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.

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.

Why a privatised NHS does not concern me

For months now The Guardian has run a hostile campaign against the NHS reforms introduced by (former) Health Secretary Andrew Lansley. However, some dissenting voices are now emerging. In an opinion piece two days ago, the Guardian commentator Ian Birrell admonishes critics of NHS reforms that their caricature of the changes in the English NHS risks missing the most important point: the NHS was established in different times to tackle different problems. If it does not change, it will fail to address the new challenges to provide health care to millions in the UK.

Birrell argues that the main difference between the original NHS and any health care provider in the 21 century is not whether or not services are supplied by private or public organisations. Rather, the main difference lies in the problem it faces. At its inception, the NHS was to tackle infant mortality and infectious diseases. To do this, the newly formed NHS board embarked on a large scale hospital building programme that lasted into the 1980s. Hospitalisation of patients was thought to be the most appropriate care.

The programme had some success as the health of communities across the UK improved significantly. However, it also created monster organisations that were difficult to steer. Change in order to address new health problems was practically impossible to introduce, and staff morale dropped markedly due to scandals of mistreatment of patients. Despite the claim that the NHS was 'centrally controlled', it was was in fact a supertanker without a skipper.

Repeatedly, politicians tried to force the NHS to be more susceptible to steering by forming organisational sub-divisions, such as local boards (Wales for example has a long history of re-organisations of NHS health boards, their number ranging at some point from 22 to now 7).

Exasperated by the resistance of the NHS to respond to the need for change, Tony Blair's government then practically sliced off large parts of the service into semi-private providers, NHS foundation hospitals, that were operating free from central control.

Andrew Lansley's reforms were only the logical extension of the reforms introduced by the previous government: devolving the main bulk of the NHS budget to GPs operating in the communities and commissioning the services they need for their patients.

Critics are scathing about the alleged privatisation of the NHS. But, as Birrell argues, this misses the point. The NHS will remain free at the point of use. GPs have always been private contractors, ever since Aneurin Bevan decided to buy their approval to the introduction of the NHS by 'stuffing their mouths with gold'.

What has changed however is that the location of care has shifted from hospitals to communities. While some surgical procedures will always require hospitalisation, most after-care is best delivered for patients in the communities. This is not just a question of cost. It is above all an issue about the quality of care. It matters little whether a public or private organisation offers this care.