All the attention recently has been on grand strategy. What's Donald Trump going to do with the American Presidency? Who's going to win the French Presidential election, and might a Le Pen victory break up the Euro and even the European Union? What's the future for the North Atlantic Treaty Organisation? What should NATO's relationship with Russia look like? Where should Britain look for its trade partners now it's leaving the European Union? All critical questions - all worthy of the obsessive comment that they've attracted.
Little noticed amidst the great storm of populism's great disruption has been a mounting drumbeat of trouble in Britain's public services. They've been able to bear the brunt of public service spending restraint for a long time: partly because in the initial stages there are always some cuts to be found, partly because of the commitment and professional ingenuity of public sector workers, and partly because the Government slowed down the pace of cuts after 2012/13. But now the knife has passed through the muscle and - after a pause - is poised to hit the bone.
Take the National Health Service. There's scarcely anything that Britons as a whole agree about these days, but access to good modern health care, free at the point of use, is probably one of them. Here Theresa May's Conservative government, so popular overall for its approach to Europe - and the paucity of any alternative - is about to run into trouble. The NHS is being asked to save £22 billion over the next few years, and that just looks undeliverable. These 'efficiency savings' will involve in many parts of the country a radical transformation of hospital provision, which in some areas will be scaled back in ways that voters perhaps have not yet quite realized. The NHS has been rising up voters' lists of unprompted concerns for some time, and it's now started to leap right up to the top of citizens' concerns. It's the most-named as being one the most important issues in the latest Ipsos-Mori figures, and it's the second-most critical single issue after Brexit itself.
Why? Well, partly because it's all very well to say that you're going to reshape hospital services, get more efficient, and collect services together at one single hub. But when you come to look at what that means on the ground, it's going to be pretty unpopular. Mrs May is finding out about all that right now, as she tries (and fails) to defend the closure of local maternity services in Cumbria - much to the opposition of local people about to vote in the Copeland by-election. Then there's the question of what you're going to do once you close all those beds. If there was a consistent and ordered plan for social care, and for looking after elderly and vulnerable Britons, all this would make sense. But there isn't. The Government does not seem to have the merest clue what to do about the ageing population and its likely increasing need for care at home and in the community. There's nowhere near the resource in Britain's health system to cope now, let alone when hospitals try to push demand back onto local authorities who hardly now know which way to turn. Britain's recent winter health service beds crisis is just one more proof of this outstanding fact.
Take a look at the historical averages. Britain has actually spent rather little on health care since the Second World War, relying on a notoriously tight-fisted Exchequer for the money needed when other European countries had smaller, more multifarious legions of social insurance contributions to press into use. But, usually, inputs went up. Sometimes they went up fairly quickly, as in the 1960s between the Hospital Plan of 1961 to the spending cuts that followed devaluation and the economic crises of 1967-68. There was a bit more money at times during the Conservatives' long period in office between 1979 and 1997, notwithstanding the tough, painful, often inefficient 'savings' of the early 1980s and 1990s. Then there was a massive, massive splurge under Tony Blair and Gordon Brown, bringing satisfaction with the NHS to record highs, and cancer treatment (among many other parts of the field) to an impressive and modern pitch that UK citizens probably thought they'd never see. Now? The Government is forecasting a pitiful, halting crawl forward into the next Parliament. It's not enough. It's never been enough before, and it certainly won't be in age of new technology, novel techniques and new drugs.
Whitehall and Westminster's spending plans simply won't be enough politically either, as the winter beds crisis partly caused by social care's incapacity and the Government's problems in Copeland demonstrate. Already the politically-damaging images have begun to turn up. People lying on trolleys in corridors. Babies sleeping on a couple of plastic chairs. At the moment, yes, the official Opposition is totally useless, and can barely get a press release out, let alone hold the Government to account on these great issues. If you think shouting 'evil Tories want to privatize the NHS' amounts to real opposition, you'll be surprised when there's a Conservative landslide. Very few people will now be surprised by that outcome, but it could change. Labour with a new leader, a new communications team, a more competent grip of language and style, could be a threat to the Government, even in 2020, and certainly in 2025. If the NHS is falling apart at the seams, just as it appeared to be in the mid-1990s, Labour can grasp that lifeline. It won't bring them back to power on its own, but it will grant them the oxygen they need to survive as a national party of government.
The NHS is going to need more cash. Chancellor Philip Hammond has a bit more money at the moment, given that the economy is a little bit stronger, post-Brexit, than some commentators believed it would be. He's going to have to spend some of his reported £12bn windfall. But that's just going to be a short-term fix. Unless British politicians as a whole can establish some sort of cross-party agreement that will last through many Parliaments - settling the vexed question of social care, building up some form of social backing for and emotional capital in more NHS spending - then that money will just be a sticking plaster.
