a substitute for justice: charity and the NHS

Adam Nedman

Health Secretary Matt Hancock recently unveiled his plan to recognise the contributions of social care workers currently risking their health and lives on the front line of coronavirus response.  It’s a badge with ‘Care’ written upon it: as his Shadow, Labour’s Jonathan Ashworth, tweeted, “Really?  A badge?”.  (I say “unveiled”, but it wasn’t even a fresh idea, but a barely-memorable year-old initiative). 

This bathetic gesture arguably says something salient about where the Conservative Party, and perhaps swathes of wider political consciousness, are at.  For what is a badge?  Definitions incorporate the words emblem, sign, indicator, image – all synonyms for ‘symbol’ – as well as token.  

We shouldn’t be surprised that a Conservative government has only a token symbol to offer those working in social care.  The ‘token’ element is perfectly in keeping with their preferred paternalistic, pat-on-the-head, approach to those beyond their class – a badge, after all, is what one gives to a pupil who has achieved a merit at school, or to an emotionally disturbed child when they have behaved according to edict.  And the symbolic and gestural is what the current administration has been particularly effective in reducing political questions to – ‘getting Brexit done’, oven-readiness, truck-through-the-wall.  It is a form of sleight-of-hand aimed, often successfully, at distracting us: in one hand they are holding up for our attention the idea of immunity certificates (another empty gesture at this stage, as the duration of any immunity one derives from a bout of Covid19 is not established) – whilst in the other, they fumble with something unseen in their pocket.

Arguably, the Tories are feeding such reductive symbolism and tokenism both into and from the wider culture.  Much of what passes for collective political consciousness appears quite weakly based in substance: one only has to think back to the Brexit debate for an issue wherein key protagonists, the EU, were symbolic for both remain and leave camps in ways often shakily supported by actuality.  For some remainers, the EU represented liberality, openness and solidarity, with little consideration given to complications such as the savage response to the Greek debt crisis, the ‘Fortress Europe’ measures, or demands for democratically-elected governments to rewrite budgets.  And for some leavers, the EU symbolised a class they felt overlorded yet abandoned by, even though much of any investment into some leave areas had come from the EU itself (though who was and was not involved in deciding how funds were spent is a salient question); for others, leaving fulfilled a fiction-driven wish to re-establish what the nation is, and who belongs in it.  In each case, key facts were forgotten or ignored.

That we should pin our hopes and fears to symbols is understandable: there is much to be done in merely getting by, much to be known in comprehending any issue, and often little time and energy to spare.  Myriad stimuli, some deliberately designed to be addictive, clamour constantly for our attention; the media speed any rush to reductionism – statements seeking to convey nuance are afforded little credibility (witness the deriding of Jeremy Corbyn’s “seven out of ten” assessment of the EU).    

However, there is currently a real danger of the Covid19 crisis, and the accompanying ‘mood music’ being composed around it, dragging much of public consciousness further into the muddy shallows of the primarily symbolic, to deleterious effect.  Most glaringly yet silently of all, it is the NHS itself – the centrepiece of current exhibitions of appreciation for key workers – which is arguably in the process of being reduced to imagery which blurs key aspects of its reality beyond recognition.  This is not to say that the thanks being conveyed by the public to those working in essential roles is not merited: it absolutely is, and its expression is long overdue.  However, the use of the NHS and its logo as shorthand for the kindness and dedication we seek to celebrate risks our failing to focus upon vital truths and questions regarding its status and direction as a body.

Consider, for instance, the fact that, as a consequence of the 2010 Health and Social Care Act, the government no longer has a legal duty to provide a National Health Service in England.  The plethora of private, profit-seeking providers being awarded contracts to deliver services in an increasingly fragmented healthcare environment can be perceived as increasingly rendering the NHS as little more than a brand name and logo.  Professor Allyson Pollock, prominent chronicler of the dismemberment of the NHS over recent decades, has written that, given the evident policy aims and direction, without the reinstatement of the government’s duty to provide it, “there will be no NHS” – rather, “a gradual shift to private insurance and charges to patients”.  This, to the shame of both the media and opposition parties, has been kept all too quiet.

Now more than ever, we should feel anger about this, and channel this effectively to ensure that this duty is restored, and protected in perpetuity.  Since the value of the NHS is now seemingly agreed upon by all – even the Prime Minister, who has previously argued for it to be replaced by a private insurance system – we should collectively demand that the government now promptly restore their legal duty to provide it.  (Indeed, maybe the leader of the opposition could use his platform to promote and amplify this demand … ?). 

However, whilst focussed ire is required, is there a danger here of there being too great a contrast between its cultivation and expression, and our warm sensations of appreciation for carers; might this lead to us being collectively wrong-footed?  Do these outpourings, shared with so many others through collective ritual, tend to feel immersive, absorb us?  As we are so often cognitively and affectively persuaded away from nuance, and towards polarised simplification, how much scope do we have to feel both happy gratitude, and determined indignation, simultaneously?  Could the glow of gladness also lull us toward the rosy notion that we are all in this together, our tear-softened sight dilute our focus on, for instance, the impact of 17,000 hospital beds being cut by the Conservatives over the last ten years?  One fears that such affective immersion and lulling, experienced on a societal scale, risks the door being left open to a further loss of hard-fought entitlements.  

This would be right up the Conservative Party’s ugly, gated street.  A friend has worked in the charity sector, raising funds to purchase for families in poverty essential goods which would previously have been available via recourse to the Social Fund (abolished by the coalition government in 2013) – home appliances, essential furnishings, clothing.  In the course of this work, they have come into contact with a series of more or less prominent Tory figures.  My friend tells me they are pretty much unanimous in expressing one fundamental attitude: if you want to do anything to help these people, that’s all well and good, and up to you; it’s nothing to do with us.  It is important to apprehend this attitude when analysing the government’s responses to this crisis: they will, at best, always struggle to provide for the people’s needs through statutory action because, essentially, they don’t want to – doing so runs counter to their core beliefs. 

Thus the Conservative Party are, in some respects, primed to profit from this crisis.  Yes, they are coming under justified fire for the tardiness, slipshodness, and slipperiness of their response.  However, they have participated significantly in shaping a situation whereby the public has almost no choice but to literally buy, in a more or less energised spirit of celebration, into the notion of essential services being resourced by charitable giving.  In this respect, one might discern that perhaps there’s an extent to which the shortages of PPE and ventilators hasn’t been a mistake: the necessary desperation that the public feel to ensure the NHS and its staff have the equipment they need has driven a mass mobilisation of voluntarism – which is just what the Conservatives have wanted all along (welcome back to the Big Society, everybody).  As Barthes put it in The Iconography of Abbe Pierre: “I get worried about a society which consumes with such avidity the display of charity that it forgets to ask itself questions about its consequences, its uses and its limits.  And then I start to wonder whether the fine and touching iconography of the Abbe Pierre is not the alibi which a sizeable part of the nation uses, once more, to substitute with impunity the signs of charity for the reality of justice”.  The Conservatives would indeed love the provision of care to be subject to the whims of charity and the philanthropy of the wealthy: it reflects and shores up what they see as a natural hierarchy – we lowly folk plead and strive; they adjudicate and award us badges.  

The obvious problem with such an approach is not simply that having to resort to charity entails the inevitable exposure of one’s lack to those who don’t lack, and the possibility of being subjected to some form of judgement which, however sensitively delivered, can undermine recipients’ sense of self-worth.  It’s also that what charity provides for cannot thereby be offered as a guaranteed right, outcomes depending instead on how much the prosperous have put into the pot, and how those they appoint to administer its distribution decide, outwith democratic parameters, to execute this task.  Clearly, then, the NHS is the last realm within which we should want charitable activity to be proliferating.

However, this is just what appears to be occurring.  NHS Charities Together, the umbrella organisation for NHS charities, has launched a campaign, One Million Claps, donations to which will be used to provide “a range of supplies and support for NHS staff, volunteers and patients – including food, travel, accommodation, mobile devices to keep in touch with family and friends, and mental health support and counselling”.  This is laudable – those raising money to fund essential equipment are not to be knocked – but not desirable: many such goods are inarguably essential and their upkeep, to decent standards, should be guaranteed by a state running one of the six largest economies worldwide, even in a crisis (a viral pandemic has been top of the government’s list of potential threats for many years).  A sharp distinction between the laudability and desirability of such giving needs to be kept clearly in view. 

A key question, then, concerns what happens once this crisis abates; developments from this point may well have a significant impact on the longer-term direction the NHS, and other essential services, are taken in.  What will we allow the government to do with them?  Or, to put it another way: how much of our own applause will turn out to have been largely symbolic, even tokenistic?  Just as food banks have become the new normal in welfare provision, will it become yet more acceptable for care to increasingly depend on charitable funds?  This would constitute a further, regressive, victory of the symbolic over the actual, as the need to resort to charity was something the NHS sought to replace through the establishment of a system of free universal healthcare, funded by taxation.  If we’re not watchful and demanding in the way we proceed through and emerge from this crisis, the Conservatives will be guaranteed what they have long desired – a ‘National Health Service’ which is in fact nothing more than a brand name masking the operation of gaggles of private, profiteering, actors, and hard-pressed charitable endeavours.  They’ve already dragged it some way down this road.

How might we prevent this from happening?  Here are some initial thoughts, which others may add to.  Firstly, public regard for essential services has to be politically mobilised: as soon as is safe to do so, parties and organisations keen to protect public services need to be out amongst the community, connecting people’s willingness to applaud to facts and arguments around key workers’ pay and conditions, the fragmentation and cutting of services, and the ethics and practical effects of privatisation.  Secondly, the popular regard for public service that has been enlivened through this crisis needs to be extended and deepened: ways need to be found to ensure that, whenever anyone passes an NHS facility, enters a public library, or visits a municipal park, there is recognition of the benefits of communitarian provision (and the pitfalls of commercial alternatives), and awareness of the broader political implications of this, both within and beyond the ballot box.  (An additional potential advantage of this may be the development of greater acknowledgement of shared interest between workers in different areas of public service).  One might, for instance, open out the question: is it conceivable that, in some imagined future pandemic, outbreaks of mass applause would be directed towards services that only offered help when they stood to make a profit from doing so? 

We must go beyond symbols: acting substantively, we need to leave lasting bruises on power with our blows.  As we applaud, donate, paint rainbows or plan, we should hold high in heart and head the notion of what the NHS should once again be.  Demand more than mere gesture; demand that your right to be treated as a fundamentally equal citizen will always be upheld, that you should never suffer the precarity of having to plead; demand repeal, now, of the 2010 Health and Social Care Act.