Another referendum? Yes, but this time on the NHS | Steve Richards

Referendums resolve nothing. The campaigns that precede them are mendacious. A thousand factors determine the outcomes, many of them unrelated to the question on the ballot paper. Yet there is an overwhelming case for holding another one.

The next referendum should not be on Europe. We have had more than enough plebiscites on that unavoidably vague and highly charged issue. Instead the question that needs to be placed in front of the electorate is more focused and precise. As people live longer and medical technology develops, everyone agrees that, alongside structural reforms, higher investment in health and elderly care is essential.

Yet no party or leader can find a way to raise the money. The scale of the crisis is vast and the response of government is puny. Look at the current incumbents, still on a buoyant honeymoon with the electorate, but struggling to find a means of providing a tiny bit of extra cash for elderly care at the end of the year.

The referendum would not be about a prime minister, the government or the opposition. It would be about us, our priorities

The situation is perverse. Nearly all voters recognise that modern health provision is worth paying for and agonise separately about the possible future costs of elderly care. Will we have to sell our house? Will we lose our inheritance? Why can’t we get access to drugs available in other countries? Why are survival rates of some diseases higher in other countries? Why do I have to wait a week to see a GP?

Part of the answer to all these questions is obvious. The government needs to raise additional revenue. It will not be cheap but in the end – for selfish reasons and not altruistic ones – we need the only mediating agency available to address the challenge, and that is a government. There is no other institution available that can be held to account in the same way and that can respond to the sheer scale of demand.

Yet the obvious cannot be delivered. The government – any government – cannot deliver because it is too scared to raise taxation or is not trusted to do so. With the UK’s uniquely hysterical pre-election tax-and-spend debates no party can win a mandate to raise taxes in order to provide the necessary levels of investment. Before a general election there is pressure on parties to show how they will cut taxes and reduce public spending.

These debates have no relation to reality and yet constrain governments subsequently. The last election was typical, fought on the fantasy that George Osborne would wipe out the deficit by the end of this parliament. Moving nervily into this fantasy battleground, the Labour leadership wondered fleetingly whether it could argue that elderly care and a modern health service were worth paying for, and concluded that it could not. The priorities would get lost in a frenzy of headlines about tax bombshells.

Even without the headlines we live in a dangerous era of extreme mistrust. Some voters turn against those they elect and, most fundamentally, do not trust them with their money. But what if they had a direct stake in a decision as to how their money was spent? Suddenly the dynamic changes altogether.

The referendum I envisage would be far removed from the mad one on Brexit. A prime minister would offer to facilitate investment in the NHS equivalent to levels in similar countries and to provide a national care service for the elderly of the highest standards, as in Norway, where the wealthiest plead to live in state-run institutions because they are the best available. A government would explain the costs and the tax rise required to pay for them. But the referendum would not be about a prime minister, the government or the opposition. It would be about us, our priorities. The politicians would be ready to act, but equally they would be ready not to act. They would insist that it is up to us.

The referendum campaign would be as much a scrutiny of the providers. Are they efficient, will they spend every additional penny wisely? It would not be a highly charged campaign where political careers are at stake.

If the referendum were lost, the voters would have decided they prefer a lower level of taxation and poorer health provision, while being willing to busk it in terms of elderly care. Governments would have to start charging for more services, and private insurance schemes would flourish. If a majority backed a tax rise to pay for improvements, the entire electorate would have a stake in making sure that what follows delivers good value for money. The scrutiny would not just be on parliamentary committees, the media and the rest. The voters would be keeping a close eye on what happens next.

The drawbacks are many. The Treasury hates any form of earmarked taxation, let alone a tax rise based on the vagaries of a referendum. And why should voters back a tax rise in a referendum? But there is no easy way through the barriers towards civilised provision of health and elderly care services, and this provides a route. The tax-and-spend hysteria of a general election would not be repeated in a referendum because the stakes are less high. The campaign would not be about electing a government.

Indeed, some anti-state newspapers with relatively elderly readers would have to be careful about being too vehement in their opposition. The framing of the argument could be transformative. Instead of the state being regarded as a stifling, profligate monster, voters will be asking of it: what can you do for us? Lost connections between those who feel “left behind” and the ones they elect might be rediscovered. When as chancellor Gordon Brown announced a tax rise to pay for NHS funding, polls suggested the move was popular. Voters make the connections if given the chance to do so.

Referendums on Europe are bound to be preposterous. They are about nothing and everything. Some people have raised the possibility of a “second” referendum on Europe, but we have had two already, one in 1975 and the vote last year. If we have a third, we will have a fourth. The multi-layered complexities of Europe mean a binary referendum is doomed to generate further crises.

Most immediately, there is no obvious solution to Brexit. There is a solution to an underfunded NHS and elderly care service. Yet no government can act without the permission of the voters. So a government sometime soon must seek their permission. I loathe referendums, but in this era of mistrust, government is paralysed. We need one urgently.

Another referendum? Yes, but this time on the NHS | Steve Richards

On one issue about the NHS, Jeremy Hunt is proper | Steve Richards

‘Jeremy Hunt’s interventions had been wholly understandable and deserve support. If there is an A&ampE calamity this winter it is his neck on the line.’ Photograph: Neil Hall/PA

Picture the nerve-shredding shock for hospital bosses who failed to meet their targets for accident-and-emergency provision. One day in the direction of the end of final year their phones rang and it was the overall health secretary, Jeremy Hunt, asking them what had gone wrong. There is typically a mountain of mediating bodies separating hospital bosses from Hunt, but there he was on the telephone telling them diplomatically to raise their game. This act of hyper-active diplomacy marks the biggest U-turn of the coalition and explains the noisy eruption of NHS-related stories at the start of the new 12 months.

For decades governments have sought with a naive evangelism to move away from Aneurin Bevan’s principle that if a bedpan dropped in a hospital corridor the reverberations must echo in Whitehall. The Conservative wing of the coalition had meant to make a revolutionary leap away from the principle. Prior to the final election I attended meetings in which the then shadow cabinet and external professionals discussed how to devolve energy as far away as possible from Whitehall to personal customers of solutions. In fairness to Andrew Lansley, then the shadow health secretary, he was fairly open about his objectives. When some thing went wrong in an person hospital or a local location he must not be appearing on the Today programme due to the fact responsibility would lie elsewhere. Other frontbenchers were equally clear. They had been going to move the levers away from Whitehall. When a bedpan dropped it would not be a matter for them.

If at these genuinely exploratory and thoughtful meetings they had been advised that a Tory overall health secretary would be phoning personal hospital bosses from Whitehall they would have all necessary urgent medical consideration.

Hunt’s cellphone calls frame one of many clashes between the well being secretary and those who think they must be operating the NHS. Shortly ahead of Christmas, Sir Malcolm Grant, the chair of NHS England also complained that Hunt was striving to micro-control. Grant advised the Observer that politicians ought to end meddling in the NHS at a time when clinicians had been supposed to be in charge. From his division in Whitehall, Hunt was taking a keen curiosity, also keen according to the mighty quango, NHS England. In both circumstances Hunt’s interventions have been wholly understandable and deserve support. If there is an A&ampE calamity this winter it is his neck, along with David Cameron’s, that is on the line, much a lot more than those of the hospital bosses or the largely anonymous figures at NHS England.

If a huge services is presented cost-free at the stage of use, paid for completely by taxpayers’ income raised centrally with the degree of investing also determined centrally, there is no way close to it. The elected overall health secretary has at least a degree of accountability and a substantial degree of accountability when a bedpan rattles.

But, despite the fact that Hunt’s assiduous focus is reassuring, it heightens the level of chaotic confusion as to who is responsible for what in the NHS. The government can’t simultaneously create a framework in which it seeks no longer to be immediately responsible for provision, dismiss the so-referred to as “target culture” and then commence phoning individual hospitals demanding that they meet targets.

The messy ambiguity is at the heart of each debate on the NHS. This week the Guardian published a letter from ten NHS organisations asking for significantly less focus on the adverse aspects of the NHS, implying that Hunt has used scandals this kind of as these at Mid Staffordshire to paint an unnecessarily bleak picture. Again this is not honest on Hunt who had each and every lead to to react lengthily and extensively to scandals that raised wider issues. But the bewilderment from the army of NHS organisations is understandable in the sense that they have been informed repeatedly they would be allowed to get on with running the wellness service with out interference from ministers.

The exact same confusion applies a lot more overtly in an interview provided this week by Dr Clifford Mann, president of the School of Emergency Medication, complaining that ministers had ignored warnings about an A&ampE crisis as they were “tied in knots” implementing their original contradictoryNHS changes. Mann captures the inevitable chaos of the early attempts by coalition ministers to devolve power and now their desperate attempts to assert control.

In this column I refer to Hunt, NHS England, the Care High quality Commission and ten separate NHS organisations. I have hardly scratched the surface. There are as well many institutions accountable for the NHS, with no one particular realizing very who is accountable for what. But at least we have some clarity. Ultimately and rightly the elected health secretary is accountable. Hunt’s mobile phone calls symbolise the finish of the fantasy, begun by New Labour, that taxpayers ought to fund the NHS and then have no mechanism to hold the government to account for the subsequent delivery of healthcare.

On one issue about the NHS, Jeremy Hunt is proper | Steve Richards