This is Iain Martin’s weekly newsletter, exclusively for Reaction subscribers.
Is there a Gove in the house? The Prime Minister is considering how to reshuffle his cabinet once the summer parliamentary recess is over. He is in urgent need of a new health secretary and there is Whitehall chatter he’ll send for reformer and moderniser Michael Gove, who used to run the education department.
Elsewhere, the departure of the Defence Secretary means this could be a wide-ranging reshuffle. It’s Rishi Sunak‘s last chance to reconstruct the government before the long run-in to the general election, expected next autumn.
A Gove appointment at Health – if he could be persuaded, he would be reluctant – would set up a fascinating tussle with Labour. Wes Streeting, Labour’s shadow health secretary, is also a reformer with Blairite tendencies. He angers the trade unions and talks in daring terms of putting patients first. Could this catch on? Goodness, at this rate next year there might even be an honest conversation – in an election year! – with the voters about improving the NHS.
It depends on how bold Sunak is prepared to be. The incumbent at health, Steve Barclay, has had a torrid time of it, although not nearly as torrid a time as that endured by the patients of the NHS. There are strikes galore and lengthy waiting lists. Is there any person in Britain who does not know multiple relatives and friends stuck waiting, often for years, with health conditions inhibiting mobility? Routine operations that in Europe’s best health systems are relatively easy to come by can take years in Britain, be it in England and Wales or the separate and equally ragged NHS in Scotland.
Rightly, money has been poured into the NHS since the start of the pandemic. And the long-term story over the last four decades is also of spending increasing in an attempt to keep up with a population that has increased by almost eleven million since Margaret Thatcher entered office.
The Nuffield Trust says: “Since 1979/80, the Department’s budget has grown four-fold in real terms, and it has doubled its share of the GDP pie. Planned spending between the current year 2022/23 and 2024/25 will add a further £13.2 billion in cash – although rising prices will cut this to around £2.4 billion.”
Yet NHS productivity is disappointing, to put it politely.
The FT reported recently: “The NHS carried out 9 per cent fewer emergency admissions, 5 per cent fewer outpatient appointments and 11 per cent fewer elective and maternity admissions in March 2023 than in the same month in 2019.”
Money up, delivery of care down.
In May, Robert Colvile, director of the Centre for Policy Studies, writing in The Times, diagnosed the problem:
“The NHS is on track to hoover up more than half of day-to-day public service spending in the next few years as an ageing population develops more and more complicated health conditions. Unless we can keep people healthier for longer, or galvanise GDP growth, we’ll soon be a health system with a vestigial economy attached.”
What is needed is reform and an honest conversation about contracting out much more to an expanded private sector, to speed up the delivery of care. Not to begin a privatisation of the health service. The British will never accept such an imposition, believing erroneously that the service is the envy of the world while refusing to acknowledge that no other country on earth has adopted the NHS system. Why is that?
Often those attacking the concept of supposed British exceptionalism in other areas are the most vocal in deriding any attempt made to learn lessons from Europe when it comes to healthcare.
Other European countries – hardly hard-hearted bastions of laissez-faire economics – use a greater blend of public, private and charity-sector care, sometimes with a social insurance model and prepayment.
Although we spellbound British would never go as far as approving of social insurance, with public frustration growing over waiting lists there might be scope now to win an argument that the NHS – publicly funded, free at the point of use – must do less and contract out more. There is no scope for more state spending, so why not encourage the expansion of the private sector to lessen the strain? Tap into private capital.
There has been a move in that direction in the last twenty years. Every step of the way it has been denounced by campaigners who denounce any hint of profit and claim it is all part of a secret plan to scrap the NHS, which it isn’t.
The BMA, the doctor’s union, complains that in 2020-21 independent providers provided 5.2% of all NHS elective activity, a rise since New Labour introduced independent treatment centres in 2003-04. Back then it was 0.02%. What is astonishing is that it has taken so long to get to 5.2% and that this is considered such a high figure. It should be way higher than that, if the welfare of patients and shortening waiting lists are the main concerns.
If it happens, Gove as Health Secretary facing Wes Streeting as his shadow, just when the money has run out, there would at last be a chance, just a chance, of an entirely different conversation taking place about improving the NHS.
China in decline
Go east, young man, he said. It was the mid-1990s and an experienced business person was explaining to our group of friends in the Ubiquitous Chip, an upmarket Glasgow pub, why the future lay in China. We would be astonished by what was about to happen, he told us. This was an enterprising sophisticate’s refrain in those days. China was stirring. A great civilisation was on the rise again. That is where the opportunity was going to be. Forget Tiananmen Square.
As he talked we listened, sipping on our gin and tonics, feeling supersonic. Yes, there were some problems with contract law and property rights, he admitted, and the Chinese business folk he had encountered could be a little cutthroat and somewhat disrespectful on questions of intellectual property, but my goodness they had entrepreneurial drive.
Many months later I ran into him again in another pub and he was in a foul mood. He had returned from another trip to China. The Chinese he had been dealing with were an irredeemable bunch of chiselers, chancers and cheats, he said. They wanted everything, all the profit, for themselves.
The dragon rises, and there’s a sting in the tail. The memory of those conversations has stuck with me throughout the Chinese boom, when I’ve had to listen to endless presentations or arguments explaining why the West and its allies would be eclipsed by the mighty new power.
Now, China’s rise is faltering or worse. There are several signs of decline appearing weekly, to complement the deep demographic crisis facing the Chinese Communist Party. China’s population is projected to fall below one billion by 2080 and below 800 million by 2100, according to the UN. China’s population is shrinking while India and the US grow. In the case of America, one of its most attractive features for immigrants is surely personal liberty and a pluralist political system. China cannot compete when it comes to freedom.
Here’s another sign. A few days ago China’s central bank announced it has a new boss. A desperate Xi Jinping has called back Pan Gongsheng, an experienced official who was sidelined last year. Now the property crash in China is so serious, and the economic recovery from Covid so sluggish, that Xi has sent for help.
In the last thirty years we have become used to every discussion about geopolitics and great power competition being framed by the rise of China. What happens when it becomes more widely understood that China is facing a period of relative decline? We’re going to need new ways to think about China, particularly as tyrannies in decline can be even more dangerous than rising powers. War is a way for a struggling regime to bolster national feeling and engender a sense of authority.
In the UK Treasury, the penny is yet to drop. The drift there appears to be back towards the disastrous policy of the George Osborne era. Then Osborne talked of a golden era in UK-China relations. Now, says a former minister who knows the department inside out, the inclination under Chancellor Jeremy Hunt is to look where possible to get back to much better relations.
Fine, engagement is necessary to minimise the risk of war and protect the trade that can be protected, the trade that is not integral to national security. Beyond that the West and its allies need to try to get their heads round the idea that the emerging superpower is in long term difficulty. This will create opportunities, and a lot of trouble.
Glasgow needs help
Speaking as I did earlier of the Ubiquitous Chip, the West End of Glasgow watering hole, another great Glasgow institution closed this month suddenly. The chef Brian Maule shut Chardon d’Or, the city centre’s leading restaurant. He blamed local rates, the hollowing out of the city’s business district since Covid, and a Scottish government that doesn’t seem to like, let alone understand, business.
In Glasgow the news has triggered an outpouring of angst about disastrous urban decline. The Herald, the city’s main paper, carried a string of pieces from writers in despair about what is happening to the place.
On one level this is infuriating. Years have been wasted. Those of us who warned twenty years ago that under Scottish devolution Glasgow would decline and be starved of resources have been vindicated. Scotland’s dirty secret is that the rest of Scotland cannot stand the place. That is a legacy of its 19th century industrial hegemony and a late 20th century tendency to boastfulness.
Glasgow today is in such a sorry state and lacking leadership. In local government terms the place is bust, yet clustered around it are numerous prosperous suburbs that do not fall within the Glasgow tax base.
The danger is that one of Britain’s major cities follows San Francisco, descending into a spiral in which the centre becomes a wasteland of shuttered stores, vagrancy, drugs and violence.
It will fall to the Labour Party, on the way back in Scotland, to fix. Good luck with that.
As a start, how about creating a post of elected Lord Provost, the Scottish term for mayor, on the model being used in England’s cities?
The SNP would never do this, because no rival centres of power must be permitted. Nothing must be allowed to rival or challenge the SNP First Minister in Edinburgh who has, under the Nationalists, only one priority. That priority is to keep the focus of grievance on Westminster and England. An elected leader for Glasgow would upset this arrangement and ask difficult questions of Holyrood and Edinburgh about funding and investment.
Gordon Brown is always looking for problems to solve. Even his critics (raises a hand) acknowledge he has energy. Now that the former Prime Minister is no longer going to be allowed to upend (again) the British constitution, because Labour leader Sir Keir Starmer has gone off the idea, Brown could turn his attention to Glasgow. After all, he was born in Giffnock, on the edge of the city.
Let me be the first to say… Gordon Brown for elected Lord Provost of Glasgow.
Happy birthday Mick Jagger, man of courage
Last week, with colleagues on Engelsberg Ideas we recorded the latest episode of the site’s weekly podcast EI Talks. This episode was on Mick Jagger at 80 and on that generation of ageing rockers and their enduring appeal. You can listen here.
As a Rolling Stones fan I’ve wasted so many hours of my life, days, weeks, in total months, talking about Mick Jagger and Keith Richards, listening to their music, reading, discussing it with friends, and trying to explain the appeal, that I feel I’ve heard it all. I’ve become blasé, cynical even. Part of the joy of being a Jagger fan is enjoying the way he seems never to take it seriously. So he is taken less seriously than his best work and track record merit.
Yet on EI Talks my colleague Paul Lay, senior editor on Engelsberg Ideas, made a point so original in the field of Stones studies that it stunned me.
Jagger, he said, needs to be recognised for his courage as a performer. Not only was he so audacious in the early years of the Stones, in bending gender stereotypes, that he shocked Britain into becoming more relaxed. Later, at Altamont, Paul pointed out, he exhibited genuine physical courage in the face of extreme danger.
Altamont was the concert policed by the Hells Angels in December 1969 in San Francisco, on the day when the 1960s ended with a bang. The summer of love had already turned dark. That night it morphed into a bad acid trip culminating in a murder right in front of the stage as the Stones performed.
Paul Lay is right. That night, Jagger was the focal point. He would have been in fear of his life, and yet he pressed on, trying to calm the crowd. Despite having been assaulted earlier in the day when arriving at the venue, he didn’t run away as today’s stars would. In the darkness he kept on singing and strutting his stuff. Long may he continue to do so, though nature suggests it can’t go on forever, sadly.
A belated happy birthday, Sir Mick.
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