Britology Watch: Deconstructing \’British Values\’

28 August 2009

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?

25 August 2009

No England victory parade, as an ashen-faced Brown is forced to say ‘England’ three times

Hard to say which is the greater victory: England beating the Aussies to regain the Ashes or the fact that this victory forced Gorden the Ashen One to at least write – if not speak – the word ‘England’ no fewer than three times! In a report on yesterday’s somewhat more subdued celebrations of England’s triumph at No. 10 than in the days of Tony Blair’s premiership, the Guardian quoted from a letter Brown had written to the England captain Andrew Strauss. It’s worth repeating in full here for its sheer rarity value:

“I wanted to write to congratulate you and the entire England squad on regaining the Ashes. The series has been yet another wonderful showcase for cricket and for all that is great about sport. It has provided high sporting drama throughout the summer that has yet again gripped the entire nation, and to win the Ashes with your magnificent display at the Oval – and coming back from the defeat at Headingley in the fourth test – shows great determination and commitment.

“There have been many outstanding performances this summer on both sides, but throughout the series you have led England from the front, with patience, resolution and courage. The country is extremely proud of what you have achieved this summer. I would like to invite the England squad in to Downing Street for a reception to celebrate your victory [my emphases].”

Yes, your eyes do not deceive you: Brown said England three times! Note, however, that despite the fact that the Ashes win wrung these words out of him, Brown couldn’t resist making mendacious mention of ‘the entire nation’ being gripped by the series (which nation, you liar? Britain or England? Say ‘English nation’ when you mean it!) and invoking the pride of ‘the country’: again, England or Britain? And also note the telling reference to ‘your victory’ at the end: not ‘our victory’, which would evoke true emotional engagement and national identification.

Well, if the whole ‘country’ of Britain is so proud of the English players, you wouldn’t mind them having a victory parade through the English and British capital city, would you – just as, last year, there was no apparent incongruity in your mind in allowing only a victory parade for the whole British Olympic team – not the English medallists only – for the English people to express their pride in ‘their’ athletes? Oh yes, how silly of me: it’s OK for the English to take pride in British achievements, but your talk of the whole of Britain taking pride in English successes is mere rhetoric. So much for your uttering the dreaded ‘E’ word: it’s all just empty talk.

Actually, I’m not really that upset about there not being a victory parade for the England cricket team like the one in 2005; nor that very few if any of the team members will be recommended for inclusion in the New Year’s Honours list, like the flurry of honours that were granted to the whole team last time we won the coveted relics. All of that was a bit OTT and something of a carrot to the English people: like the ancient Roman practice of organising games to appease the people and make them forget they don’t have any real power over their lives. But if it had been a British cricket team, then what a different story it would have been!

Anyway, just as he’s not really an England man, Brown isn’t a cricket man, either; and after his six-week break, he’s far too busy and got far too many important concerns to attend to than the celebration of a national (English) triumph.

On top of which, I’m not sure that, as a true Scot, his sympathies weren’t really with the Aussies. But he’s got plenty of opportunity to pay England back (not monetarily, you understand) through his political actions. England may have got back the Ashes of English cricket; but Brown will make sure she doesn’t rise from the ashes of her abolished nationhood. Now that’s a British victory Brown would drink a dram to, I feel sure.

17 August 2009

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.

16 August 2009

Afghan War: How many British dead will there be after the next 40 years?

Today, the sad milestone of the 200th, and indeed the 201st, death of a British soldier was reached in Afghanistan. Gordon Brown came out with the usual blandishments on such occasions, re-stating that while these deaths were “deeply tragic”, they were still necessary: “We owe it to you all [the families and communities of those killed] never to forget those who have died. But my commitment is clear: we must and will make Britain safer by making Afghanistan more stable”.

If those deaths were really, deeply ‘tragic’, Brown and all the others in the political establishment that support this war (but not to the extent of supplying our brave troops with adequate equipment to ensure their safety as much as possible) would not effectively write off the lives lost with such seamless ease under the ostensible justification that it is ensuring Britain’s safety.

I have written about this conflict extensively before (see here, here and here). Suffice it to say that it is far from obvious whether and how this conflict is really serving the security of the UK. In some respects, it has helped to make us more of a target for terrorism and has destabilised the whole region, including Pakistan, which is the real threat to our security, as it’s a nuclear power. Plus it’s highly unlikely that we could ever ‘win’ a war in Afghanistan or even stabilise the country through military means. Afghanistan has never been subdued by a foreign army in thousands of years of history; and the fierce and proud fighters that are resisting Western interference today, and all of their fanatical jihadist supporters from around the world, will never put down their arms until the Westerners leave Afghanistan.

Perhaps it’s this sort of reflection that led the incoming head of the British Army, General Sir David Richards, to state last week that Britain might need to maintain a presence in Afghanistan for the next 40 years; albeit that he – grossly naively, in my view – thinks it may be necessary to maintain the present level of military engagement only in the medium term (so ‘only’ 20 years, then?); while the main task will be nation building. I’ve speculated before where people come up with this arbitrary ’40 years’ figure. I’m sure it’s some sort of subconscious echo of the nearly 40 years of the Cold War coupled with the biblical 40 years of exile that the people of Israel spent in the desert on their migration from slavery in Egypt to freedom in the Promised Land. Not a comfortable cultural reference to evoke in the Muslim world! But are we supposed to accept this figure with blind, biblical faith?

If you want to build a nation, there has to be the will among the people who live there to become a nation. But Afghanistan is a deeply divided land, ethnically, and it’s controlled by feudal warlords that aren’t going to sit back and let Westerners take over and transform their power base into a modern democracy. Unless we’re prepared to pour shed loads of dirty money into their pockets, that is.

Maybe I shouldn’t write off Afghanistan so cynically. Maybe ‘progressive’ forces in Afghanistan will win out. Maybe. But I think the odds are heavily stacked against them; and meanwhile our national security is being undermined, not strengthened. And our young men and women are being needlessly slaughtered – as are thousands of Afghan civilians.

And how many more grim milestones of hundreds and thousands of armed forces deaths must we expect if we do indeed stay in Afghanistan for 40 years?

15 August 2009

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

Filed under: BBC,English NHS,NHS,Today Programme — David @ 7.42 am
Tags: , ,

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: https://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.

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