Bernie Sanders' brother on healthcare

Larry Sanders on the NHS, social care, and more.

Most Americans have heard of Bernie Sanders—TOO BLOODY RIGHT, I scream at no one—but not many are familiar with his older brother, Larry, who has lived in the United Kingdom since the 1960s. If they do know of him, it’s likely from the incredibly heartwarming video of a tearful Larry casting a nominating vote for Bernie at the DNC in 2016, where Larry was a delegate for Democrats abroad. During Bernie’s 2020 run, there was a handful of articles in the American press about Larry, stumping for Bernie in London and giving quotes about what his little brother was like as a boy.

But I have a different interest in Larry. Until very recently, Larry was the British Green Party’s spokesperson on health and social care, and for decades, he has been an advocate for a stronger social care system in the UK—akin to what’s known as long-term care in the US, basically referring to publicly financed care for the disabled and elderly—in Oxford, just down the road from where I grew up. (In fact, the first time I ever heard about Bernie at all was when my 11th grade government and politics teacher told us that there was just one socialist senator in the United States—and that his brother was a Green Party councillor in Oxford.) The social care system in the UK is far from the equitable, guaranteed provision that characterizes the National Health Service. It’s not uncommon for local or even national British papers to feature articles on individuals deemed not disabled enough for social care spending or, more commonly, who have been denied other disability payments, like those administered by the Department of Work and Pensions for disabled individuals who can’t work. Where the NHS is still a point of national pride, the British government’s record of caring for the disabled is a shameful thing, compounded by years of Tory austerity.

And so today’s Sick Note interview is with Larry Sanders, the cool (maybe even cooler?) older brother of Bernie Sanders, whom Larry exclusively calls Bernard. We talked about the beautiful heart of the NHS, and how it has been attacked; the cruelty of means-testing access to social services in times of desperate need; and the necessity of single-payer in the United States. We didn’t talk a lot about Bernie, because today, it’s the Larry Sanders show.

Sick Note: I think it would be useful to explain how you ended up in the Green Party rather than the Labour Party—obviously, in the US, I think the Green Party doesn't have quite the level of sort of importance, frankly, that it does in the UK.

Larry Sanders: Well, I was in the Labour Party actually, with difficulty. When Bernard got elected mayor in 1981, I came back from his inauguration and I thought, I need to get active! I had been politically active but not in the party, I'd been very active in the nursery campaign we had— a Conservative county council wanted to close all the nurseries in the county, a huge number of places. Crazy idea. So that had been my real first main activity in British politics. And we succeeded, we saved about 80 or 90 percent of the classes, which was an unusually big victory for this sort of thing. So when I came back, I applied to join the Labour Party. And the Labour Party said, we don't want you! Take your money and go away, because you've been consorting with Trotskyists!

So I was learning something about the Labour Party. Anyhow, I appealed, and I got turned down. I appealed finally to the highest court of appeal and they let me in. So I was active in the Labour Party for pretty much the whole of the 80s. The early 90s I was hither and thither, I was in America for two years at different times, I really wasn't very active. I could see what was coming with Blair, it was not very difficult. And then the next thing that got me connected with politics that tied up with the Green Party in ‘96/’97, I went to work for an organization called the Oxfordshire Carers' Forum, which represented and advocated for people who had disabled relatives, basically, mostly legal advocacy and advice.

The county council has responsibility for social care, so they were a large focus of my activities. The county council didn't have a dominant [party,] it was a coalition—I don't know if it included the Labour Party, it might have just been the Conservatives and Lib Dems. But the Labour group, most of whom I knew, because one of my roles in the Labour Party had been as a delegate from Oxford City Labor Party, to the Oxford county council members. So I knew a lot of them, good people and stuff, but they started doing those horrible things, because it was the Blair's first year, he decided to keep Thatcher's budget. And many of the people that I knew from my work were being—I'll give you an example, they were voting on getting rid of the night care service. So imagine who uses a night care service, you can't get through the night without help. You are very disabled person who's trying desperately to hang on to their own home. And so it's very hard to argue against this. And they there were, they were going to do away with it—not only were they going to do away with it, but because the law hadn't changed, these people remained entitled to it. So the only way you could get rid of the cost, the money is really what they were after, saving the money. The only way you can do that is by somehow deceiving the people to see that because the services had been taken away, their rights to a service had also been taken away, but it hadn't. All that meant they would have to do it one by one, at crisis points. So, it was deception on top of destruction. And my Labour Party colleagues were raising their hand. The only person saying the kind of things I would at that point was the Green Party councillor.

Sick Note: What led you to sort of focus on health and social care?

Larry Sanders: I suppose, like, most Americans coming to Britain, the NHS really stands out. At lots of meetings, despite the small number of Americans in any given population, half the people in the room will be Americans, you know, when it's some kind of NHS issue. So that was obvious to me. The social care thing I suppose stems more from when my wife was ill. And we got marvelous help from the NHS, from the GPs, it was really terrific. And nothing from social care, it was very difficult and I did a lot of stupid things. We had two children 10 and 14, so they weren't babies but they were young and there was a lot of practical stuff we needed. So I became very aware of all that, and what it could be and what it wasn't. And it really almost immediately struck me as, it's a house divided, it's got to go one way or another. You have a free NHS whose target is top notch service everybody. They don't always meet it, but that's the principle.

And then you've got a social care system which is charged, which is means tested, and which is not required to meet everybody's needs. Although some of the legislation were very good in words, but there was very little legal defense when you got into court. In fact there was a desperately sad case, where the House of Lords at that point, acting as a Supreme Court ruled three to two on whether local authorities could take their budgets into account in assessing the need for social care. So that probably was in my mind, that there's something here. And then later, in the late '90s, I still there was an advertisement I saw for the job working for the Oxfordshire Carers' forum. And I thought, ah, that really sounds very good. And it was very small organization, there were only two paid people, me and the Secretary, and all the other active people were people who were caring for relatives and friends and stuff. So I joined up. From the mid '80s, I had a sense of what was there, and what was not there, and then from '96 on, almost everything I've done has had a social care element in it.

Sick Note: I think Americans do understand that the NHS is free, although a lot of them I think even when I say that to them, they're like, wait, but really free? But with the social care element, I think even a lot of Brits don't realize how patchwork it is until they until it's too late until they need it.

Larry Sanders: Absolutely.

Sick Note: And so I was wondering if you could talk a little bit about the the impact that that means testing process has on people, when they come to the point where they need this care, and then suddenly they have to prove that they're destitute enough or whatever to need it. Can you talk about how that actually works in practice?

Larry Sanders: Well, it's a question of theory and practice. The theory is that you're not supposed to, they're not supposed to say a word about money until they've assessed the need. In practice, of course, it doesn't work out that way. But what you're saying is very significant—I think about half the population doesn't understand that it's different from the NHS, they expect to be treated, they think they have an idea of how the system works, and they're wrong. So they get hit with that. And it's usually kind of a mess, what they get hit with is not only a means test—and you do have to be very poor, you have to be very nearly destitute to qualify. But there's a needs test as well, so you have to be very poor, and very disabled. The whole idea of preventive work, of anything that's not desperately needed, crisis now, you're not going to get help.

So you face a system, which doesn't feel—the first way you get to know about it is that it's telling you, "No, go away, you're not sick enough, or you're not poor enough." And you have to argue, you turn to the care system, when something dreadful is happening. You know, you're not out of the blue saying, "Oh, I think I'll phone them up and see how they respond." What happens is that a relative of yours has a desperate disease, has Alzheimer's, a learning disabled child is born with enormous needs. And in that moment, of need and fear and all the rest of it, instead of getting a helpful sympathetic response—which you will usually get from the NHS, you turn up, the GPs 90 percent of the time will be listening and thinking and working with you—here you're not, you're getting the exact opposite. You're getting a kick in the teeth.

And if you're very assertive and you know your rights, you'll fight and you'll go here, and you'll go there. But the normal thing when you talk to people who've gotten these services, "I had to fight every inch of the way." So it is the combination of the fact we often don't get what you need but it also is at a time when you really need support and help, you get the opposite. It's interesting, despite the fact that it's never become a big political issue, I'm not quite sure why, but if you're in a room 20 or 30 people you say, "How many people here have felt that they've had a hard time with social care?" Half the room looks, up and the stories will start, and you'll have to say, "Shut up. I just want to prove a point, I'm not interested." [Laughs] But it is like that. I think it has a very powerful negative impact on the whole country.

Sick Note: And I think it's also important in making people distrust the role of government in general, to think that the government couldn't possibly help them because the one time they did need desperate help, and to them, it feels like the most desperate situation that they've ever been in in their life—and it is—the government said, "No, piss off. We don't we don't do that," or you have to call back on Tuesday, you know, that kind of that kind of stuff.

Larry Sanders: Yes. And, of course, it's gotten worse and worse with over the last 10 years , the systematic destruction of what was a core service. They say, "we'll call you," kind of thing. And often the call the call comes after the disaster happens.

Sick Note: During my lifetime, the first few years of my life were under the Tories, and then under Labour, and then back under Tories. And I actually moved to the US just about when when the Tories took office, and so, I've been away from a lot of the really bad downfall of the NHS and I imagine social care alongside that. But certainly during my lifetime, it has been a downward trajectory the whole time, including under New Labour. And so I was wondering if you could talk about a couple of the basic things that Labour and also the conservatives have done to sort of dismantle that system.

Larry Sanders: Well, starting with, with the NHS, what was quite a simple system—there always been flaws in the NHS structure, it never know what to do with local input. So you have a system that run from the center has some very good elements locally, but hasn't got a real way of local people getting into that system. It's had one thing after another, and none of them really work. But it's very coherent, easy to understand. It's one system, everybody's entitled to full care. And then Labour got these ideas. The suspicious part is a large part of the reason for those ideas was an intention to move onto dismantling and privatizing. In fact, the NHS has not been that much privatized, about 90 percent of the work is done by NHS staff.

But they set up these foundation hospitals, which gave each hospital trust much more power over its own doings, disconnected. So instead of having one system in an area, you could have three, four or five systems in an area. And then there were systems brought in at various times; each of these things have had stages. Foundation hospitals sounds very strange. What is a foundation hospital? What is a foundation? I mean, it has got a meaning in English, but it's not a common word. Turns out it's a translation of a Spanish word—somebody went to Spain, when there was a right wing government dismantling their service, fundación I guess, he came home and translated it into English, and nobody knew why. But it was part of this fragmenting of the service—you can't sell off a service that covers the whole country and 60 million people. You can sell off a service that covers half a million or a quarter million much more easily. So that was one of the kinds of things. The fragmentation was under Labour. The good thing that Labour did was halfway through his term, Blair decided to put more money in so there were a few years where the service had average amount of European spend per capita, which was very good. It worked.

Then the Conservatives came up with a whole system where virtually every new project, and then eventually every old project as well had to be tended for competitive bids. One of the things this meant is that you had all these very skilled, professional people, doctors, and all sorts of other professions spending a huge amount of time bidding to get the service that they were already providing. And they're often bidding of course against private companies, private companies could bid—in fact, it was required to be fair, they were entitled to. The private companies are not medical companies, they're bidding companies, their professionals are professional bidders. So you have this vast amount of money, time, and effort going into bidding for these services over a fairly short period of time. I can't remember, if they were all the same period, but every once in a while you went back into it, you'd need to say, oh, we've got ten years to run the service. And, of course, in some cases, five and then growing up towards ten percent, they were lost, they went to somebody else.

So instead of one group running services in an area, you had two, three, five, ten, twenty. And of course, each of those things make it much more difficult to run an efficient service. So you've got a combination, a certain amount of privatization, a tremendous amount of work, and fragmentation. It's always been bad for the system. I can't see any particular reason why that kind of competition is good. I could tell you why it's a phony to start with, because you can't really have competition, because to really have competition, you'd have to have two sets of hospitals. Otherwise, what are you bidding for? All right, come to my house, but we do it better. But you don't have a hospital? Oh, sorry. We don't have a hospital. Well, we'll come and run your hospital. The competition is just nonsense. But it's very demoralizing and disruptive.

Sick Note: Yes, exactly. I think that is the big takeaway—it's very like other dismantling of public services, both here and in the UK, which is just to make the government worse so that people won't want it anymore. It's like the post office—make the post office worse, and then say, "Oh, isn't the post office terrible? Don't you like FedEx more? What if we just had FedEx do it?" That sort of thing. Well, maybe if you tried to make it good instead, that would be better, you know?

Anyway. One thing I'm interested in—it's hard, because we've talked a lot about the way the NHS is being underfunded, and undervalued, and so on. But then you have the contrast to America, where it is just obviously, objectively even worse, you know, that the health care system is just miles worse. Do you have other any sort of particular things that you wish Americans knew about the NHS and the way it works?

Larry Sanders: Well, the first thing is, there is this very deep business about how public organizations just can't work well, and every day, the NHS works well. It works better if it gets enough money, it works better if it's not being assaulted. But it just... You get up, you don't feel well, you phone up your doctor, usually, up until recently, you get to see somebody quite quickly that day or the next day. You go see somebody who knows that 99 percent of the time what they're doing, is more or less sympathetic, who is part of a system that can deal with you. You need tests, you'll go for tests, you need immediate access to whatever care or operation, whatever, you get it. This is when it works well, but 90 percent of the time, it works well.

And I want to say to people: It is such a relief not to wonder what your what your insurance covers. Whether you made the right choice about leaving things out because you didn't want to pay a larger amount for your insurance. And I think it's also a great pleasure certainly to me, you walk into a room in your surgery. And it's full of all sorts of people. And I like that better. First of all, I wouldn't like to be thrown out of a place because I wasn't rich enough. But I also don't want to be in a place which everybody poorer than me is not getting access to. So there is something very, very nice about it. And I remember I said something on television, and I went back to it and I said, Wow, that was really sensible. I said, the NHS is not just a method of delivering health service. It's a statement that everybody in the country makes to each other, when you're in that difficulty, your country will stand behind you, your society is on your side and wants to help you when you're facing the big challenges of your life. And I thought, he's a very clever guy to say that. [Laughs] I'm sure it's been said many times, but—And I cry. That's my other big thing public speaking is I cry a lot. Which Bernard always thinks is funny.

Sick Note: No, I think that speaks extremely highly of you as a person, because this stuff is very moving. I think that's beautiful. The last thing I would ask is just, it's a pretty grim time to be a person who wants single-payer in the US. The last year was really difficult, obviously, because of Bernie losing, and then the pandemic happening, and there was this sort of sense of like, what more evidence could you need of the necessity of single-payer, and it feels like even the idea of a public option is slipping, there's no chance now. And so it's a difficult time to be an advocate for this policy, what would you say what would be your advice to Americans who want single-payer?

Larry Sanders: It is very hard. The central thing that comes to my mind is the sheer expense and waste of the system. One reason why these options are not relevant is that they build on top of the whole insurance system, they pour more money into it, I think somebody said it's like pouring money into a leaky bucket—it flows through, no matter how much you put in, somebody else gets the advantage. Anybody who says that you can't afford a universal service is just mistaken, and probably deliberately misleading because the reason like the American system costs so much more, two, three times per capita more than British system, twice any other better-financed system, is that insurance—and I remember writing an article once, so I tried to look up the things about cost, and as you would expect, the actual insurance system itself spent I think, at that point, 200 or 300 billion a year, all which was unnecessary. If you have a single payer you sign people up, it costs about 10 cents per person.

But what really struck me is to actually they wasted more money on providing services that weren't necessary, so people had good insurance were being tested too many times, getting too many x-rays, too many scans. Sometimes unnecessary operations in gray area things like hysterectomies, some areas with good service have a very low number and some have a very high number. Now, any operation is not good for you. It's good if you need it, but in itself it's not a great thing for the body. So it not only is very expensive, but it's damaging. From beginning to end, the whole insurance system is a scam, and a good system would cost so much less. And all the things that are in Bernard's bill, which include long term care, which is the American phrase for social care, so we come back round circle. You could have all those mental health services and dentistry services and all the rest, could be afforded without an extra penny. So it's the bargain of the century.

Sick Note: I agree. And that's the thing that I wish to convey to Americans too, is that I do think that just growing up under a system like this one in the US, it's hard to imagine a system where it could work. And it's not to say that you can point to the UK and say everything is working perfectly, but to say, no, you actually can have those things, you could go to the doctor, and it could be free, you could go to the doctor and not worry that they're going to try to upsell you on a knee surgery or something that these things are possible, I think, is the thing that, even that it seems like such a minor, or such a sort of basic thing to try to convey. And that's I guess, that's the overwhelming thing about the scale of the challenge here, is that it's a really basic premise, like—no, this thing that we're talking about could happen.

Larry Sanders: And there's a history. In the 1940s, there were polls taken in the UK and in the US. And there was a very similar support for a National Health Service in both countries. The American doctors won at that point—the British doctors lost—at the cost of trillions of dollars, and more importantly, God knows how many deaths and wasted lives because of that failure and a different political outcome in the 1940s.