Saturday, 28 February 2015

Why Andy Burnham will never be health secretary (again)

Labour has built its electoral strategy for the May election around the NHS. That made sense given it polls strongly on the NHS. Yet, its NHS policy boils down to only two components: a robust rebuttal of the so-called 'privatisation' of the NHS and a proposal to integrate health and social care provision. Both are looking increasingly too weak to function as the main pillar of a general election strategy and here is why.

'Privatisation' is a serious concern for many people in the UK. Labour has read the polls carefully and consistently identified the Health and Social Care Act 2012 as being widely discredited. Andy Burnham, the Labour's shadow health secretary, built his health care policy around the repeal of the Act. This has brought him plaudits from people who dislike tampering with the NHS. However, the agreement around the rejection of the Act is brittle and insufficient to act as long term policy. And the electoral appeal of 'anti-privitisation' rhetoric does not extend much further than Labour's core supporters. In addition, repealing the Act may also quickly emerge as disruptive to the fabric of the NHS. The 'anti-privatisation' agenda could thus become tarnished with exactly the same brush as the Act itself: endless re-organisation of the health care service.

Going nowhere - Labour's Shadow Health Secretary Andy Burnham (Foto: EPA)

To offer something positive, Burnham suggested to integrate health and social care. Yet, his proposal, three years in the making, still remains obscure. Health care through the NHS is free, whilst social care is means tested. Burnham's proposal was riddled with contradictions and he knew it. So, with only slightly more than 2 months to go to the general election, he has still not spelled out how the integration of the NHS and social care is to be achieved. The policy remains a shell at best.

Cue George Osborne. On Thursday, the Chancellor announced that Greater Manchester will have direct control over the entire NHS budget for its area. In 2017, the elected Mayor of Manchester will assume full responsibility for social care and health care provision for almost 3 million people. It's hard not to see this as a preemptive stroke of genius by the Chancellor (and a snub to Burnham by the local Labour councillors who did not even bother to inform him about the imminent agreement). Without having to fill in the detail of HOW to integrate health and social care, Osborne has given local authorities the powers to embark on integration as a local response to local problems.

The consequences are devastating for Burnham. As the consensus around his 'anti-privatisation' rhetoric becomes increasingly fragile and reveals its ideological thrust, his other main policy proposal is stuck in the mud of detail. In the meantime, Osborne devolves health care budgets to local authorities, strengthening the narrative around local accountability without having to provide any detailed health care policy on the complexities of integration.

The upshot is that Labour's health policy hangs by a thread and so does Burnham's political career. During his tenure as shadow health secretary he has failed to develop any significant and substantive policy proposals and the Labour leadership knows this. Their entire electoral strategy was built around the NHS and Burnham has left their flank undefended and open to attack. He is likely to pay the price for this blunder.

Wednesday, 18 February 2015

It's the rules, stupid

As the drama of the Greek show down moves to the second stage, observers and commentators cast around for interpretations. Austere Germans versus profligate Greeks is one of the popular topoi, and so is responsible versus irresponsible governments. Yet, what is often forgotten is the main protagonist: the Euro itself.

The Euro as a common currency originated in the German re-unification and the desire of France's president Mitterrand to have the German Mark. And it was Chancellor Kohl's bargaining chip in the negotiations to reconcile France with the fact of a resurgent German economic powerhouse. Attached to the deal was the so-called fiscal stability pact which was promptly broken by Germany and France. The former failed to stick to the pact because national finances spiralled out of control in the wake of re-unification and the costs of upgrading East German infrastructure to West German standards. The latter, France, failed to keep its budget under control because ... well, because they was little incentive to do so. 

To be clear, all this happened well before the financial crash of 2008. In fact, it was Chancellor Schroeder, a social democrat, who, in 2004 embarked on a fundamental reform of employment regulations which set Germany on a path to fiscal rectitude. This first drama of the Euro stability pact is often forgotten in public debate today. But it was a key experience for German politicians. Embarrassed and shamed into a climbdown on the rules they had formulated themselves, they learned a simple but important lesson. A currency is only stable if the budgetary rules are enforced that come with it. 

That's the main reason why German politicians (Social Democrats and Christian Democrats alike) are playing hardball with Greece today. It has little to do with fears of inflation Weimar style. Nor is it to do with spite or resenting the Greeks their living standards financed by debt. Rather, it is the realisation that enforcing the rules strengthens the currency rather than weakens it. Seen this way, a Greek exit (though highly undesirable for everyone involved) may actually send a strong signal to the markets: we are determined to enforce the Euro rules, to safeguard the currency's stability. 

Sunday, 8 February 2015

What's the possible end game of the Ukrainian civil war?

As the civil war in the Eastern Ukraine drags on, German Chancellor Merkel and French President Hollande made a last ditch attempt at peace. They travelled to Kiev first, and then to Moscow to consult with Presidents Poroshenko and Putin. The absurdity of this war lies in its lack of purpose for all parties involved. Despite some cold war rhetoric from the US State Department, Russia has no interest in a war at its borders. Almost a million Ukrainians have now fled to Russia and are causing serious problems to the Russian government in terms of provision of food, shelter and medical supplies. Russia has nothing to gain from a civil war, only to lose, as NATO is ramping up the rhetoric and strengthening its defence capabilities in the Baltic.

The worst that could happen now is that the US government, in a move motivated by a lack of interest and public anxiety about perceived weakness, starts to supply weapons to the Ukrainian government. As the German Defence Minister Ursula von der Leyen recently noted, there is no lack of weapons in the region.

So why the rhetoric on the Russian side? On one hand, Putin has no other option but to support Russian speaking Ukrainians fighting the government in Kiev. His authority is poorly legitimated and based on demonstrating strength in foreign affairs. A fall of the Ukrainian rebels would be interpreted as a sign of weakness. Yet, more importantly, the cause of the Ukrainian rebels is a question of principle. When Kosovars fought against the Serbian government, they were granted autonomy and, eventually, semi-independence by European governments. So it is in this case. Ukrainians in the East of Ukraine will not want to return to live under a government that has shelled their homes indiscriminately and fought a civil war against its own population.

The only feasible outcome is similar to what happened in Kosovo. Autonomy for Eastern Ukraine that gradually morphes into full independence. The earlier the EU and the US recognise this, the better for everyone involved.

The death of Andy Warhol

Tonight, the Liverpool Tate will close the doors of its Warhol exhibition. Attendance figures are staggering and, yesterday evening, when I viewed it, the exhibition space was more like a crowded train station than a museum of art (depending of course on what you think either should be like). So, Warhol's popularity is undimmed. Yet, can the same be said for his relevance? 

The exhibition contained some of the iconic images that made him famous. There were the Marilyn Monroe portraits and the canned soup pictures. These images have seeped into our collective consciousness and are part of our memories of pop art as a movement. Yet, apart from those iconic pieces, there was little that stood out through originality or aesthetic value. Perhaps the most instructive piece was a brief advertising clip for a chocolate sundae, a genuinely crafty piece, that mixed novel filming techniques with a slowly distancing lens. In this commercial work, Warhol seemed to reveal some originality. The remainder of the exhibition was filled with random tapings of television programmes and snapshots of varying yet usually gratuitous irrelevance. 

What struck me most about Warhol's work was its almost deliberate and wilful rejection of meaning in art, a stubborn resistance to be relevant within a social and cultural arena. In a sense, his work is even incapable of cultivating a cocky attitude, the ironic sticking two fingers to the world as later post-modernists would do, such as Damien Hirst. Throughout the exhibition the most dominant impression of Warhol as an artist was his absence as a political, cultural or social interpreter, or simply as somebody who cares about something, anything. This approach of wilful irrelevance is certainly not celebrated by Warhol. He does not imbue it with meaning, or pseudo-religious undertones. It is simply there and he appears to say: I couldn't care less, make of this what you want. 

This stress on social and cultural irrelevance goes hand in hand with a complete lack of humour or irony in his work, regardless of the repetition of Monroe's portrait. This does not mean that the exhibition was not educational. Somehow along the way, as Warhol taped TV programmes, his work captured a sense of irrelevance that may have been prevalent at a certain time, dominating the lives of a whole generation of a small cultural elite (no doubt fuelled by copious consumptions of drugs). I emerged from the show with a deep feeling of gratitude that these times were behind us, that the deliberate celebration of emptiness did not catch on, except of course in the realms of television, film, advertising, pop music and social media. Not that those are of any importance... 

Friday, 6 February 2015

Labour's NHS trap

It all seemed so clear. The battle lines were drawn and the trenches dug. As Andy Burnham came on Newsnight on Thursday night to talk about the NHS, Labour had prepared a well rehearsed argument, something well liked by its faithful and seemingly cutting through to the public: ‘The Tories are privatising the NHS’.

The Labour leadership believed that this argument resonated with rank and file members and offered the simplicity of clear ideological division. Tories equal private, Labour equals public. In addition, the argument has ‘recognition value’ as marketing experts would say, harking back to a pre-Blair time when Labour was against privatisation of public services. It also linked in with other policies, such as public ownership of the railways, a potential battleground with the Greens challenging Labour from the left.

As Burnham started the interview, the position fell apart fairly quickly. Kirsten Wark’s point of attack was Labour’s own record of ‘outsourcing’ and the fact that, under the last Labour government, private business amounted to 4.4% of the total NHS budget. Now, it stood at just above 6%. Hardly the ruthless Tory privatisation wave Labour claimed, Wark argued. Yet it seems that it was current levels of outsourcing that broke Burnham’s argument. More likely, Labour appears to have misjudged the depth of knowledge (or lack thereof) about the NHS within the population. The main confusion at the heart of Labour’s argument about the privatisation of the NHS was that, from the perspective of ordinary people, it is little more than a deliberate obfuscation.

People encounter the NHS as patients. The patient doctor relationship determines the perceptions and views of people on the NHS. That relationship is governed by clinical guidelines designed by NICE and Labour’s privatisation argument somehow suggests that this could change.

Yet, the complexity of health care delivery through the NHS in the UK means that privatisation anxiety makes little sense. GPs in the UK are in fact private enterprises. Aneurin Bevan’s National Health Service Act in 1946 made them so. Yet, this is not what Labour trained its guns on. Its main artillery was pointed at the health economy around the patient doctor relationship. It claimed that, somehow, because of private involvement, doctors would have to take profit into consideration when making clinical decisions.

This is a difficult argument to sustain for two reasons. On one hand, doctors are bound to make decisions in line with clinical guidelines, and profit is ostensibly not part of the picture. Yet, on the other hand, efficiency (and consequently rationing) is and has always been part of the NHS. In fact, NICE guidelines take into account both the effectiveness and the efficiency (in terms of life years saved) of medication and interventions before approving it. So, in a sense, considerations of efficiency have always been with us. The notion of a fully resourced health care system is a utopian make belief. Doctor’s clinical decision making process will always need to navigate patients’ expectations, in other words: say ‘no’ at times.

The real issue is whether, within the health economy that is grouped around the clinical patient doctor relationship, competition would drive down costs or increase costs for the NHS, or the tax payer. This argument is worthwhile having and Lord Darzi has made an important contribution to this recently. Everything, from pharmaceuticals to protective gloves, is after all produced within the market economy of the UK and to advocate a unilateral withdrawal of the NHS from this health economy is like saying we should bake our own bread at home. It may be wholesome and nutritious but hardly ever enough to feed a large family.

So, Labour’s argument about privatisation offers a false dichotomy. When articulating an anxiety that profit considerations would encroach on the patient doctor relationship the argument is ostensibly false. Doctors are bound by clinical guidelines. If taken to refer to the health economy around medical care, the argument is little more than a common place. The NHS always operated as a public service within a market economy. An autarkic healthcare system, insulated from economic pressures, is a pipe dream.

Boxed into the argument about privatisation and sensing its failure, on Thursday, Burnham tried to move the discussion on to the issue of integrating health and social care. It is a valuable idea and one that has been around for decades. It cannot have escaped him though that the earliest protagonists of health care integration are Kaiser Permanente; you guessed it: a private US insurance company with nearly $50 billion in revenues and more than $1.6 billion in profit. Health care may just be a policy field that proves impervious to ideological battles. And that may be a good thing.