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The real public services debate By Martin McIvor May 2003 To claim that history is on your side, as if the path of progress always points in one direction only, can be an effective polemical trick. But if you start to believe it yourself it can be your own thinking that gets stuck in a rut. Faced with a looming parliamentary rebellion this week over legislation to create Foundation Hospitals, Tony Blair insists he will not "depart from the path of reform". "Public services can either be renewed, which is what we want, or dismantled, which is what parts of the right want, but they will not stay with public support unreformed", says the Prime Minister. Health Secretary Alan Milburn last week set out a similarly "stark choice" between "cautious incrementalism" and "fundamental transformation". "The direction of travel is now set - and it must not be reversed", he insists. Rather, we must press ahead with reform with foot firmly "on the accelerator and not on the brake". This is disingenuous - the government's proposals have run into opposition from former ministers and moderate Labour backbenchers not because they are against any reform to the NHS. Most, in fact, would be wholly sympathetic to some vision of devolution and democratisation - the end of "top down", "one size fits all", "Whitehall knows best" paternalism - that the government invokes in its defence. The central charge from critics is rather that such language serves only to obfuscate a very different underlying agenda - the creation of a new commercial market in health services that has little to do with real professional empowerment and user participation. The fundamental idea behind the establishment of Foundation Trusts is that some and eventually all NHS hospitals become independent of the Secretary of State and responsible for their own financial viability, effectively competing for NHS business with each other and with private providers (who may themselves be granted "Foundation" status). The premise, that this will incite new powers of entrepreneurialism and innovation from Trust executives and managers, is at best unproven. But we have the experience of the Conservatives' "internal market" experiment to demonstrate that breaking up the health service in this way will increase administration costs, inhibit cooperation and the sharing of good practice, and undermine any notion of designing a strategically planned and "joined-up" network of care services. Most insidiously, as standalone entities Trusts will be under pressure to minimise their financial exposure and maximise sources of revenue through commercial ventures and deals with the private sector. It was in response to such concerns that various amendments to the original proposals have been announced, from restrictions on the amount of private practice Foundation Hospitals can undertake to new structures of "stakeholder governance" via elected boards. But as Professor John Mohan of Portsmouth University argues in a paper for Catalyst, the reforms still run against basic principles of an equitable, comprehensive and integrated national health service. Under the Bill now before parliament there remains scope and incentive for Foundation Trusts to seek competitive advantage over other hospitals by drawing away scarce capital and staff, "cream-skimming" the more economical patients, shifting costs onto other agencies, retaining operating surpluses and selling off assets, and bringing private sector involvement right into the heart of clinical services. Moreover, it is clear that the superficial layers of community representation, belatedly superimposed on what is essentially a new internal market, are simply too weak and underdeveloped to contain the powerful dynamics of competition and commercialisation this restructuring will unleash. As the Catalyst paper argues, overseas experience shows how even fully mutualised "non-profit" healthcare providers can find it hard to survive in a market environment without abandoning "important elements of their historic mission like their community orientation, leadership role and capacity to innovate", and becoming increasingly indistinguishable from their profit-maximising competitors. It would have made far more sense to start with the goal of a more democratic and decentralised health service and look for genuinely "bottom-up" ways devolving power and engaging local service users - by democratising Primary Care Trusts, for example, as many have suggested. A radical set of proposals for creating local accountability and strengthening community "ownership" was tabled by the Commission on the NHS chaired by Will Hutton - but the government abolished the Community Health Councils who had set it up. Meanwhile clinical professionals and health workers have been totally sidelined by the process, their alienation reflected in the frustrations expressed by the trade unions and professional bodies representing them. We needn't look far to see how an alternative reform agenda might work in practice. In Scotland, where Labour held onto its majority in the Holyrood parliament this week, the Executive has just published its own "blueprint to transform Scotland's health services". Health minister Malcolm Chisholm affirmed that increased investment "will only deliver the necessary improvements if it is matched by a programme of modernisation that is based on the needs of patients." The White Paper promises "a health service that is fit for the 21st century", characterised by "patient-centred services" and - wait for it - "decentralisation of decision making and an end to traditional command and control approaches". The rhetoric sounds familiar, but the policy and the politics are refreshingly different. For Scotland is dissolving the separate NHS Trusts created as part of the Tories' internal market, rather than entrenching their independence as in the Foundational Hospitals scheme. At the same time the Scottish plan - developed in close collaboration with health service unions and local partners - institutes a real devolution of "power and responsibility to clinicians and patients" by giving new autonomy to "frontline units" and involving the public through a new Scottish Health Council and better links with local government. Nothing could more clearly demonstrate the multiple meanings of "modernisation", the different routes that "decentralisation" could take, and the lesson that integrated networks of cooperation and support offer the most promising basis for real flexibility, innovation and responsiveness on the frontline of service delivery. Blairites will perhaps cite the specificities of the Scottish national context in reply. But this only confirms that their programme for public services is less about "devolution" and "responsiveness" as such, and more about playing to an assumed Thatcherite bias in English politics by seeking to emulate the attractions of the private sector, blurring the boundaries between consumerism and social citizenship, and picking fights with the defenders of the public, its employees included. The real question for debate is whether this insistent mimicry of the right does indeed constitute a viable political strategy for retaining and rebuilding popular support for tax-funded public services. Labour has embarked on a historic journey of public service renewal that presents the most essential political challenge of its term of office. The MPs raising voices of concern this week are looking not for halts or u-turns, but for new directions. Published in The Observer, 4 May 2003. Martin McIvor is Director of Catalyst. |
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