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.