The Progressive

'Sicko' and what it means here

There is an excellent review of Michael Moore's latest film, 'Sicko', here at the ever-vibrant Harry's Place.

As someone who disagreed strongly with Moore's agit-prop in 'Fahrenheit 9/11', it may be perhaps a little hypocritical to embrace Moore when he salutes the sacred cow of British Labour politics, the NHS. But, for all Moore's faults, there is no doubt that 'Sicko' will ignite a debate that is necessary in US politics. I remember well how effectively Bush savaged Kerry's very moderate plans for health reform in the US at the last Presidential Election by accusing reformers of wanting 'health rationing'. Bush pointed at Europe with its queues for health provision and correctly identified our system of rationing. This rhetoric is hard to counter, and in fact has already been embraced by those who wish the NHS ill in the UK.

It is interesting to note that in debates over the provision of cancer drugs by the independent licensing body NICE, the Daily Mail has used the language first used by Bush of 'rationing', in this case of medicines. I shalln't repeat all the arguments in favour of NICE, which Polly Toynbee does in the Guardian here will aplomb, but I shall repeat the mantra that democratic socialists must learn by rote: "NICE has sanctioned 25 of the 26 cancer drugs it has been asked to review: these cost up to £25,000 per person per year and are free at the point of use on your NHS."

The language of 'rationing' is dangerous because it is true. The NHS does prioritise healthcare and does prioritise which drugs and treatments to use on the basis of cost. This isn't to say it isn't well funded, it is, but we must recognise that our healthcare system has queues as an intrinsic outcome. When the state decides the supply of healthcare, rather than individuals, you will always have queues, especially if it is free at the point of use. Free healthcare means no restrictions on demand: people will demand as much healthcare as possible because humans wish to preserve themselves and their families as best they can. However, this is not to say this method of supply is wrong. When, like the US system, individuals get to decide how much healthcare to purchase, the rich buy far too much rather than too little - hence US healthcare expenditure reaching nearly 14% of GDP, even with a third of the population having no healthcare (compared to around 8-9% in the UK). The neuroses of the rich push up the cost of healthcare for the poor - the rich hog doctors when little Timmy has a cold; the poor can barely afford to send Tanya to the doctor when she has serious breathing difficulties.

When 'Sicko' is released in UK cinemas, there is no doubt the old arguments will be reopened. The Mail, et al., will point to French healthcare and ask why we don't embrace social insurance, some more radical observers may even ask why we don't embrace US style personal insurance with top-ups for the poorest families. 'Sicko' shows effectively how drug companies are becoming increasingly effective sales operations, providing miracle panceas to the neuroses of the middle-classes - at a price - with our healthcare system we ought to avoid the sirens calling for insurance (whether social or private). Unless of course you want the marvellous site, common in France, of doctors discussing prescriptions with drug company reps whilst on the golf course.

Debating a constitution for the NHS

Thanks to those of you who attended last night's excellent seminar, 'A healthy debate: Does the NHS need a constitution?' Aside from the slightly hackneyed pun in the title (for which I take responsibility!), the level of discussion was very high and very interesting.

Andy Burnham, the minister who recently floated the idea in a recent Progress pamphlet, conceded that the idea was still a formative one, and that the process of debating what the constitution would contain would serve as a way of setting down the NHS's underlying values. Amazingly, surely fundamental ideals such as the service being free at the point of use, based on need not the ability to pay, and that is comprehensive, have never been codified.

The commitment of its staff and the public to these ideals, which Will Hutton later described as being something similar to the notion of 'public value', could be enshrined in any constitution. But this is the point at which some of the more sceptical contributors - such as John Carvel, Vanessa Bourne and Margaret Jay - interjected.

There were dangers: a constitution of broad values might amount to little more than what Bourne termed 'tokenism'. It needed to be specific and backed up by sanction, should any of the principles be breached. Yet Baroness Jay raised the opposite danger - if it were a 'rulebook', it might be over-prescriptive, whereas the management of successful organisations was usually too 'fluid and complex' to be written down.

Another, associated issue is this: who would have the power to interpret such a constitution? Will Hutton briefly mentioned the US constitution as a document which continually sparks debate as to its interpretation, far from having a 'depoliticizing' effect. But surely some kind of 'constitutional court' for the NHS would be unfeasible and undesirable, sparking endless wrangling as to the real implications of certain broad underpinning values.

John Carvel and Will Hutton instigated a lively discussion on how 'independent' the NHS could be from political control. Certainly, a constitution could pose dangers for democratic accountability, but there again, there was agreement that Ministers had shown themselves to be capable of some very poor managerial decisions, when it came to the NHS.

Post any thoughts below!