Better a localist NHS than a nationalist one

Yesterday, Health Secretary Andy Burnham wrote an article for the Guardian aiming to set out the clear blue water between Labour and the Conservatives on the National Health Service. In doing so, he inadvertantly demonstrated quite how vapid Labour’s vision for the NHS really is. It was summed up in one sentence:

For Labour, it all comes down to defending the N in NHS.

You read that right. Given the choice between “national”, “health” and “service” the word that Burnham considers most key to the Labour approach is the former. Ignore “health”, never mind “service” – who needs a bandage when you can wrap yourself in a flag?

Think I’m being unfair? Burnham is of course a repeat offender. His response to Dan Hannan’s American adventure last week was to attack Hannan for being “unpatriotic.” With Labour floundering in the polls, never has Samuel Johnson’s adage that “Patriotism is the last refuge of a scoundrel” seemed so apt.

Burnham goes on to set out three specific examples of what he means:

Labour’s job is to speak up for the N in NHS – for national standards, national pay and national accountability

Let’s take these in turn. It is certainly the case that Labour has focused on national standards and it would be churlish to deny that over the past 12 years we have seen significant improvements. But it is foolish to suggest that mere regulation of health standards is a significant dividing line; even the US is pretty strict in this respect. And all too often Labour’s achievements have been bought by throwing money at the problem and by entrenching a target culture. Certain things, such as hospital hygiene, seem to have escaped them entirely.

But standards don’t automatically lead to results and the experience of healthcare around the country varies enormously. After writing about it last week, I am loathe to use the phrase “postcode lottery” but what is clear is that all the national standards in the world can’t get you an equal level of standard at a local level. Labour has tried everything – short of localism – to tackle this problem and after twelve years it has comprehensively failed. Burnham offers nothing new, merely that the Tories would have fewer national standards. This displacement activity fools no-one.

His second dividing line, unbelievably, is pay. Whatever the rights and wrongs of national pay bargaining, it is frankly gobsmacking that a Secretary of State considers this to be one of the crucial dividing lines in health on which Labour will fight the election. And you could argue with some force that its approach to national pay bargaining has been one of Labour’s biggest screw ups in recent years, driving the epitome of a soft bargain. Is Burnham serious about his desire to fight the next election on this record? Or is this more a case of deference to Labour’s paymasters, the unions?

Finally, somewhere below pay, comes the piffling issue of accountability. Here we are told we have two options: Labour’s centralised health service or a Tory quango. If ever there was a false choice, it is this.

The problem with the Tory’s policies on health are not that they are localist but that they aren’t localist enough. As we saw with IVF, at the first sniff of controversy they tend to reach for the national comfort blanket. They have nothing to say about the most important tool at a localist’s disposal: tax. They might support democratic administration of health services at a local level but the decision making will continue to be made centrally.

The social liberal alternative is spelt out on this website in Richard Grayson’s chapter on the NHS from Reinventing the State. Current Liberal Democrat policy is broadly along these lines. Far from leading to a decline in standards, the experience of continental Europe is that devolving decision making is key to ensuring them. The lesson learned is that accountability and standards are inter-dependent.

As a party, we have rejected social insurance as a funding model. Chris Huhne, who chaired the party’s public services working group in 2002 gives three reasons for doing so (pdf):

The first is that insurance schemes usually insist on co-payment. Thus patients pay nearly a third of primary care themselves in France, and in Germany the sick pay charges for the first period they spend in hospital, rather like an insurance excess in this country. The result is inevitably to exclude some of the poor. These schemes do not ensure universal access to health care when and where people need it.

The second problem is that social insurance schemes are surprisingly bureaucratic. Far from abolishing NHS administration, insurance schemes require more paperwork by both GPs and hospitals so that they can ensure proper reimbursement of insured costs, but no more. This is the flip side of the patient knowing how much operations cost, but it is itself costly and timeconsuming for the health professionals.

The third difficulty is that they also involve a separate and often expensive premium collection system, and even supposedly universal schemes based around employment suffer holes. Although much more comprehensive than the United States reliance on private health insurance – where some 45 million people currently have no health insurance at all – the safety net is not universal.

Moreover, if people are allowed to top up either spending or insurance payments, there can be the rapid development of a two-tier service. There would be choice and quality for the well-off, but a rump service for the rest.

Instead, we party has generally favoured the Danish model, a model which – as Richard explains – has been further reformed in recent years and could be emulated in the UK.

After twelve years, the model that Labour has demonstrated it is most comfortable with involves inconsistently applied standards and virtually no accountability. Andy Burnham’s comfort with such a patchy record is quite galling. If he thinks it is an election-winning position to hold, he is quite wrong.

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4 comments on “Better a localist NHS than a nationalist one
  1. David says:


    You repeat here a claim from a previous article re: the Tories and localism, saying “They have nothing to say about the most important tool at a localist’s disposal: tax”.

    Though I am the least likely person to defend the Tories on localism (I remember the comments of their local government spokesperson all to well re: the reasons they were more willing to trust it now), I have to argue that the reason they say nothing on local taxation is because that is the most contentious area, the most likely to create so-called “postcode lotteries”.

    I am holidaying in Sweden at the moment, and the biggest complaint the friends I am staying with have about the local education services is that more economically affluent areas are able to raise more in tax, and that therefore there is not equality of funding, which sometimes leads to schools in poorer areas shutting down. Though I am inclined to agree with your reasoning re: localisation of services providing accountability to insure against the “lottery” in “postcode lottery”, I do not agree with your thoughts re: local taxation improving this, because to my mind that creates a recipe for economic inequality being transferred to local services.

  2. David Heigham says:

    I am no expert in the National Health Service, but:

    - Are there “national standards”? I have the impression that the NHS started out with some wide differences in local health care provision; and most of those differntials are still there; 50+ years on.

    - Is there “national accountability” for health care outcomes? Where and how?

    - “National pay”? I am not sure if the NHS has London differentials at the moment; they seem to come and go. However, surely one of the objectives of Labour (and Tory)contracting out NHS ancilliary activities is to not pay more than the going rate in the local labour market?

  3. Simon says:

    Excellent article. However, the idea of co-payments is not that bad. Many of the defenders of our policy on tuition fees cite the fact that you can’t have too much education, and so introducing co-payments (in the form of tuition fees) is a bad idea. This doesn’t hold for health, as one can definitely overconsume health services. We also see people book GP appointments and not even turn up. A famous RAND study showed the effects of co-payments on health consumption, which anyone interested in health policy should read.

    And, of course, we could always do what we do with prescriptions and waive the co-payments for the elderly and poor.

  4. Noma Torian says:

    would it be possible to translate your website into spanish because i have difficulties of speaking to english, and as there are not many pictures on your website i would like to read more of what you are writting.

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