After its Glasgow kiss, will Labour pull together or pull apart? Health Policy Today, 29 July 2008

While many commentators are examining the implications of the Glasgow East by-election (to paraphrase Frank Sinatra, if Labour can’t make it there, can they make it anywhere?), Tom Smith asks whether there are any implications for health policy from the Glasgow East by-election.

At first sight, the answer seems simple: no. After all health was hardly debated.  The SNP declined to campaign on an issue they are in charge of in Scotland, not the Labour Party (who are in opposition in Scotland).  They found themselves making technical policy points - without wanting to fully oppose free prescription charges, for example, they pointed out the alternative ways the money this cost could be used – hardly riding on the crest of a popular wave.

Labour's 'Janus' health policy: facing two ways

The most obvious implication of the Glasgow result is that no Labour seat can be considered safe at the moment.  Worried about small majorities, a lot of Labour MPs might take a greater interest in specific NHS issues that arise in their constituencies.  At the same time, prospective MPs, and opposition candidates, will seek to exploit problems and pin them onto the ruling party.

For some Labour members, the question that arises from defeat in Scotland, is should Labour in England rule as old-Labour, like the administrations in Cardiff Bay and Holyrood?  

At a time when answers are short, this question is answered with others.  Is Labour really doing badly because they are not old-Labour enough? Was the problem in Glasgow that Gordon Brown is not unequivocally New Labour?  For others, it is a red-herring debate and rather than a battle between the two wings of the party, instead, different corners of the party should search for a consensus on which they can passionately campaign together.

A poll in yesterday’s Guardian suggested that voters aren’t clear about what Labour stand for - and therefore a key challenge for the Government that has been made clear in Glasgow East is the need for a clearer vision on policy.  

Although health policy is an area where the Government feel comfortable, because they think they are right and the Conservatives wrong, it is still difficult terrain. The Government has been facing two ways: convincing the opposition that they are reform-minded (and in fact more radical than others), yet at the same time reassuring its own members that some of the most radical planks of reform will not undermine the NHS.

While the press this weekend was full of speculation about who would tell Brown his time was up or who might be position themselves to replace him, the Labour Party, in the form of the national policy forum, were debating policy issues, negotiating a range of policies of which health policy was one of the most important issues under consideration.  

The national policy forum searches for consensus in Warwick

Last weekend, the Times and the Telegraph both said the meeting in Warwick was an opportunity for the unions to try to force the Government leftwards, in return for their support.  One of the most contentious issues is the involvement of the private sector.  The Daily Mail (26 July) said that Alan Johnson was ‘in fraught meetings with union bosses trying to thrash out an agreement over the extent of private involvement in public services such as the NHS’.

The question is, can this line be maintained?  Will the blow from the Glasgow East electorate drive the different views within the Labour Party together, or will it force them - and the wings of the party - apart?

Yesterday, the consensus statement that had been agreed saw the light of day: http://www.sochealth.co.uk/news/npfconcensus08.htm. In linguistic terms, the consensus document brings together left and right.  The language in many ways suggests a turn to the left – something interpreted in Monday’s Times as a policy shift forced on Brown by the unions.

Headline areas of consensus from the statement

The key statements can be seen in the following excerpts, in italics. There is an explicit commitment to the continued dominance of public service provision, for which the unions have been calling.  

‘Investment in public services also supports our future economic development and can also play an essential role in regenerating local economies and maintaining stable growth and high levels of employment’. In another statement, the document says, ‘we are committed to maintaining and developing a central role for public provision and a directly employed workforce’

But at the same time there is a commitment to reform.

'Labour is committed to pressing ahead with the next stage of reform to improve quality, increase the responsiveness and enhance the fairness of public services. Our objective is that everyone and not just those able to pay should have access to high quality public services that meet people's rising aspirations, available when they need them and tailored to their individual circumstances'.

In relation to alternative providers, there is a suggestion that they will provide additional services that the public sector cannot provide.  The following words could be interpreted as a slight retreat on competition (which is, of course, what they are designed to achieve).

'Different sorts of providers will sometimes offer innovative, high quality services not routinely available in the public sector. Where that is the case we will continue to use voluntary and community organisations, social enterprises and the independent sector in providing services. Where they are used to provide services they must offer value for money'.

The trade unions, including the BMA, have also called for choice to be extended beyond choosing where to be referred.   Something like this appears in the document.

'We will extend the range of choices on offer to patients, providing choice not only in elective surgery but in other areas of healthcare including maternity services and general practice and ensuring patients can make real choices about their treatment as well as when and where they are treated'.

The statement doesn’t go so far as to call for an end to the market in England, but it does rail against the creation of a European market.

'In relation to health services, we will work with the EU to ensure British patients are not disadvantaged by needing care across EU borders and we will ensure the approach taken by the EU is consistent with the fundamental principles of the NHS. We will oppose any attempts to create an EU single market for healthcare which could undermine the NHS'.

Again the document reiterates the centrality of the public sector.

'We are committed to maintaining a central strategic role for public provision in services as a guarantor, comparator, standard setter and leading innovator. We will take steps to ensure that all commissioners give full consideration to in house options and public sector solutions'.

An important symbolic statement is made to illustrate this point.

'This is exceptionally important in priority services such as hospital cleaning, where the decision to use a particular provider must be based on the strongest evidence about effectiveness. Where providers fail to deliver a satisfactory service, its contract should not be renewed or in exceptional circumstances, terminated. Hospital cleaners are an essential part of the healthcare team, playing a vital part in avoiding healthcare acquired infections. All hospitals must give full consideration to in-house options for their cleaning contracts with a view to maintaining and developing critical public sector capacity in the management of cleaning and hospital hygiene.'

What difference does the statement make?

Though the words sound right, it is difficult to pin down the specific differences that will emerge from the consensus document.  A lot of the statements were already policy, such as the idea of extending choice and a tendency to see hospital cleanliness as a core NHS function.

Even when ideas are more radical, there is no real commitment to them.  For example, one of the criticisms of private sector involvement in health is the lack of a playing field.  While public providers are required to be transparent, the independent sector is able to hold some information back, on commercial grounds.

'Information about independent and third sector providers of NHS services is usually available from the public authority under existing Freedom of Information rules, except where valid exemptions apply. However, we will consider introducing a voluntary Code of Practice for private organisations which provide public services to provide information about their public activities' .

The key word is ‘consider’.  The statement will not necessarily lead to any change.

In other areas of the document, many of the statements seem symbolic.  Clearly, a lot of the pressure from the trade unions was to treat workers better.  There are some statements about the importance of development, but in terms of practical measures, the agreement does not break new ground.

For example, ‘to promote healthier eating for NHS staff and patients, we are developing a new kite mark for public sector canteens that provide healthy, nutritious food to public sector staff and those in their care. This will initially be piloted in the NHS, HM Prison Service and central government staff canteens, before eventually being rolled out across the public sector.'

Jamie Oliver will be proud.  

Will Labour pull together or fall apart?

In the short term, the implication of the Glasgow East by-election for Labour has been to force a discussion about the words that could represent a common stance on policy, across the various parts of the party.  All in all, the words would be attractive to all:  those on the left will be reassured by the position given to the public sector; the reform minded within the party will be pleased to see a commitment to enter a new phase and continue change. The notion of triangulation continues – wrapping reform in a left-leaning discourse for the left, and in radical reforming terms for the right.

Despite the fine words in the consensus statement, there are real questions about whether it can hold.  It will be tested over the coming weeks.  All the talk about equal treatment for public sector tenders does not position them as preferred providers, for example.  While one part of the document says the role of social enterprises are necessarily limited, another suggests they hold promise as a way of empowering front-line staff.

The Times yesterday suggested the statement is a sign that ‘Gordon Brown has caved in to the unions’.  As if it proved this, Dave Prentis, the Unison general secretary is quoted as saying the statement marks a return to Labour’s “core values”.

The consensus formed in Warwick can and will be revisited.  One trade unionist is quoted as saying that the Government have promised one more national forum before the next election.  At this stage of the cycle, the end of the 2007-8 political season, six weeks ahead of the Labour conference and the beginning of the 2008-9 season, even the best-informed observers are saying we will have to wait and see whether Glasgow East means that the Labour Party will pull together, pull apart or carry on regardless. Right now, health policy seems a good test of how cohesive Labour policy can become.

Will greater clarity in policy make a difference?

The real question is whether greater clarity in policy or, indeed, new policies are able to help Labour.  A Populus poll, published in today’s Times and undertaken over the weekend, suggests that time is running out: http://www.timesonline.co.uk/tol/news/politics/article4419035.ece.

The proportion of voters who believe that significant policy change would make a difference to the Government’s fortunes has fallen from 69 to 56% since a similar poll two months ago, in May. ‘The number saying that new policies would not boost Labour has jumped from 25 to 41 per cent’.  The poll suggests that a different leader would not help Labour, but a change in policy might.