention that the Conservatives’ ‘manifesto’ for the NHS relates to England only? Is the BBC unaware of the effects of devolution in this policy area? Just because the Conservative Party fails to refer to England once in a manifesto that only concerns England, this doesn’t mean the BBC has to parrot them in such an uncritical manner.

“The BBC website performed a little bit better, saying that ‘[David Cameron] pledged maternity reforms in England to “meet mothers’ needs”‘. But even that could suggest that this was just one England-specific pledge in a manifesto that in other respects relates to the whole of the UK, which it doesn’t.

“This example also illustrates a tendency – on the website, and in TV and radio scripts – to signal that policies relate to England only in an incidental, passing manner, some way into the article, rather than up front in a way that unambiguously flags up the fact that the policies in question affect England only. For example, the website article begins: ‘Conservative leader David Cameron has said the NHS will be his “number one priority”, as the main parties step up their pre-election campaigning’. A casual reader could think Cameron is making the NHS across Britain his number-one priority. But he isn’t, as a Tory government would have responsibility for the NHS only in England. So why not say, “Conservative leader David Cameron has said the NHS in England will be his ‘number one priority’”?

“This complaint relates to an ongoing series of complaints I have with the BBC over its failure to properly report on English policies and legislation as English, not as ‘British’ as the parties try to pretend they are. Does the BBC have a political parti pris on this?”

Let’s see what they come back with on this. They still haven’t sent a full reply to my criticism of their coverage of the government’s plans to build nine nuclear power stations in England, one in Wales and none in Scotland, back in November.

One good thing to emerge from the Queen’s Speech

In the spirit of praising best practice when it arises, I feel it incumbent upon me to record that, for once, the BBC’s radio and online reporting of Wednesday’s Queen’s Speech was exemplary in pointing out when the proposed legislation related solely or mainly to England and not the whole of the UK. The news broadcasts I heard on Radio 4 pointed out explicitly that the key measures for schools, the NHS and social care applied to England alone: something quite unprecedented for the BBC. And the summary of the legislative programme on the BBC website indicated for each item which UK nations they related to. E.g. Children, Schools and Families Bill, “Whole bill applies to England. Other parts cover Wales and extends in part to Northern Ireland”; Personal Care at Home Bill, “Applies to England only”; and Health Bill, “guaranteeing cancer patients in England a consultation within two weeks, a free health check for all over-40s and that no-one will have to wait more than 18 months [I think that should read 'weeks'] between a GP referral and hospital treatment”. Well done, BBC!

I can’t comment on the TV news or on other news media, as I didn’t see them. But I was further encouraged yesterday by Radio 4′s reporting on the farcical row that has broken out about the proposals for free personal care, with some Labour MPs complaining they have pre-empted the conclusions of a consultation that ended only this week (a blatant case of electioneering, then). The Radio 4 report, on ‘Today In Parliament’, was prefaced by the mention that the proposals related to England only.

If the BBC can make it clear in this way which parts of the UK the government’s legislative programme relate to, then there’s hope that, come the general election, it will similarly make an effort to point out which of the UK’s nations are affected, and which are not, by the policies the parties present and debate during the election campaign. In any case, I’m keeping a watching brief and will be bashing off further emails of complaint should the occasion arise. I nearly did so the other night, in fact, when I heard a BBC World Service discussion on the work of NICE (the National Institute for Clinical Excellence): the body that decides whether to approve drugs for the NHS in England and Wales based on a cost-benefit analysis. The World Service report failed to mention NICE’s geographical remit, implying that its work related to the whole of the UK; whereas we know that Scotland enjoys better per-capita funding than England for drug treatments and is not under NICE’s thumb. But it was kind of late; and I need to get out more!

I have, however, received a holding reply to my last complaint, about the misreporting of the government’s proposals for ten new nuclear power plants, all but one of which are to be located in England – and none in Scotland (wonder why). So watch this space.

Patients Association report on mistreatment of vulnerable patients in the NHS: why hide its England-only character?

The Patients Association – a lobby group that looks after NHS patients’ concerns and rights in England and Wales – yesterday published a shocking report containing 16 case studies of the mistreatment and neglect of elderly and vulnerable patients in NHS hospitals.

It probably won’t surprise my readers to learn that all the case studies in question related to English hospitals. However, this fact appeared to elude the media yesterday. At one point, on BBC Radio 4′s Today programme, it was stated that the case studies were drawn from “across the UK”, wording that was reiterated on the BBC website. Later in the programme, in the news headlines, they did indicate that all 16 case studies involved the experiences of English patients only, while clarifying that people from throughout the UK had contacted the Patients Association with similar examples of neglect. Another article on the BBC website does make this explicit while failing to make clear that not only the examples of abuses but the whole objective and scope of the report are to highlight instances of malpractice in England, and to call on the Department of Health (England) and the Care Quality Commission (the quango that looks after the quality of health- and social care in England) to take action.

Sky News are no better. The report on their website equally makes no mention of the England-only content and purpose of the Patients Association report. The Sky News web page contains a video in which agony aunt Claire Rayner, the president of the Association, asserts that many of the problems derive from the government’s obsession with targets, which force NHS staff to regard patients as mere units and as boxes to tick off rather than real people needing time, care and attention. Of course, this government-driven target culture, and the innumerable targets themselves, affect the English NHS only. They do things differently in the devolved NHS’s.

(Incidentally, I drew the failure of the Sky News report to mention the England-only nature of the story to the attention of their person in charge of dealing with viewer concerns, with whom I’ve been having an email dialogue following on from an open letter to the BBC that I posted on English Parliament Online and drew to Sky News’ attention. I received an initial response from the Sky News executive in question, in which he maintained that Sky does always take care to indicate when a political story relates to England only. I’ve since drawn to his attention two instances relating to the English NHS – including the present one – where this has manifestly not been the case; but I have yet to hear back from him.)

One of the reasons why the lazy media got it wrong – again – is that the Patients Association report does not make it explicit at any point that its observations and recommendations relate to England only. But they do affect only England: as I said, all the case studies concern events that took place in England; and the report’s call to action is addressed only to the authorities that deal with the English NHS. This absence of explicit references to England is in fact a characteristic of all the Patient Association’s communications and campaigns. Indeed, looking at its website, you’d be hard put to work out that the Association’s active campaigning is limited to England and Wales, and then in the latter country only in instances relating to common English and Welsh law. However, reading between the lines, all of the Association’s campaigns dealing with issues of health-care delivery, and the way in which they’re described on the website (with references to ‘the government’ and the Department of Health (England)), emerge as England-specific: GP services, care of older people, health-care-associated infections, dentistry and mixed-sex wards. I then discovered that there is a separate Scotland Patients Association – not affiliated to the (England and Wales) Patient Association – that deals with the corresponding issues for the Scottish NHS.

Why does the Patients Association (England and Wales) appear to go out of its way to conceal the in fact mostly England-specific nature of its activities? This seems in part to be an issue of funding. The PA reported that, after its report was publicised in the media yesterday, it had been “inundated by hundreds of emails and calls from patients across the country contacting us to offer their support and relate their own experiences of poor care”. This will in effect have served as a massive membership drive, and the Patients Association welcomes members (and corresponding financial contributions) from across the UK. It was therefore important for the Association to emphasise that their report deals with issues of concern to people across the UK, which the rush of offers of support and information on further abuses yesterday confirmed. Also, to be fair, the PA does provide information on how to complain about, and seek legal redress for, poor NHS treatment in each of the UK’s nations. But in terms of campaigning for action and change, the Patients Association’s activities are largely limited to England. The Association is in effect soliciting financial support from Scottish and Northern Irish citizens that would probably be more effectively directed to their own patients’ associations, which can actually do something about issues in those countries.

A similar situation applies to corporate sponsorship. The Patients Association’s list of corporate sponsors contains some impressive names; e.g. AstraZeneca, Denplan, GlaxoSmithKline, Johnson & Johnson, 3M, Napp Pharmaceuticals, Pfizer and Virgin Healthcare. Compare these with the sponsors of the Scottish Association: Arnold Clark, Barrhead Travel, It’s so Easy! Travel Insurance, Lloyds Pharmacy, Mobility Scotland, ScotWest Credit Union, Ross Harper Solicitors and Vision Call – Eye Care Home Services. Hardly as prestigious nor, one suspects, as remunerative! The Patients Association is clearly passing itself off as the ‘British’ association in order to secure the backing of such global blue-chip enterprises. Does it fear that if it more accurately designated itself as the Patients Association for England and Wales, it would lose some of these sponsors and the revenue they bring, and would have to rely on more ‘parochial’ English names?

On one level, I am reluctant to criticise the Association for this, as it is clearly important that it maximises its income in order to act as an effective advocate for English and Welsh NHS patients. However, is this advocacy not itself severely impaired and limited by the Association’s almost total avoidance of references to England, or to England and Wales, in the campaign material it puts out? Referring to issues relating to health-care delivery in England without any reference to England itself, as if they were issues of relevance to the whole of the UK, insulates the Association’s critiques and prevents them from becoming a truly powerful cross-UK analysis involving comparisons between practices, patient satisfaction and funding in each of the UK’s health services. It is as if the Association does not want in any way to connect its criticisms of bad practice in England with the politics of devolution, and of health-care funding and provision in the rest of the UK. But isn’t it vitally important to compare the experience of patients in England with that in Scotland or Wales; and if they’re doing things better in those countries, what can we in England learn from them – and do we need to direct more funding into improving the situation in England, given that per-capita expenditure on health care in England lags that in the other UK nations?

But clearly, the Patients Association has decided to avoid getting enmeshed in such political controversies. It would rather carry on working away in its own little bubble: drawing its concerns to the Department of Health (England) and the (English) Care Quality Commission without embarrassing either of these bodies by pointing out to the public that they’re letting England down compared with the corresponding bodies in the other UK countries that are more focused on the needs of their countrymen and -women. After all, rock the boat too much, and you could put off the corporate sponsors; and go on about England too much, and you could put off the individual members from Scotland and Northern Ireland.

But is it possible for the Patients Association to help bring about real improvements to the care provided to English NHS patients if the Association itself doesn’t care enough about England to mention her by name?

The debate on the National Health Service is a proxy for a debate on nation-specific ideologies and policies

I’ve been particularly struck in the past few days by the extent to which the debate on the two main parties’ commitment to the principles and funding of the NHS has been completely blind to its English dimension. I suppose this should not come as any surprise, as it’s totally normal for Labour and the Tories to discuss England-specific matters as if they related to the whole of the UK. But this time, the blanket ignoring of the fact that the debate is relevant to England alone has been total, not only on the part of the politicians involved but also the media and bloggers. What is it about the National Health Service that makes us blind to its national specificities?

I suppose part of it is that the NHS is one of those national British institutions we like to think of as being present and valued to an equal degree in all parts of the UK, like the BBC, the Royal Family (for some, at least) and Parliament itself. But like Parliament and, to some extent, even the BBC, the national character of the NHS has been fundamentally changed by devolution. There are now four NHS’s (one in each of the UK’s constituent countries), with four government departments looking after them, four separate organisational structures, and separate funding arrangements. As with all legislation and social policy for England, the NHS in England is looked after by the UK government and the UK Department of Health. So although the government and Westminster politicians discuss policy for the NHS in the British terms relating to the level at which policy is made for it (at the UK level), the NHS in question is the English one, not a British one as such, which does not exist any more after devolution.

Given the apparent total unwillingness of the parties and the media to engage with the fact that the NHS whose future is being discussed is the English one, it is necessary to ask what they have to gain in ignoring this fact. In essence, the parties are trying to avoid framing an ideological polarity in national terms: ‘English’ political philosophy and social policy = support for privatisation, market principles and a reduced-size public sector; ‘British’ ideology and policy = support for nationalisation, state control of essential services and a generously funded public sector.

The truth of the matter is that, in England, the New Labour government has carried out major reforms to the NHS that have introduced more elements of privatisation than the previous Conservative governments were ever able to get away with; e.g. Foundation Trusts; autonomous GP surgeries competing for funding based on ‘performance’; public-private partnerships to build and run hospitals; outsourcing essential and ‘inessential’ services to private contractors; the introduction of patient ‘choice’, causing treatment centres to compete against each other to deliver the most lucrative and ‘popular’ treatments; more ‘consumer-friendly’ polyclinics being forced through despite the objections of practitioners fearing it would result in the break-down of individual doctor-patient relationships; etc. etc.

Not to put too fine a point on it, the Tories’ actual policies as outlined in policy documents such as their Plan for NHS Improvement are pretty much more of the same: advocating a flexible blend of public-sector and private-provider approaches to deliver the desired health benefits supposedly more cost-effectively and efficiently. This document, by the way, is an absolute master class in the art of dodging the issue of which National Health Service, or rather which nation’s health service, is being discussed, as it studiously avoids referring to England in all but some statistical examples that strangely relate to England alone (strangely, that is, if you thought the policy document was referring to Britain when in fact it was dealing with the English NHS only).

So for all the hullabaloo over the past few days, it turns out that there are in practice no ideological differences between Labour and the Conservatives over the NHS (in England, that is); just minor differences in the methods to be adopted to deliver the same type of ‘reforms’ – by which is meant the introduction of market mechanisms that supposedly lead to greater efficiency, and improved patient choice and outcomes. But to listen to the politicians from both parties as they traded blows over this you could be mistaken for thinking that what they are really falling over backwards to agree about is their commitment to the principles of a generously funded, public sector-based ‘British’ NHS that lives up to its founding mission to provide health care free at the point of delivery.

Two aspects are key here: 1) a general ideological shift has occurred, prompted by the recession, whereby people’s faith that markets could go on delivering ever greater prosperity, and hence the mechanisms and means to continually improve the NHS, has been shaken; and they are worried that talk of increasing private-sector involvement in the health-care system is simply an excuse to make expenditure cuts. Labour are clearly playing on these concerns; and the Tories are having to emphasise the fact that they plan to increase expenditure on the NHS (in England) in real terms, and underplay the fact that they are still intending to introduce more private-sector mechanisms for allocating those resources and delivering care; 2) both parties have a strong vested interest in suppressing the fact that the marketisation of the NHS they have been carrying out and intend to extend even further is limited to England, whereas the separately administered and funded NHS’s in the other countries of the UK have continued on more traditional public-sector lines.

In other words, the parties’ concern to underplay their commitment to market principles in the NHS is of one piece with their need to suppress the England-specific character of those market reforms – by which I do not mean that those reforms are supported by the English people and reflect the English ‘character’ as such; but rather the mere fact that those reforms have been and would be driven through in England only. Why is this? Because both parties, for their separate reasons, want to be seen as parties for Britain, not England. Labour is appealing to its core support, particularly in Scotland and Wales where it has supported and provided funding (via the Barnett Formula) for traditional public-sector NHS’s. Ignoring the rather different market-orientated policies that have been specific to its management of the English NHS helps Labour to invoke the folk memory of the nationalised health service when it was indeed a uniform public-sector service for the whole of Britain.

The Tories, for their part, are desperate not to be seen as a party associated with the Thatcherite market economics and wholesale privatisations that always enjoyed far more popular support (though never that of a majority of English voters) in England than in Scotland or Wales. For the Tories, openly supporting private-sector initiatives to improve public health-care outcomes, even though (and in part because) such measures would be limited to England, would be electoral suicide in Scotland and Wales. The Conservatives would then be portrayed as the party for the wealthy south of England, intent on cutting public expenditure in England, leading to reduced budgets in Scotland and Wales via the workings of the Barnett Formula. And, in fact, this is true. As I stated in my previous post on this subject, although the Tories are actually pledging to increase expenditure on health in England, they’re planning overall cuts in spending, which will result in lower budgets for the Scottish, Welsh and Northern Irish administrations, and possibly the need to cut spending on their NHS’s. So in fact, the Tories may end up spending more on the English NHS resulting in less spending on the NHS’s in the other UK countries.

So, by referring to the English NHS as the British NHS, the Labour Party are trying to gloss over their record in government, which has involved a substantial degree of privatisation of the service in England that the party has not supported in Scotland or Wales. And the Tories are also trying to downplay their actual support for market reforms of the NHS in England, which risks conjuring up the ghost of Margaret Thatcher and the idea that the Conservatives are the party for the wealthy and privileged of England (particularly, the south), not a progressive party for the whole of Britain.

But the consequence is that neither of the parties can be honest about their plans for the English NHS as such. Can we really be sure that if, by some freak, Labour got re-elected, they would not deepen their marketisation of the NHS – in England, only? And can we be confident that when the Tories set about extending the role of the private sector in the NHS (in England only), this will not become an excuse for delivering ‘efficiency savings’ that can then be passed on to the less efficient NHS’s in the other UK nations via the superior state funding they are guaranteed by the Barnett Formula? We don’t know, because the parties won’t tell us. They merely talk in misty-eyed terms of the British institution that is the NHS and how they stand firmly by its principles – even if those principles are put into practice in very different ways in England from the rest of the UK.

On one level, that’s fine: why shouldn’t the different nations of Britain develop the NHS along divergent lines in accordance with popular and national priorities? Why not, indeed? Except, in England, our actual priorities are not taken into consideration at all: the parties appeal to our affections for a fully state-funded and -run ‘British’ NHS and then they deliver an NHS in England that suits their own ideological and economic agendas, and is not what most English people are expecting, I would think. If the politicians actually engaged in dialogue with the English people and debated with them what sort of NHS we think we can afford, and the mix of public- and private-sector approaches that might best deliver the desired result, they might be surprised at the response they got. I don’t actually know what that would be: it might be more traditional public-sector, or more innovative, commercial and hybrid public-private. Genuine public consultation across the nation could deliver surprising results.

But the point is we’re not consulted, because a politics of dialogue between the English people and their political representatives would actually create a national English political community: one which might in turn design an English NHS that was worthy of the name. Instead, under the guise of a supposedly uniform British NHS that no longer exists, the parties canvass our support and that of those living in the other UK nations in order to deliver their own unspoken agendas for England. Unspoken, that is, because if they can’t even say the name of the country whose NHS they are supposedly standing up for, then such a health service is not a National Health Service that is truly designed with the best health outcomes in mind for the English nation.

And then they have the gall to talk of patriotism.

Email of complaint to the Today programme on coverage of the ‘British NHS’ debate

Just sent the Today programme this email:

Do you think that Today and the BBC in general could take a bit more care to differentiate between what relates to the NHS across Britain as a whole and what is specific to England? In none of the discussion anywhere in the BBC yesterday did anyone point out that the party spokespersons’ competence related only to the English NHS, and that many of the discussion points concerning NHS funding and organisation were relevant to England only.

Another example: the discussion on this morning’s programme comparing US and British attitudes to each other’s health-care systems. The ‘British’ expert was in fact an English health-care practitioner and most of his points related to England only; e.g. NICE, the two-week cancer pledge, the statistics on waiting lists, etc.

Please when talking about the English NHS, call it as such. For further discussion on this, see my blog post: http://britologywatch.wordpress.com/2009/08/15/the-conservatives-are-the-%e2%80%9cparty-of-the-nhs%e2%80%9d-but-which-one/.

The Conservatives are the “party of the NHS”: but which one?

It’s as if devolution never happened and we were back in the ‘good old days’ when there genuinely was only one National Health Service. Not one single item – not one – in all of the news coverage I saw or heard yesterday on the reaction to Tory MEP Daniel Hannan’s criticism of the NHS on US TV correctly referred to the organisation in question as the ‘English NHS’ (or, at least, the ‘NHS in England’), which is what they were actually talking about.

At least, David Cameron, Andrew Lansley (the Conservative Shadow Health Secretary (for England)) and Andy Burnham (the actual Health Secretary in England) can only have been referring to the NHS in England in their comments following Hannan’s contribution, as that’s the only NHS they either will have (if the Tories win the general election) or presently have responsibility for. But you couldn’t tell that from what they said.

David Cameron: “Just look at all the support which the NHS has received on Twitter over the last couple of days. It is a reminder – if one were needed – of how proud we in Britain are of the NHS. . . . That’s why we as a Party are so committed not just to the principles behind the NHS, but to doing all we can to improve the way it works in practice.”

Andrew Lansley: “Andrew pointed out that many of the NHS reforms promised by Labour, including practice-based commissioning, Foundation Trusts, patient choice and independent sector investment, have stalled under Gordon Brown. And he stressed, ‘All those who care about the NHS know that these are the kind of reforms that will enable us to achieve the combination of equity, efficiency and excellence which should be the hallmark of the NHS’.”

Andy Burnham: “I would almost feel . . . it is unpatriotic because he is talking in foreign media and not representing, in my view, the views of the vast majority of British people and actually, I think giving an unfair impression of the National Health Service himself, a British representative on foreign media”.

Let me note in passing what a complete and utter joke those last remarks of Andy Burnham’s are. Has Burnham suddenly transmuted into an English patriot, as it’s only the English NHS that he and the government of which he is a part has anything to do with? I don’t think so. Hannan’s not a ‘British representative’, i.e. a representative of the British government or parliament. But if he was, then doubtless Burnham feels his job would be to do what Burnham himself does: not so much misrepresenting the ‘British NHS’ abroad but misrepresenting the English NHS to the English public as the British NHS!

And as for that Twitter stream, don’t waste your time checking it out. It’s full of junk now, and I had to click down a couple of hundred entries before I got any reference to England that wasn’t either a porn link or a job ad, or indeed practically any reference to the political debate.

But actually, Twitter is quite a good metaphor for the debate: full of sentimental waffle but very little substance. It’s easy to prattle on about the NHS as a great British institution of which the people of Britain are rightly proud and keen to defend from unfair criticism from abroad. But the reality is that as a national-British institution, the NHS already no longer exists. It’s New Labour, not the Tories, that did away with it through devolution. And its the New Labour British government that did far more than the Tories ever did to privatise the NHS in England, with things like public-private partnerships to build and run new hospitals, the introduction of internal health-care markets, Foundation Trusts, and competition between GP surgeries and the new supposedly ‘consumer-friendly’ polyclinics, etc. Admittedly, while all of that was going on, the NHS’s of the other UK nations were – for good or ill – remaining more faithful to Labour’s traditional socialist principles, with fully public sector-based organisations amply subsidised by the English taxpayer.

Does it matter, though, whether you call it the ‘English NHS’ or the ‘British NHS’? Isn’t this just semantics? Well, I think the English believe in the principle of calling a spade a spade: if you are talking about something that relates to England only, you should at least have the honesty and courtesy to let people know that’s what you’re doing. Of course, on one level, it’s legitimate to refer to the ‘British NHS’ even when discussing policy for its English variant; i.e. when talking about the founding principles that are said to inform the NHS throughout Britain to this day: fully public-funded health care free at the point of delivery. But the point is those principles are not applied evenly, and equally, across the whole of the UK. There is no longer a single UK model for how public-sector health care should be funded and organised. And the model presently applied in England has moved further away from the NHS’s original principles than that in any of the other UK nations.

This does matter for the political debate going forward into the general election. Daniel Hannan has helpfully exposed a vulnerability of the Tories in England, because it’s clear that the Tories do support further reform of the English NHS along the lines set out by New Labour. Those Tory reforms mentioned above in the context of Andrew Lansley’s reaction to Hannan’s remarks (“practice-based commissioning, Foundation Trusts, patient choice and independent sector investment”) are precisely New Labour policies that the Tories claim the government has failed to deliver. If the Tories pursue them, they will indeed drive further marketisation of the NHS – but only in England. By appealing to the founding ‘British NHS’ principles, and by promising to increase NHS funding in real terms, the Tories are trying to make out that they back the traditional, fully nationalised model for health-care delivery in the UK. They may well support a generously public-funded health-care system; but in England, at least, the delivery model will involve a much greater role for private companies and market competition, which will inevitably lead to inequalities and increased variations in the availability of high-quality NHS treatment for different conditions in different parts of ‘the country’ – England, that is. But the more they talk up their allegiance to the traditions of the ‘British NHS’, the more they hope we won’t read the English small print.

Plus the Tories are also addressing the non-English electoral ‘market’, of course, and are hoping that the uninformed (misinformed) public there – again, through the emotive appeal to the NHS as a national-British institution – will be deluded into thinking that a Conservative government will have direct influence on health-care policy in their countries (which it won’t) and will stand guarantor for traditional NHS values there – which it may do, through acquiescence with the policy variations and funding inequalities that have flowed from asymmetric devolution and the Barnett Formula. But actually, a real-terms increase in public expenditure on health in England will not necessarily deliver corresponding and proportionately greater increases in NHS funding in the other countries of the UK. This is because public expenditure overall under the Tories is set to decrease, so that increases in the health budget will have to be paid for by cuts elsewhere. And a decrease in overall spending in England will result in even greater proportionate decreases in Scotland, Wales and Northern Ireland. In other words, increased investment in the NHS in England may actually result in the need to cut the NHS budget in the other nations. While some of us in England might derive malicious satisfaction from what would in effect be a levelling out of healthcare apartheid (and, after all, the Tories have promised, dishonestly, to improve equality of NHS care throughout the UK), this is a wilful deception of voters in Scotland, Wales and Northern Ireland: the Tories appear to be promising to increase NHS funding throughout the UK; but actually, they’re talking about England only; and increases in the English health-care budget may indirectly lead to decreases in the health-care budget in the other parts of the UK.

But Labour can’t talk, either. This system of unequal funding and differing delivery models throughout the UK is the one that they set up; and to claim that they support a uniform UK-wide NHS organised along traditional lines is a pure, downright lie. Well, they might emotionally support it, with misty-eyed reverence towards Nye Bevan and the post-war settlement; but in practice, the New Labour government has already broken up that British NHS beyond repair. The truth of the matter is New Labour has run out of policy ideas for the NHS in England but has supported a traditional-type NHS in the other UK countries. So all it can do is appeal to ‘patriotic’ and nostalgic support for a great British institution that is no more (in England, at least) in the hope that it can deceive enough of the English people for enough of the time to secure another election ‘victory’ that will enable it to continue to cross-subsidise a traditional NHS in Scotland, Wales and Northern Ireland through further privatisation of the system in England – as they have done since 1997.

Well, the English people won’t fall for that one again. But they might fall for the similar trap the Tories are laying. The English people need to have an informed debate on the type of health-care system they want in England; because that’s what the whole argument is really all about. Health care in Scotland, Wales and Northern Ireland is dealt with separately by the devolved administrations. So it’s only the English system that the Westminster politicians can do anything about. By claiming, as David Cameron did yesterday, that the Conservatives are the “party of the NHS”, the Tories are trying to reassure the English people that the NHS is safe in their hands. But that’s not the point. There will still be an NHS; but what sort of NHS will it be in England, as opposed to the doubtless very different NHS’s that are developing along divergent lines in the rest of the UK? The Tories need to be honest and up front about the small print of their plans for England, and not obfuscate the whole discussion by misleading references to a monolithic British NHS that is no more. But so do the politicians of all parties.

After all, Mr Cameron, Brown and Co., you can’t fool all of the English people all of the time, even if you think you can.

The Dark Nationalist Heart of New Labour’s Devolution Project

I was struck last night by how the panellists of BBC1′s Any Questions displayed a rare unity in condemning the ‘nationalism’ to which they imputed the recent assaults on Romanian migrants in Northern Ireland. ‘There can be no place for nationalism in modern Britain’, they intoned to the audience’s acclaim.

Apart from the fact that statements such as this articulate a quasi-nationalistic, or inverted-nationalist, pride in Britain (‘what makes us “great as a nation” is our tolerance and integration of multiple nationalities’), this involved an unchallenged equation of hostility towards immigration / racism with ‘nationalism’. This was especially inappropriate in the Northern Ireland context where ‘nationalism’ is associated with Irish republicanism, and hence with Irish nationalism and not – what, actually? British nationalism à la BNP; the British ‘nationalism’ of Northern Irish loyalists (no one bothered to try and unpick whether the people behind the violence had been from the Catholic or Protestant community, or both); or even ‘English’ nationalism?

Certainly, it’s a stock response on the part of the political and media establishment to associate ‘English nationalism’ per se with xenophobia, opposition to immigration and racism. But this sort of knee-jerk reaction itself involves an unself-critical, phobic negativity towards (the concept of) the English – and certainly, the idea of the ‘white English’ – that crosses over into inverted racism, and which ‘colours’ (or, shall we say, emotionally infuses) people’s response to the concept of ‘English nationalism’. In other words, ‘English nationalism’, for the liberal political and media classes, evokes frightening images of racial politics and violence because, in part, the very concept of ‘the English nation’ is laden with associations of ‘white Anglo-Saxon’ ethnic aggressiveness and brutality. English nationalism is therefore discredited in the eyes of the liberal establishment because it is unable to dissociate it from its images of the historic assertion of English (racial) ‘superiority’ (for instance, typically, in the Empire). But the fact that the establishment is unable to re-envision what a modern and different English nationalism, and nation, could mean is itself the product of its ‘anti-English’ prejudice and generalisations bordering on racism: involving an assumption that the ‘white English’ (particularly of the ‘lower classes’) are in some sense intrinsically brutish and racist – in an a-historic way that reveals their ‘true nature’, rather than as a function of an imperial and industrial history that both brutalised and empowered the English on a massive scale.

This sort of anti-English preconception was built into the design of New Labour’s asymmetric devolution settlement: it was seen as legitimate to give political expression to Scottish and Welsh nationalism, just not English nationalism. Evidently, there is a place for some forms of nationalism in modern Britain – the ‘Celtic’ ones – but not the English variety. While this is not an exhaustive explanation, the anomalies and inequities of devolution do appear to have enacted a revenge against the English for centuries of perceived domination and aggression. First, there is the West Lothian Question: the well known fact that Scottish and Welsh MPs can make decisions and pass laws that relate to England only, whereas English MPs can no longer make decisions in the same policy areas in Scotland and Wales. This could be seen as a reversal of the historical situation, as viewed and resented through the prism of Scottish and Welsh nationalism: instead of England ruling Scotland and Wales through the political structures of the Union, now Scotland and Wales govern England through their elected representatives in Westminster, who ensure that England’s sovereignty and aspirations for self-government are frustrated.

It might seem a somewhat extreme characterisation of the present state of affairs to say that Scotland and Wales ‘govern England’; but it certainly is true that a system that involves the participation of Scottish and Welsh MPs is involved in the active suppression not only of the idea of an English parliament to govern English matters (which would restore parity with Scotland and Wales) but of English-national identity altogether: the cultural war New Labour has waged against the affirmation and celebration of Englishness in any form – the surest way to extinguish demands for English self-rule being to obliterate the English identity from the consciousness of the silent British majority. In this respect, New Labour’s attempts to replace Englishness with an a-national Britishness – in England only – are indeed reminiscent of the efforts made by an England-dominated United Kingdom in previous centuries to suppress the national identity, political aspirations and traditions of Scotland and Wales.

This notion of devolution enabling undue Scottish and Welsh domination of English affairs becomes less far-fetched when you bear in mind the disproportionate presence of Scottish-elected MPs that have filled senior cabinet positions throughout New Labour’s tenure, including, of course, Gordon Brown: chancellor for the first ten years and prime minister for the last two. And considering that Brown is the principal protagonist in the drive to assert and formalise a Britishness that displaces Englishness as the central cultural and national identity of the UK, this can only lend weight to suspicions that New Labour has got it in for England, which it views in the inherently negative way I described above.

However, the main grounds for believing that devolution enshrines nationalistic bias and vindictiveness towards England is the way New Labour has continued to operate the Barnett Formula: the funding mechanism that ensures that Scotland, Wales and Northern Ireland benefit from a consistently higher per-capita level of public expenditure than England. One thing to be observed to begin with is that Barnett is used to legitimise the continuing participation of non-English MPs in legislating for England, as spending decisions that relate directly to England only trigger incremental expenditure for the other nations.

But New Labour has used Barnett not only to justify the West Lothian Question but has attempted to justify it in itself as a supposedly ‘fair’ system for allocating public expenditure. It seems that it is construed as fair primarily because it does penalise England in favour of the devolved nations, not despite this fact. This sort of thinking was evidenced this week during a House of Lords inquiry into the Barnett Formula. Liam Byrne, the new Chief Secretary to the Treasury, described the mechanism as “fair enough”, only to be rounded on by the Welsh Labour chair Lord Richard of Ammanford: “It doesn’t actually mean anything. Look at the difference between Wales, Northern Ireland and Scotland – is that fair?” So it’s OK for England to receive 14% less spending per head of population than Wales, 21% less than Scotland and 31% less than Northern Ireland; the only ‘unfairness’ in the system is the differentials between the devolved nations!

The view that this system is somehow ‘fair to England’ – except it’s not articulated as such, as this would be blatantly ridiculous and it ascribes to England some sort of legal personality, which the government denies: ‘fair for the UK as a whole’ would be the kind of phrase used – exemplifies the sort of nationalistic, anti-English bias that has characterised New Labour. It’s as if the view is that England ‘owes’ it to the other nations: that because it has historically been, and still is, more wealthy overall and more economically powerful than the other nations, it is ‘fair’ that it should both pay more taxes and receive less back on a sort of redistribution of wealth principle. But this involves a re-definition of redistribution of wealth on purely national lines, as if England as a whole were imagined as a nation of greedy capitalists and arrogant free marketeers that need to pay their dues to the exploited and neglected working class people of Scotland and Wales: the bedrock of the Labour movement.

In short, it’s ‘pay-back time’: overlaying the centuries-long resentment towards England’s wealth and power, England is being penalised for having supported Margaret Thatcher and her programme of privatisation, disinvestment in public services and ruthless market economics. ‘OK, if that’s how you want it, England, you can continue your programme of market reforms of public services; and if you want a public sector that is financially cost-efficient and run on market principles, then you can jolly well pay yourselves for the services that you don’t want the public purse to fund – after all, you can afford to, can’t you? But meanwhile, your taxes can fund those same services for us, because we can’t afford to pay for them ourselves but can choose to get them anyway through our higher public-spending allocation and devolved government’.

Such appears at least to be the ugly nationalistic, anti-English backdrop to the two-track Britain New Labour has ushered in with asymmetric devolution. This has allowed Scotland, Wales and Northern Ireland to pursue a classic social-democratic path of high levels of funding for public services based on a redistributive tax system; that is, with wealth being redistributed from England, as the tax revenues from the devolved nations are not sufficient to fund the programme. Meanwhile, in England, New Labour has taken forward the Thatcherite agenda of reforming the public sector on market principles. In a market economy, individuals are required to pay for many things that are financed by the state in more social-democratic and socialist societies. Hence, the market economics can be used to justify the unwillingness of the state to subsidise certain things like university tuition fees (an ‘investment’ by individuals in their own economic future); various ‘luxuries’ around the edges of the standard level of medical treatment offered by the state health-care system (e.g. free parking and prescriptions, or highly advanced and expensive new drugs that it is not ‘cost-efficient’ for the public sector to provide free of charge); or personal care for the elderly, for which individuals in a market economy are expected to make their own provisions.

These sorts of market principle, which have continued and extended the measures to ‘roll back the frontiers of the state’ initiated under the Thatcher and Major governments, have been used to justify the government in England not paying for things that are funded by the devolved governments: public-sector savings made in England effectively cross-subsidise the higher levels of public spending in the other nations. Beneath an ideological agenda (reform of the public services in England), a nationalist agenda has been advanced that runs utterly counter to the principles of equality and social solidarity across the whole of the United Kingdom that Labour has traditionally stood for. Labour has created and endorsed a system of unequal levels of public-service provision based on a ‘national postcode lottery’, i.e. depending purely on which country you happen to live in. Four different NHS’s with care provided more
free at the point of use in some countries than others, and least of all in England; a vastly expanded university system that is free everywhere except England; and social care offered with varying levels of public funding, but virtually none in England. So much for Labour as the party of the working class and of the Union: not in England any more.

There’s an argument for saying that English people should pay for more of their medical, educational and personal-care needs, as they are better off on average. But that’s really not the point. Many English people struggle to pay for these things or simply can’t do so altogether, and so miss out on life-prolonging drug treatments or educational opportunities that their ‘fellow citizens’ elsewhere in the UK are able to benefit from. A true social-democratic- and socialist-style public sector should offer an equal level of service provision to anyone throughout the state that wishes to access it, whether or not they could afford to pay for private health care or education but choose not to. The wealthy end up paying proportionately more for public services anyway through higher taxes. Under the New Labour multi-track Britain, by contrast, those English people who are better off not only have to pay higher taxes but also have to pay for services that other UK citizens can obtain free of charge, as do poorer English people. One might even say that this extra degree of taxation (higher income tax + charges for public services) is a tax for being English.

But of course, it’s not just the middle and upper classes that pay the England tax; it’s Labour’s traditional core supporters: the English working class. On one level, it’s all very well taking the view that ‘middle England’ supports privatisation and a market economy, so they can jolly well pay for stuff rather than expecting the state to fund it. But it’s altogether another matter treating the less well-off people of England with the same disregard. It is disregarding working people in England to simply view it as acceptable that they should have to pay for hospital parking fees, prescription charges, their kids’ higher education and care for their elderly relatives, while non-English people can get all or most of that for free. What, are the English working class worth less than their Celtic cousins?

How much of this New Labour neglect of the common people of England can truly be put down to a combination of Celtic nationalism, anti-English nationalism, and indeed inverted-racist prejudice towards the white English working class? Well, an attribution to the English of an inherent preference for market economics – coming as it does from a movement that despised that ideology during the 1980s and early 1990s – could well imply a certain contempt for the English, suffused with Scottish and Welsh bitterness towards the ‘English’ Thatcher government.

But an even more fundamental and disturbing turning of the tables against the English is New Labour’s laissez-faire attitude to job creation, training and skills development for the English working class. The Labour government abandoned the core principle that it has a duty to assist working people in acquiring the skills they need to compete in an increasingly aggressive global market place, and to foster ‘full employment’ in England; and it just let the market take over. It’s as if the people of England weren’t worth the investment and didn’t matter, only the economy. And it’s because of Labour’s comprehensive sell out to market economics that it has encouraged the unprecedented levels of immigration we have experienced, deliberately to foster a low-wage economy; and, accordingly, a staggering nine-tenths of the new jobs created under the Labour government have gone to workers from overseas. Is it any wonder, then, that there is such widespread concern – whether well founded or not in individual cases – among traditional Labour voters in England about immigration, and about newcomers taking the jobs and housing that they might have thought a Labour government would have striven to provide for them?

How much of the liberal establishment’s contempt and fear of English white working-class racism and anti-immigration violence is an adequate response to a genuine threat? On the contrary, to what extent has that threat and that hostility towards migrants actually been brought about and magnified by New Labour’s pre-existing contempt and inverted racism towards the white working-class people of England, and the policies (or lack of them) that flowed from those attitudes?

Has New Labour, in its darker under-belly, espoused the contempt towards the ‘lazy’, ‘loutish’, disenfranchised English working class that Margaret Thatcher made her hallmark – and mixed it up in a heady cocktail together with Celtic nationalism, and politically-correct positive economic and cultural discrimination in favour of migrants and ethnic minorities?

One thing is for sure, though: English nationalism properly understood – as a movement that strives to redress the democratic and social inequalities of the devolution settlement out of a concern for all of the people residing and trying to earn a living in England – is far less likely to foster violence against innocent Romanian families than is the ‘British nationalism’ of the BNP or the various nationalisms of the other UK nations that have seen far lower levels of immigration than England.

But is there a place not just for English nationalism but for England itself in a British state and establishment that are so prejudiced against it?

Stillbirths and Neonatal Deaths: Ten Years of Devolution, Ten Years Of Failings

I first came across this story on the BBC News website on Wednesday morning last week. According to the report: “The number of stillbirths and deaths shortly after birth remains stubbornly high, claiming 17 babies every day on average in the UK, a report reveals. Every year in the UK nearly 4,000 babies are stillborn and another 2,500 die within four weeks. The stillbirth rate has not changed for a decade.”

The article then went on to quote a comment from the “Department of Health in England”, saying “there had been an increase in midwives and consultant obstetricians, and increased investment in the field”. This combination of statistics supposedly relating to ‘the UK’ and reaction from the DoH England [give them their due, the BBC do now more consistently make it clear when a UK government department has England-only responsibilities] immediately registered on my Britology radar: ‘are these UK figures actually England-only figures?’, I asked myself. Otherwise, why gauge reaction only from the English department concerned without any further comment relating to the rest of the UK? Such a practice usually is code for England-only information passing under the generic UK / Britain label.

The report about stillbirths and neonatal deaths was produced by the charitable society of the same name, the Stillbirths and Neonatal Deaths Society, or ‘Sands’. In fact, the document was due to be launched at the House of Commons later the same day, so it was not yet available for download. I scoured the Sands website in vain for information about whether the research and the activities of the charity were focused on England only or on the whole of the UK. The website talked only of UK-wide facts and figures, and in fact, it did not mention the word ‘England’ once anywhere. After more extended web research, I did manage to confirm that Sands is the established UK-wide charity organising emotional support and raising funds for research on the topic.

Later on in the day, I caught the BBC1 lunchtime news, where there was a more extended version of the report than had appeared on the BBC News website. This was an absolute masterpiece of ambiguity, which managed to completely avoid mentioning whether the Sands report related to England or to the whole of the UK, failing to (or perhaps succeeding in not) utter(ing) any of the words ‘England / English’, ‘Britain / Britain’ or ‘UK’. Any casual viewer would undoubtedly have been left with the impression that the information related to the whole of the UK; but this was never explicitly stated, even though Sands was calling for a ‘national’ [by implication, UK-wide] action plan to reduce the number of stillbirths and deaths in early infancy.

By now, I was getting really intrigued, and really frustrated. ‘Does the Sands report relate to England only or not; and if it does, why do they seem to want to suppress this fact rather than drawing comparisons between the situation in England and elsewhere in the UK, which would almost certainly be more embarrassing to the government?’, I wondered. I checked the Sands website in the evening – and still no report available to download. I was so irritated that I fired off the following email to the organisation:

“Dear Ms Duff [Sands' Communications Officer],

“I followed with interest the press coverage today surrounding the launch of your Saving Babies’ Lives report. Will this report be available for download from your website soon?

“I am also interested to know whether its findings and recommendations relate to the whole of the UK or to England only, as the UK government and the Department of Health are responsible for healthcare and the NHS in England only. The media coverage (e.g. on the BBC1 lunchtime news) was somewhat unclear on this point. On your own website, you call for a nationally co-ordinated action plan (implying across the UK). But clearly, the government can only really co-ordinate all the measures required to reduce the number of stillbirths and neonatal deaths in England – unless your report recommends some sort of high-level, UK-wide co-ordination involving the participation of the governments of Scotland, Wales and Northern Ireland.

“I look forward to your reply.”

I don’t know whether this letter was viewed as a nuisance or irrelevance, or whether they were just plain too busy, but I haven’t yet received a response. In fact, it may well have been too close to the bone, as became evident when the report did finally appear on the website on Thursday and I was able to download it.

This is where I have to throw in a disclaimer. In some respects, I’m reluctant to critique this report, which is full of heart-breaking pictures of would-have-been parents cradling their stillborn infants, and desperate accounts of the devastating effect that stillbirths and neonatal deaths have on individuals and families. I’m not blaming Sands for the approach they’re taking, which is completely consistent and conscientious. I blame the UK-cum-de facto-English government and the effects of poorly managed, asymmetric devolution. So, as they say, the views expressed in this post are mine and do not necessarily reflect the opinions of Sands.

Apart from all the detailed data on stillbirths and mortality in early infancy, and the recommendations for alleviating the situation, a clear underlying message that emerges from the Sands report, for me, is that the failure to reduce the incidence of these traumatic events is closely connected with asymmetric devolution. Sands don’t spell this out because they want to encourage government to develop a co-ordinated cross-UK strategy and set of policies that strongly prioritise the issue. Hence, their tactic appears to be that of taking the moral high ground and arguing that this is such a critical social issue (responsible for far more deaths, for instance, than road accidents or cot death) that the government should rise above the political obstacles and start dealing with it.

But the political barriers are evidently key. As the report itself says:

“In the UK a combination of problems means we fail to identify many babies who are at risk, and to ensure their best possible chance of life:

• We lack knowledge, data and research into why babies die.

• We have no reliable way to predict which pregnancies are at risk of stillbirth or death early in life.

• There is little awareness of the extent of the problem or what the risks are.

• We don’t have the resources in maternity care to ensure optimal care for every baby.

Above all there is no political will to make things change [my emphasis].”

Why is there no political will to make things change? The problem, it seems to me, is twofold:

1. The UK government – which is the primary intended audience for this report – lacks the political will and, more importantly, the political muscle and power to co-ordinate and implement a UK-wide strategy in this area. Post-devolution, the remit of the UK Department of Health stops at the borders between England and Scotland, and England and Wales. And there’s been a failure, precisely, to develop mechanisms to co-ordinate strategy, share knowledge and implement best practice in areas of social policy, including healthcare and the (four) NHS(‘s), across the four nations of the UK. (See my discussion of this elsewhere.) And this sort of co-ordination is especially critical with respect to stillbirths and neonatal deaths, according to the Sands report.
2. The UK government has even been unwilling to own and embrace its responsibilities to formulate priorities and develop social policies for England as England, and has tended to wash its hands of its duties as the de facto English government by passing on or outsourcing the setting of healthcare priorities to Primary Care Trusts and an increasingly marketised healthcare sector. This has also resulted in a failure to set adequate priorities and co-ordinate measures to deal with stillbirths and deaths in early infancy, as emerges from the report; although Sands does not link this explicitly to the contrast between the situation in England and the devolved UK nations.

One area where the government could co-ordinate action at a UK-wide level, and which is vital according to Sands, is in research into the causes of stillbirths and neonatal deaths. As the report says, “A serious lack of direct funding for scientific research to understand and prevent stillbirths is holding back progress that could be made in reducing the numbers of deaths”. Scientific research is a reserved power, so the UK government could directly fund research in this area; and Sands is calling on the government to match the £3 million it is raising for this purpose. £3 million: absolute peanuts compared with the billions the government is pumping into the banking sector. But, as I said in that previous discussion, as the UK government has retained the responsibility for managing the economy but not the ability to formulate joined-up social policy throughout the UK, it tends to prioritise the economic over the social: in England, that is, as the devolved administrations do have a social vision for their respective nations.

Indeed, one of the problems about a direct-funded research programme is that it has to be underpinned by co-ordinated cross-UK data gathering. As the Sands report says in its next recommendation: “Data collection on pregnancies is limited in the UK, the exception being in Scotland. We need nationally collated, detailed and standardised data about all pregnancies and outcomes on which to base research”. Well, yes, that says it all, doesn’t it? In fact, before devolution, there was a ‘national’ (i.e. UK-wide) programme for gathering data on the issue, called CESDI: Confidential Enquiry into Stillbirth and Deaths in Infancy. But, as the report indicates, “these enquiries have stopped since the formation of the Confidential Enquiries into Maternal and Child Health (CEMACH) which has less funding to cover a far wider remit of work. We would like to see resources to enable a return to enquiries into all stillbirths, in particular those which are unexplained”.

The last CESDI report was published in 2001; and from 2003, its work was taken over by CEMACH, which looks into maternal and childhood deaths (up to the age of 16) alongside perinatal and neonatal mortality – and does in fact have a much smaller budget than did CESDI alone. In England, Wales and Northern Ireland, that is. In Scotland, on the other hand, as the report reiterates elsewhere, “detailed information about pregnancies and outcomes is available”. Why? Because the CEMACH work in Scotland is separately funded by a body known as NHS Quality Improvement Scotland (NHS QIS), which in fact will be taking over the whole CEMACH survey in Scotland from October of this year. (I add that this particular gem of information is not contained in the Sands report; I trawled it up from the CEMACH website.)

So let’s summarise. Research in Scotland is still focused on the specific problems of stillbirth and neonatal deaths; it enjoys superior funding to England, Wales and Northern Ireland, which are dependent on the CEMACH process; and until as recently as 2007, the CEMACH survey was also using a flawed methodology. As Sands informs us: “From 2007 CEMACH has adapted [the Wigglesworth] classification system to address its widely recognised limitations, particularly in gathering information about conditions associated with a death”. On top of this, the Scottish NHS is abandoning the CEMACH process altogether from later this year. And no political will exists to sort out these disparities and ensure that rigorous data gathering of the kind that still takes place in Scotland is co-ordinated across the UK. Surprise, surprise.

A similar lack of political will seems to prevail with respect to ensuring the dissemination of best clinical practice. For example, the report states: “The Royal College of Nursing and other stakeholders are currently working on a UK-wide framework for the education and training of neonatal nurses. But this framework must be adopted in order to be effective”. Well, clearly, there has to be the ‘political will’ to standardise processes and share knowledge across the four national NHS organisations. And there would have to be a commitment to make the necessary investments to raise standards, which would be particularly costly throughout England, whereas this is easier to achieve in Scotland owing to its smaller scale and higher per-capita level of public expenditure, guaranteed through the Barnett Formula. I’m reading between the lines here; but it stands to reason that if there were enough political will to introduce the improved training framework in England, then there would be no problem about standardising it across the other UK countries owing to their higher proportionate share of the public finances. So the issue must be that the government is unwilling to spend the extra money in England (with the Barnett consequential of even greater expenditure in the other countries), while the devolved administrations presently do have the financial and political latitude to roll out improvements in this area.

And evidently, to judge from the Sands report, these improvements are desperately needed. At times, the report reads like a catalogue of failure to learn from avoidable mistakes in antenatal care, childbirth and neonatal intensive care, resulting in babies continuing to die unnecessarily from the same causes. And there is not just a failure to disseminate best practice, share knowledge and prioritise the issue but also a lack of resources: insufficient antenatal healthcare personnel, such as midwives and other specialists, who might be able to help detect problems earlier on in pregnancy; inadequate staffing levels in intensive-care units for premature babies, such that only 14 out of 50 of such units ‘in the UK’ are able to provide the one-to-one nursing care that the British Association of Perinatal Medicine (BAPM) regards as a minimum standard.

The fact that the statistics are aggregated across the whole of the UK in this way is one of the shortcomings of the Sands report. This prevents one from being able to gauge whether the problems are significantly worse in England than in the other UK countries, which would be linked to the funding inequalities and strategic issues (lack of UK-government focus on this as a serious social issue in England) resulting from asymmetric devolution. I have no way of knowing how many of those 14 under-resourced intensive-care units are located in England; but I’d be willing to bet that none of them are in Scotland. It has to be said that all the specific examples of bad practice and inadequate resourcing, and all of the references in the body of the report to comments from clinical experts or to other reports on the issue, are drawn from England.

Another aspect of this topic that is exclusive to England is the way that the processes of funding the NHS contribute to the inadequate priority and insufficient resourcing that are given to stillbirths and neonatal deaths. These are described by the report as follows:

“Newly implemented commissioning structures between the Primary Care Trusts (PCTs) and hospital trusts have been evolving to meet new government structures. While this brings more focus to what is required from maternity services in each hospital, contracts may omit any proactive remit to reduce perinatal deaths. An issue that is not highlighted in a contract for funds is less likely to attract specific focus or resources.

“As the contracts come into place hospitals can negotiate additional funds for posts or for focus as they see fit. However, many hospitals see contract negotiations as being driven by the PCTs and only a few have seen the opportunities provided by being able to focus on local issues.

Tariffs

“It is unclear what is or is not included in the tariffs paid to trusts for obstetric services, with a great deal of room for interpretation on whether or not tariffs have been adjusted to allow for the funding of quality improvements. For neonatal care there is no nationally mandated funding system and health economies are left to make their own local arrangements which leads to an inevitable variability in the level of care provided.”

What the report doesn’t state explicitly at this point is that these funding mechanisms that have evolved to meet ‘new government structures’ and this lack of a ‘nationally mandated funding system’ for neonatal care exist in England only; as it is only in England that the government is still calling the shots when it comes to NHS funding and healthcare priorities. The system described above has been developed deliberately to allow a greater role for market forces, with individual hospital trusts competing for funding from PCTs based on their proven record to meet government targets and treat larger numbers of patients with different types of medical need. What this leads to is the creation of centres of excellence and a concentration of investment in particular ‘generic’ areas (such as maternity services, as described here), which can then more successfully bid for funding. But this means that certain specialisations within those generic areas (such as neonatal care) are not prioritised in a strategic way, as the focus is more on generating a critical mass in more ‘fashionable’, headline-grabbing areas of care that can attract funding in a bidding war, rather than on actual clinical and social need: in this case, more resources for preventing and dealing with stillbirths and neonatal deaths. By contrast, as is evident from the dedicated resources allocated to the issue at a national level through NHS Quality Improvement Scotland (referred to above), stillbirths and neonatal deaths are a nation-wide NHS priority in Scotland.

Conclusion

For me, one of the things that emerges clearly from the picture of failure painted by the Sands report is a demonstration of the harmful consequences of asymmetric devolution. No progress has been made in improving clinical outcomes in ten years: the ten years during which devolution of healthcare has been in place, with different systems, and levels and mechanisms of funding, in place in each of the UK’s four nations. This has led to an absence of strategic UK-wide focus on stillbirths and neonatal deaths, with the consequence that there has been inadequate funding of scientific research, and a failure to disseminate best practice and drive through better training of specialist nursing staff. This is clearly linked to the funding inequalities built in to the asymmetric devolution settlement. The report cites Scotland as the only example of adequate data gathering on the causes of stillbirths and neonatal deaths, after the successful pre-devolution information-gathering process (CESDI) was abandoned in favour of a more poorly funded and less specifically focused system (CEMACH) in England, Wales and Northern Ireland (but not Scotland) under the auspices of the infamous NICE (National – e.g. English – Institute for Clinical Excellence).

Meanwhile, there has been a lack of strategic focus on the issue in England, which in my view is linked to a general unwillingness on the part of the UK government to assume its responsibilities as the de facto English government in most areas of social policy, including the NHS. Instead, funding and prioritisation in England has been left in the hands of PCTs as part of a process designed to foster the development of a competitive healthcare market within the NHS. But, as we know, markets lead to winners and losers, and stillbirths and neonatal deaths have lost out to more market-friendly areas of obstetric and paediatric medicine where it is easier to demonstrate a return (improved patient outcomes) on investment, compared with the difficulties in making gains in stillbirths and neonatal deaths, where the causes of mortality are still often a mystery. But unless the resources are devoted to greater research and improved clinical care in this area, no improvements will ever take place.

Where I take issue with the Sands report is with its tactic of treating the issue purely at a UK-wide level, without differentiating between the nation-specific circumstances that are contributing to the ‘postcode lottery’ of varying standards of care and prioritisation throughout the UK. The report correctly identifies that the political dimension is key. And one absolutely fundamental aspect of this is that the UK government, in this area as in so many other aspects of healthcare, is unwilling to commit the levels of investment and to prioritise the issue at a national level (that is, an England- and hence UK-wide level) in the same way that it is prepared to enable the devolved governments to do so on a more limited scale. The pattern is: cut expenditure in England, and hand the thing over to the market as a supposedly more efficient way to deliver healthcare in line with patient customer demand, in order to release higher levels of funding on a smaller scale for Scotland, Wales and Northern Ireland.

Until these structural and national inequalities are removed, there can be no integrated UK-wide strategy for beginning to reduce the number of stillbirths and neonatal deaths. Perhaps we may never be able to reinstate a coherent UK-wide strategy in this area given the lack of political will to reform the present asymmetric devolution settlement. But the government at least has a duty to drive a strategy on stillbirths and neonatal deaths for England. However, I doubt this will ever happen until there is a proper elected English government, genuinely accountable to the English people.