by Peter Watt
There was a debate yesterday instigated by Labour on the introduction of regional pay into the NHS. Labour’s argument is clear, that by allowing the introduction of regional pay into the NHS the government risks breaking it up. Of particular focus for criticism were the group of twenty trusts in the south west, the south west consortium. They are seeking to opt out of the national agenda for Change framework for pay and conditions as an element of their plans to achieve their required cost reductions. As Andy Burnham said in the debate:
“National pay is part of the glue of a national health service, part of what holds it together, and in turn the NHS is part of what holds our country together.
A one nation service bridging the social and economic divides of our country, uniting east and west, north and south. The N in NHS should be cherished, but instead it is coming under ideological attack.”
Powerful stuff and you may think hard to disagree with. But Labour has some form in this area, in both government and opposition, which makes their position a little tenuous. It may well be that there is a perfectly good reason for this apparent inconsistency but you can be sure that this inconsistency will be exploited by opponents.
First, in government it was Labour that introduced the very flexibilities and freedoms that allow NHS trusts to make decisions that ensure their responsiveness to local needs. And rightly so; as commissioners agree local priorities it was important that the local providers were able to operate flexibly and choose what they did in order to deliver on these priorities.
This didn’t mean an end to national pay and conditions but it did mean that if needed trusts could be flexible. So for instance, if there was a need for one particular service to be expanded in an area where attracting the right staff was difficult, then a trust could respond.
It is the same flexibility that allows service provision to vary from area to area as local decisions are taken. I know that we like to complain about the “postcode lottery” in terms of care, but it is an inevitable, and in many ways welcome, consequence of local decision making.
Second, the NHS is also required to make billions of pounds of efficiency savings, and would have had to under a Labour government. Its staff costs are a huge proportion of its cost base. For Trusts not to be able to look at how they manage staffing budgets is nonsense. Whilst there are clearly many business processes that can be streamlined and procurement improved to reduce costs they simply cannot ignore staffing costs. The alternative to some variation in pay within a national framework is employing less staff or providing fewer services.
Third, Labour in opposition has said that they support regional rates of welfare benefits. The argument being that as local housing and other costs vary hugely from area to area so should the amount of support provided by the taxpayer to those in need of support. So regional welfare rates yes; but regional pay rates no. It simply does not make sense.
At the heart of this argument is a refusal to fully accept the consequences of local decision making. If you think, as pretty much all of the parties say that they do, that decisions are best made locally then there is a consequence to this. It is why there are different approaches to the NHS, student finance and social care between England and the devolved nations.
It is why you can get IVF on the NHS in some areas and not in others. Or more or less library provision from borough to borough. From next Thursday we may well see even more differences in the way that crime is tackled across the country as police and crime commissioners are elected. Personal budgets for the delivery of social care means that care packages vary and free schools and academies are creating different approaches and styles of educational experience in state schools.
In other words there is an inexorable drive for localisation. It is a key part of delivering responsive and efficient services. And as budgets are squeezed then local decision making and accountability can only become more and more important. The age of the one size fits all state monolith is well and truly gone.
Naturally, this creates uncertainties and tensions as people become used to the complexity of arrangements and new relationships. But unless one nation Labour intends to reverse this trend – to remove the NHS trust status that a Labour government introduced; to centralise all decision making on what money should be spent on local health priorities; to close the school academies; scrap personalisation and co-production in the delivery of social care – then Labour need to be honest about the consequences.
And the consequences are clear; the way that public services are delivered, what is delivered, whether or not things are free and in some cases how much people are paid to deliver them will vary from place to place.
Although this does not mean accepting a free for all in pay and conditions in (say) the NHS, it will inevitably mean that local providers will push to set their own rates albeit within a national framework.
And the truth is that Labour knows this even if the party’s speakers in yesterday’s parliamentary debate didn’t make this clear.
Peter Watt was general secretary of the Labour party