Operative word is ‘phoney’
PUBLISHED: 08:52 22 June 2018 | UPDATED: 13:31 22 June 2018
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MICHAEL WHITE on May’s supposed ‘Brexit Dividend’ - and an alternative plan to revive and sustain the NHS
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I’ve been thinking more than usually about the NHS since my operation. Yes, fine, thanks for asking, it was only a small one. But it was a slightly big deal for me, the first time I’d been under the knife since February 1950 – when the infant NHS was barely 18 months old and I was four. Theresa May was not yet a twinkle in the Reverend Hubert Brasier’s eye, though this week she promised the health service a £20 billion 70th birthday present disguised as a “Brexit dividend”.
So I’ve been very lucky, certainly luckier than May who was diagnosed with late-onset Type 1 diabetes in 2012 and with chronic Boris Johnson in 2016. No heart attacks or (thanks to the pills) a stroke for me, no Caesarian births (unlike my wife), no nasty car accidents or bones broken falling off my bike. That bowel cancer scare was just that and in my Fleet Street days Boris was just a joke.
But the NHS has been lucky too, not only in my relatively clean medical sheet either. It has survived changes in political fashion (it even saw off Margaret Thatcher) and the self-indulgent habits of its customers, perennial shortages of money, costly new procedures and both rising demand and expectation.
If Aneurin Bevan could see robotic keyhole surgery, the wonders of MRI scans or IVF treatment (the Whites have had that too), the great orator would be speechless with admiration before fretting about the expense. The bill for obesity and diabetes in year 70 would have shocked him, as would the ravages of booze and drugs, though Nye was no puritan.
Legalise pot, as Lord Hague suggests? Doesn’t Billy understand the risks in poor communities like mine, Tredegar’s Bevan would have replied. Gender reassignment ops on the NHS? Let’s not go there, Nye.
All the same, hard though it is for some people to accept, even in the austerity decade since the bankers crash, the NHS’s luck has held compared with every Whitehall department except overseas aid (DfID). Their budgets have all been slashed, so that police officers aren’t hired, warships don’t patrol, affordable houses remain unbuilt and students pay £9,000 a year in tuition fees.
Yet the NHS has had an average 2% increase a year. It is half the post-1948 average of 4% and well below what it needs to keep pace with demand-led costs. But it has been spared the brutal treatment meted out elsewhere. As Lord ‘Cliff’ Lawson once remarked, the NHS is the nearest thing secular Britain has to a national religion. So as soon as a patch of blue sky appeared in public borrowing – however small and temporary – it was inevitable that the vicar’s daughter would have to overrule her parsimonious chancellor and cough up.
Which is what has happened this week as the battle over Dominic Grieve’s meaningful vote amendment raged on in parliament and self-styled parliamentary sovereignty democrats, Frank Field even reacted by calling for Lords abolition. No surprise on either count really. NHS chiefs have been expecting something in the post since Jeremy Hunt raised his low profile this spring to join the service’s CEO, Simon Stevens, in openly pressing for more money, if necessary funded – shock, horror – by higher taxes.
The surprise has been the timing and the packaging, the spin put on the deal. Call me naïve, but I never expected May personally to lead an attempt to present the extra funding as payback to Brexit voters, a vindication of that dodgy, dishonest ‘£350 million a week for the NHS’ slogan on the Brexit campaign’s bloody battle bus. Except it’s going to be £394 million.
A chorus of experts have denounced the fraud, including the reputable Institute for Fiscal Studies (‘EU-funded,’ moans the Tory press, but isn’t Nigel Farage EU-funded too?).
There can’t be a Brexit dividend yet, we haven’t left and will be paying in for years, not to mention writing cheques for all those promised EU-substitute subsidies at home.
What’s more, most analysis expect the post-Brexit contraction of the economy to squeeze out whatever extra revenue is notionally saved from the clutches of Brussels. As March 29 approaches – or is postponed by Britain’s failure to sustain a coherent negotiation – fewer and fewer economists share the optimism of Kool Aid Kids like Prof Tim Congdon or the City’s Gerard Lyons. Brexit veteran, Christopher Booker, exiled to the Sunday Telegraph’s lifestyle supplement for the crime of candour, reports that business still doesn’t grasp what leaving the single market will mean.
So May’s attempt to contaminate what might have been good news about NHS funding looks like a cynical lie, Boris-style. She may hope expert denunciations help ram home the subliminal message ‘Brexit NHS dividend’ among inattentive voters, a ploy from the Trump populist playbook, further weakening frayed public trust. She has signed up to a phoney Brexit triumph in order to keep the peace in her party
To more thoughtful Brexiters, as to Remainers, this has been embarrassing, a further blow to her reputation as dull but decent. So why do it? It must surely be that No.10 strategists – chief of staff, ex-MP, Gavin Barwell, shares the credit – had hoped it would lance a notorious Brexit boil and start re-uniting the party behind a wider, more inclusive vision for Britain that would re-engage voters.
Boris and Govey can now say ‘the NHS has got its Brexit dividend like we promised’. That gives them cover to swallow further retreat from their impossibilist positions against accepting vestigial adjudication from the ECJ, on the Irish border – May’s backstop deal that might keep us all in the customs union a while longer – and even aspects of the single market.
These issues now look even less likely to be resolved at next week’s 27+1 EU summit in Brussels which has other worries, fast-growing and centrifugal, to absorb its limited energies – immigration, budgets, trade wars with Trump’s America, rising populism across the continent. Michel Barnier thinks he controls the Brexit process because he holds most of the cards – he does – but the Commission’s ability to overplay its own political hand should not be underestimated either.
Meanwhile May’s blatantly political handling of the extra funds for the NHS is fast unravelling. Tuesday’s papers were full of alarm about what it actually means to the service, to rival departments and to the taxpayer. The FT reported that No.10 has given No.11 a free hand (I bet it hasn’t) to ditch pledges in the ill-fated Tory 2017 manifesto to cut corporation tax from 19p to 17p, to raise the personal allowance to £12,500 and the 40p tax rate start to £50,000, all by 2020.
Pensions tax relief? An extra 1p on NICs, ring-fenced (hypothecated) for the NHS? It was Gordon Brown’s device in 2001 which Hunt now endorses, but the Treasury dislikes, rightly in my view. Levying NICs on pensioner earners? Politically costly, but probably justified in my (gritted teeth) opinion to defray the fast-rising cost of social care for the frail elderly. May got the details wrong in 2017 and was forced into a U-turn, but she was on the right track. Oldies who can pay should pay. Inheritance is not a sacred right.
“Nothing is ruled out,” say briefers as No. 11 seeks to give meaning to May’s mumbled words to the BBC’s Andrew Marr about extra tax and borrowing. But, according to the Times version of Monday’s cabinet, its members went very quiet when Philip Hammond told them the NHS bung is an exceptional event and that there will be no more for them – possibly less.
This comes at a time when concern over police numbers and crime is rising, when the justice system is causing concern and schools have ever-larger classes and teacher vacancies, in part because teachers can’t rent, let alone buy, homes near where they teach.
There is a circularity to much of this. Troubled families get stressed, kids get into trouble with knives or drugs, big brothers start mugging, mum or little sister show symptoms of mental illness, damp and over-crowded homes lead to physical illness. A&E and hospital wards fill up, nurses from abroad decide to leave or not come here at all. Doctors, who have taken seven years and £500,000 to train, decide to check out the less-stressed lifestyle in sunny Brisbane. Yet ministers blithely promise parity of esteem for mental health, always the NHS’s poor relation.
The Mail and Sun’s response to such a picture is to insist that a clean Brexit will liberate national energies and drive to restore faltering prosperity, that negative Remoaner talk of economic trouble ahead is selling Britain short and helping Barnier.
The second string to the Mail and Tory right’s adaptive strategy is to insist there is no need for extra taxes or borrowing to fund the 3.4% increase (to 2023) because the NHS is awash with waste. Never mind that it has been under the productivity/efficiency cosh since Brown’s invest and reform drive 15 years ago and treats millions more patients than it did, despite those relentless pressures dramatically captured by BBC2’s fly-on-wall Hospital series. There are still lots of improvements to make, but the biggest efficiency is the one timid politicians hesitate to urge on voters: eat, drink and smoke less, exercise more.
Never mind either that the NHS has proved a good deal more nimble and efficient than the armed forces in recent years, let alone those behemoth Whitehall departments – or police forces that solve 5% of burglaries. Never mind again that May is now promising to reverse high-minded Andrew Lansley’s 2010-12 reforms and get rid of those clumsy clinical commissioning groups (CCGs) which health experts warned him would never work.
Sustainability and Transformation Plans (STPs), managed by Accountable Care Organisations (ACOs) within a 10-year planning budget are now the buzzwords to urgently needed integration of health and social care and – more important – Ken Clarke’s purchaser/provider split in the 1990s. Since ‘top-down’ reorganisation in pursuit of fairness and efficiency has been the curse of the NHS for decades, don’t hold your breath. But it sounds better than Lansleyism.
At the launch of Bevan’s centrally-directed model of a nationalised health care system in 1948 – two years before I fell on a bottle and severed a tendon in my four-year-old index finger (it’s still not right) – the wholesome assumption was that the NHS budget would fall once the docs had cleared the hideous backlog of decades of poverty and neglect.
It didn’t quite work out that way, did it? Medical innovation and wonder drugs which have doubled life expectancy in a century are a wonder, though their abuse and the licence it gives us all to duck the consequences of our own folly add to the burdensome cost. In 1948 the NHS cost 2% of GDP (0.3% in 1914) and reached a fluctuating 5-6% when Blair & Brown decided to match the EU average of 8.5% in 2000. They got to more than 8% before austerity pushed it back to below 7%. May now promises to catch that moving EU target again.
Well, maybe. When I finally had my hernia fixed at St Mary’s, Paddington (of BBC2’s Hospital fame) in May, after a nine-month wait, the procedure went very smoothly, apart from being told to dress and go home (“we have to prioritise the cancer cases, Mr White”) a month earlier. Far more significant for the NHS budget is that the same trust has parked my sprightly 90+ neighbour in an expensive private recuperation hospital because he is deemed too frail to be home alone.
Home care might bridge the gap, but local authorities have seen their Whitehall budgets halved since 2010 as the number of elderly patients rises: four million more over-65s in the next 15 years. Their means-tested care (an important distinction from free NHS medical care) costs are now more than half their budgets. No wonder some are going bust, as are care homes, victims of falling fees, belated pay increases, Brexit labour-shortages and property speculation. Elderly bed-blocking fills the equivalent of 36 general hospitals.
As the IFS’s Paul Johnson regularly points out, the NHS funding model has survived remarkably. But it can’t go on. One benefit of private sector NHS contracts has been to expose the costly weaknesses of private sector care, no magic cure after all.
The low efficiency of much US health care (three times as many hip readmissions as Sweden) and Trump’s ignorant bombast – “the NHS is going broke and not working,” says the obese billionaire – reinforces the point.
So taxes must rise and ministers must make the case. Not by legalising high-grade skunk or taking up the UN’s advice to make computer game addiction another treatable burden for the NHS, but by being more honest than May has been this week over lifestyle folly and elderly care. As for the NHS itself, Cameroon Tory analyst, Camilla Cavendish, offered a good list in the Sunday Times: move to a proper seven day NHS and put GPs into hospitals; hire more district nurses and home carers for my neighbour; don’t flog off NHS land for luxury flats; build homes for nurses again; create more, bigger, specialist hospitals. That’s a polite way of saying ‘close other hospitals’. No politician got elected promising that, but it’s true. And the NHS must protect its precious store of health data, millions of individual records over decades which are unique in the world and, if properly crunched by state-of-the-art AI, could unlock medical insights for the world’s benefit. “Predict and intervene” as surgeon Lord Darzi puts it.
Worth an estimated £10 billion, NHS data is at risk from predatory US (Chinese too?) tech giants whose selfish interests are mostly money. DeepMind, Google’s brilliant, British-devised AI business is already circling the NHS. What value does the Treasury currently put on the data trove Nye Bevan inadvertently bequeathed? Nothing.
Here is a simple remedy that could unite the cabinet’s Remainers and Brexiteers, as well as show the world – this in the week when a super-computer in San Francisco out-debated a human expert – that they’re not quite as dumb as they often seem. We don’t want the super-computers to lose patience and switch off the human race, do we?
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