machines,markets and morals - compassmachines, markets and morals: the new politics of a democratic...

Machines, marketsand moralsThe new politics ofa democratic NHS

Neal Lawson

Contents Page

Acknowledgements 2

Executive summary 3

1 Introduction 6

2 The NHS as a political entity 12

3 The NHS as a machine 18

4 The NHS as a market 22

5 The NHS as a paradox 27

6 The NHS as a democracy 30

7 Conclusions 41

Endnotes 44

MMaacchhiinneess,, mmaarrkkeettss aanndd mmoorraallss The new politics of a democratic NHSNeal Lawson

[2] www.compassonline.org.uk Email: [email protected]

MMaacchhiinneess,, mmaarrkkeettss aanndd mmoorraallss:: The new politics of a democratic NHS

Acknowledgements

I would like to thank the following people forcomments on an early draft of this paper: BobHudson, Colin Crouch, Alan Finlayson, MartinRathfelder and Peter Hunt, Judith Wardle and BrianCox.

Others I am very grateful to are John Appleby, PaulCorrigan, Anna Dixon, Dave McCoy, Ben Page,Allyson Pollock, Dick Sorabji, Simon Stevens, TimStone and Richard Wilson for giving up their valuabletime to allow me to quiz and question them.

I’d also like to thank Anna Coote for spending timetelling me that this should be about the prevention ofhealth problems and a decisive movement away fromthe NHS as a sickness service. Anna is absolutely right,not least because a focus on resources aroundprevention would help equalise health inequalities.There is an excellent article on this by Anna on this inRenewal (Vol. 11, No. 3). But this piece of workturned into a political analysis about thedemocratisation of the NHS – a process which I hope

that will lead to Anna’s vision of a service based onsymptoms not cures.

This is essentially a political pamphlet aimed atgetting the left thinking about the politics of publicservice reform. It is not a managerial treatise onhealth policy. It is about the underlying philosophyof the NHS in particular and public services ingeneral and how we perform that difficult trick ofpursuing ‘traditional values in a modern setting’.

Finally I would like to thank the public serviceUNISON, which sponsored work on the pamphlet,and in particular Martin McIvor at UNISON, whogave invaluable help and advice on an early draft.

Responsibility for the final words of course restsentirely with me.

NNeeaall LLaawwssoonnChair of [email protected]


www.compassonline.org.uk Email: [email protected] [3]

! After the financial ravages and upheavals of theThatcher years, New Labour came to save the NHS.Huge improvements have been made over the lastdecade. By redefining staff and professional rolesthrough Agenda for Change, developing new pointsof access through NHS Direct or walk-in centres,finding ways of involving staff and patients in moreimaginative and better managed trusts and inparticular massively increased funding the NHSunder Labour has been saved.

! At least for now. The service faces huge social,economic and political pressures. Financial problems,closures, job losses, low staff morale and patientuncertainty about the quality and extent of service alladd to an air of crisis about the service. The Tories arevigorously challenging Labour on its home turf.

! But Labour has a second chance to breathe newand lasting life into the NHS. Next year the NHScelebrates its 60th anniversary. Now it faces theopportunity of a new Prime Minster and a newpolitical leadership. Gordon Brown has described the

NHS as his ‘priority’. Alan Johnson, the new Secretaryof State for Health, has announced a year-long reviewof the NHS under the leadership of Professor LordDarzi and there are expectations of a new NHSconstitution being published. Johnson has called it a‘once in a generation review’ into the future of theNHS.1

! But the opportunity is only valuable if it is taken.Initiatives like polyclinics may improve the service butthere are more profound and structural issues thatneed to be dealt with if the NHS is to become apractical and political success for Labour. Theestablishment of 14 private sector companies,including US giant UnitedHealth, to take over thecommissioning of the bulk of NHS services is a veryworrying trend back towards privatisation.

! There needs to be a profound change of politicaland cultural direction, not just a change ofpersonnel at the top. The predominant method ofNHS reform, focusing either on centralised targetsor the commercialisation of the service, has created a

Executive summary

TThhee ffoouurr bbrrooaadd mmeetthhooddss ooff ggoovveerrnnaannccee

CCEENNTTRRAALLIISSAATTIIOONNWhat: Targets, plans and regulationWhy: Important because it is the basis ofequality; those who get the worst services wouldlove a big dose of uniformity if it meant theirservices were raised to the standards of the bestHow: As little as possible to ensure the maximumamount of equality

DDIIVVEERRSSIITTYYWhat: localism, working with or learning fromprivate and third sectors, organisational autonomy,challenge, contestability and choiceWhy: Important for innovation and localinvolvement and freedom to experiment, to learnfrom best practice and from mistakes; localismalso allows for setting of local prioritiesHow: As much as possible commensurate with thedemands of equality

PPRROOFFEESSSSIIOONNAALLIISSMMWhat: Ethos, training, judgement and experienceWhy: Because doctors, nurses and other staff haveunique expertise and experience that will always bean essential ingredient of any successful programmeof modernisation, and can work on long-term goalsHow: As much as possible while ensuring it isaccountable and responsive

VVOOIICCEEWhat: Participation, democracy and co-productionWhy: Because it is the only route to sustainablereform improvementsHow: As much as possible, in all circumstances and atall times up to the point that citizens and workerswant no more of it; care must be taken to ensure allvoices are heard otherwise there can be a clash withequality.



cocktail of fears about health inequalities as well as ahost of unintended consequences and inefficiencies.It has led to the alienation of staff and widespreaduncertainty among the public.

! Crucially, the long-term foundations for a reformand modernising agenda based on the enduring valuesof the left – equality, liberty and solidarity – have notyet been established.

! The improvements that have been made come inspite of the politics of centralisation andcommercialisation, not because of them.

! That is because neither the market nor the centralstate machine can get to grips with the essentialparadox at the heart of the NHS between our desirefor equality and the need for diversity. We want theNHS to guarantee equal opportunity for health andwellbeing to all, but as pluralists we also wantexperimentation, innovation and local input fromworkers and patients. The two are at odds with eachother. This paradox cannot be wished away but has tobe managed.

! There are essentially just four types ofgovernance decision that can manage the NHS. Allare necessary, but what matters is the balancebetween them. The challenge for the new leadershipof the NHS is to establish a framework in which theparadox of equality and diversity can be bestmanaged between centralisation, diversity,professionalism and voice.

! The central argument of this pamphlet is thatthe management of the equality–diversity paradox isbest executed through as much direct involvementas possible of the people who produce, create anduse the service, to improve the service throughvoice, not just through exit.

! The democratisation of the NHS, using all thetools of voice, participation and empowerment,could revolutionise the experience of the patient andthe efficiency of workers. In addition it couldestablish an even more popular basis for futuresupport and funding of the NHS.

! But this requires, above all else, a shift in theculture of leadership of the NHS, away from theheroic CEO model of command and control(especially where it commands greater use of theprivate sector) towards a more collegiate, gradualbut purposeful reform process that sees the designand redesign of the service based on the direct inputof all the people who work in and use the NHS.

! The types of democratic reform that now needto be considered and trialled include:

* general practices to have annual generalmeetings of patients, and virtual notice andcomplaints boards, and the mutualisation of generalpractice services

* hospitals to be held to account throughcommissioning

* general practices and primary care trusts (PCTs),advised by the new health and social care regulator

* PCTs to be subject to local accountabilitythrough a range of possible measures like localcouncil overview and scrutiny committees, theelection of local health boards, the election of PCTCEOs, the merger of PCTs and local authorities,and the election of health regulators

* national governance of the NHS throughcitizens’ juries with binding decision-makingpowers; the implementation of a NHS charter orconstitution decided by the public, patients andworkers

* the mainstreaming of co-production throughoutthe NHS and the development of methods such as8self-directed teams to ensure that staff and thepublic are consistently and coherently involved inthe design and redesign of health services.

! If the democratic impulse is not applied to theNHS then we will experience another round ofreforms that turn everyone in the service on theirhead once again – with little if any discernableimpact on service improvement. After its heydays in

Executive summary



the 1950s and 1960s the NHS has first beenpummelled by the wave of neo-liberalism that sweptthe country after 1979 and then by thedisorientation of targets, further re-organisation andcommercialisation under New Labour. The nextlooming threat is David Cameron’s vision of therebeing such a thing as society but it not being thesame thing as the state. The new Tories will claimthat the statist NHS is too cumbersome andcentralised. And they will have a point. But theirresponse will be to break it up and fill the gaps withthe third sector and more of the private sector. Butthis will decisively undermine the NHS as a vehiclefor the collectivist and egalitarian instincts of the

left. Labour must take this last opportunity to getthe politics of the NHS right – that meansdemocratising it.

! A report from the Department of Health inOctober 2007 on the health profile of the nationshowed that more people consider themselves to bein poor health than when Labour came to power in1997, and the inequalities between the north andsouth of the country are wider than ever.2 Stateintervention to redistribute and equalise lifechances is what the NHS exists for. Neither themarket model nor the machine model can achievethis goal.

Executive summary



Introduction

Why should I write about the NHS? I’m not adoctor, I’m not a health specialist and I’ve rarely everused the NHS (touch wood). The reason is that theNHS is probably the most politically importantpublic service institution for the centre-left.Comprehensive secondary schools run the NHSclose but have yet to find the same place in thenation’s heart as the NHS. The NHS is seen by theoverwhelming majority of British citizens as ‘themost valuable institution for this country’ – farmore important in this regard than Parliament, thepolice, the BBC or the Royal Family.3 The NHS isone of the institutions in which the values of the left– those of equality, liberty and solidarity, and theresolution of the tensions between them throughdemocracy – are protected, sustained and embeddedin our society. This pamphlet is about how the NHSfunctions in relation to those values now and how itmight function better in the future.

Those who support the principle of the NHS as aforce for equality and solidarity have been on thedefensive for more than two decades because of aperceived resistance to modernise. The issue is notwhether we want to reform and modernise butwhether change can be managed in a way that isaligned with left values.

We live in an age of autonomy but the NHS wasconceived in a world of deference. By that I meanpeople now want to be able to express and act ontheir desires and beliefs. The end of the era ofdeference means people are much more likely towant to self-manage their lives, at work, home andthrough the state and civil society. But there aredifferent means by which the demands of this age ofautonomy can be met: either by feedingconsumerism or by deepening social citizenship.The two are not always irreconcilable and clearlyboth have a role. But is it our roles as consumers orcitizens that the NHS should primarily championand nourish?

In researching this pamphlet I spoke to a lot ofpeople. Perhaps the most poignant discussion waswith Paul Corrigan, the then health policy adviser toTony Blair in Downing Street. To give what I hope

is a fair caricature, our debate revolved around myconcern about individual choice and Paul’sinsistence on encouraging it. On reflection bothpositions feel like nightmares. The NHS cannot beeither a stifling bureaucracy or a rampant freemarket. The reality, as I hope to show, is that NewLabour’s reforms exhibit some of both tendencies –both a machine to control and a market to fostercompetition – and that they combine in ratherunhelpful ways.

New Labour should be praised for addressing thehistoric under-funding of the NHS and takingspending to record levels. The fact that all partiesnow talk about investment in public services beforetax cuts is perhaps the major political victory for theleft since the 1980s. There are 20,000 moreconsultants and general practioners (GPs), 70,000more nurses, and more than 250,000 new NHSstaff overall since 1997. Neo-corporatist processeslike Agenda for Change have helped manage staffengagement and morale during difficultnegotiations over grades and structures; 118 newhospitals have been opened or rebuilt; waiting listsare down; and some services like cancer treatmentshave been transformed.

But the tragedy is that this record investment instaff and infrastructure might be squanderedbecause of ill thought through, wrong-headed andoften conflicting reforms. Somehow New Labourhas managed to spend record amounts on the NHSand commit huge amounts of energy and politicalcapital to it but still emerge, at least temporarily,behind the Conservatives as the party best placed torun this national treasure. In part this pamphlet triesto explain the chasm between political action andpublic perceptions of the success of investment andreforms of the last decade.

The latest polling evidence from Ipsos MORI tells asorry but highly contradictory tale. When askedwhether the NHS is going to get better or worseover the next few years, 33 per cent of respondentsthink it will get worse. Only 2 per cent think it willget much better while 13 per cent believe it will getmuch worse.



In terms of satisfaction with the job the governmentis doing overall there is a net dissatisfaction rating of?36 per cent But when asked what people thinkabout the local NHS provision, 47 per cent aresatisfied. If you ask people whether they weresatisfied with their last hospital visit the figurejumps again, to 62 per cent. And satisfaction ratesof local inpatients have risen from 65 per cent in2003 to 80 per cent for the most recent IpsosMORI figures. If everything has gone so right whydoes it feel that it has gone so wrong?

Healthcare remains atthe top of the politicalagenda, just behindcrime as the nation’snumber one concern.59 per cent think theNHS is one of the besthealth services in theworld and 74 per centthink that ‘The NHS iscritical to British society

and we must do everything we can to maintain it’.Incredibly, though, the Tories have enjoyed a 4 percent lead over Labour as having the best policies onthe NHS – despite the fact that they don’t really haveany polices for health. That has now changed sinceGordon Brown has taken over – someone viewed asless enamoured of the quest to commercialise theNHS and more likely to manage it effectively.

New hospitals, more staff and some betterperformance has clearly lifted people’s experience ofthe service. But there is a massive disjuncturebetween local experience of success and nationalperceptions of failure. The improvements that havebeen made are largely to the result of the hugeincrease in investment and the hard work put intomodernisation by staff and professionals at all levelsof the service. But these performance andinvestment increases are now set to tail off. There iswidespread confusion about trust deficits, ward andspecialism closures, job losses and local campaignsagainst cuts. Morale among staff from mangers toconsultants, junior doctors, nurses and ancillarystaff is at rock bottom. Some workers like midwives

are incredibly angry at being over worked and undervalued.

Ipsos MORI figures show that those who work inthe NHS or know someone who works in the NHSlike the service less than other people do: 36 percent of those who don’t know anyone working inthe NHS are satisfied with the service; 25 per centof those who know someone who works in the NHSare satisfied; and only 14 per cent of those whowork in the NHS are satisfied. If you are a nursethen your £20,000 salary is 25 per cent more thanyou got before 1997 but it won’t get you on thehousing ladder. Doctors are fed up with being toldwhat to do. Support staff and ancillary workers haveseen their work outsourced and been told that theyand their unions are dinosaurs who are unwilling tomodernise.

You cannot rebuild or properly modernise anyinstitution by demoralising the workforce or bypositioning every reform as being against them –‘them’ being essentially Old Labour, which NewLabour continually defines itself against. Increasedpay has helped, but GPs are one of the mostnegative groups despite their large pay increase.What motivates health professionals at all levels isnot just pay but doing a job well in a service theybelieve in. Happy staff produce happy patients.

It’s not just in the polls that the people are revolting.Out on streets people are taking action. Thousandshave marched and formed human shields to stopclosures. Tens of thousands have signed petitions.All of this is being exploited by the Tories who nowclaim to be the party of the NHS.

CCoommppeettiinngg vviieewwss ooff tthhee ssttaattee;; ccoommppeettiinngg vviieewwss ooff tthhee cciittiizzeennThe huge tale wind of 1997 in favour of investmentin public services is in danger of turning against theleft unless a qualitative leap in the substance andstyle of health provision can be created. The moneyand good will is drying up. Improvements basedonly on providing extra funding or creating topdown targets are unlikely to be the driving force forperpetual and long-term modernisation of the NHS

Introduction

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in tune with left values. But a new Labour primeminister, the Darzi Review and the 60th anniversaryof the NHS provide an opportunity to think afreshand learn the lessons of New Labour – the successesand the failures – to build a health service that isboth new and Labour. The process of modernisationcannot stop but it must be in tune with Labour’score values of equality, liberty and solidarity. Thestakes are now very high. This is not just aboutwhether New Labour or the Tories will win the nextelection, important as that is, but whether we canmodernise the NHS and more broadly our publicservices in tune with the values of the left. Thepublic are unlikely to give us another chance.

New Labour’s claimhas been that only itsparticular method ofincreasinglycommercialised reformwill save the publicservices in general andthe NHS in particular.The other two partieswould in essence gofurther and faster inthe same direction oftravel. The argumentin this pamphlet is that

other potentially more successful methods of reformare still available. New Labour has adopted anaggressive form of new public management, whichsees the government primarily as a servicecommissioner and people as consumers. The role ofthe state is to facilitate delivery through increasinglyautonomous vehicles whether private or third sector,to cut costs, increase efficiency and provide choices,albeit in limited form, for consumers. This model iscounterpoised to the ‘old’ centralised state modelbased on top-down control that was viewed as toocostly, inefficient and insufficiently consumerfriendly. This is the ‘supermarket state’ triumphingover the ‘corporatist state’. Neither will do.

Behind these competing views of the state arecompeting views of the good citizen. On the rightgood citizens are autonomous individuals pursuingtheir own rational self-interest. This version of the

good citizen is law abiding and bound by ‘duty’ but isnot obliged to interact. On the left the goodautonomous citizen not only has a much greaterawareness of and commitment to social and politicalactivities but believes that we are made better citizensthrough social interactions. But the left hastraditionally viewed citizens as too passive in its ratherpaternalistic view of reform from the top.

But this debate takes us to the heart of the NHS as akey institution of the left where competing views ofhuman nature either take root or wither. The centralbelief of the right is that people have both thepropensity to be individualistic, selfish and greedyand that these are the most appropriate forms ofbehaviour, which need to be encouraged through theinstitutions that right wing politicians either build ordestroy because they are too solidaristic in intent. Theleft on the other hand champions the values ofcooperation, care and compassion. The truth ofcourse is that we are a mixture of both character types– individualistic and socialistic, greedy and generous.We are born with certain traits and characteristics andare socialised into certain behaviour patterns, beliefsand values. There is little we can do about ourparticular DNA but there is a lot we can do about theway in which we are socialised as we pass through keyinstitutions like the NHS.

The value of the NHS is not just its instrumentalworth – does it make us healthier? Of course this isvital but it is a necessary not sufficient componentof a reform agenda. There has to be a moralunderpinning too. The difference between left andright is that we see the intrinsic worth of aninstitution like the NHS because of its capacity tobuild and foster social citizenship and the egalitarianspirit that goes with it. It is the moral underpinningof the NHS that can re-enforce public commitmentto it and so increase its instrumental performance.Our goal must be the creation of a virtuous cycle ofexperiential and emotional commitment to keypublic institutions like the NHS.

TThhee TThhaattcchheerriisstt vviieeww ooff ssoocciiaall iinnssttiittuuttiioonnss aanndd NNeewwLLaabboouurr’’ss rreessppoonnsseeThe right understand the key role that institutionsplay in shaping the political agenda. Mrs Thatcher

Introduction

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once famouslyremarked ‘Economicsare the method, butthe objective is tochange the soul.’4What she wasadvocating was a formof social and politicalengineering; thatthrough the use of theeconomy and thereform of publicinstitutions she wouldhelp shape people inher preferred image aspossessive individuals.The economic meanswas privatisation ofnationalised industries,council housing andpublic services to createmore privatised andless socialised people.The economy wouldbe shaped anddeveloped in a way thatencouragedcompetition and choiceand therefore

individual advancement over collective needs.Thatcherism believed that people could onlyadvance when the burden of the state was liftedfrom their back. In this way Thatcherism and itsneo-liberal creed set out to shape society in theirimage by building institutions that encouragedbeliefs and behaviour that fitted their view of thegood society and the good life. By taking people tothe market, rational choice theory would becomethe daily habit of the population. The marketallocates everything, values everything and directseverything. Freedom, or at least its market variant,would be forced on to the people.

New Labour has given a contradictory response toThatcherism in its view of social institutions like theNHS. It came to save the state by modernising itsprocesses and investing in it. Unlike Thatcherism,

New Labour believed in the active role of the stateto help people survive and thrive in the globaleconomy. But the nature of global competitiveeconomy and the stringent demands it makes onnation states, governments and societies was neverquestioned by New Labour. Indeed it was activelyembraced.

Tony Blair wrote that ‘complaining aboutglobalisation is as pointless as trying to turn backthe tide’.5 In this sense New Labour presenteditself as a form of enlightened neo-liberalism orperhaps more succinctly neo-Labour. By acceptingthe rules and the end point of the global economyNew Labour also accepted the means; thisoverwhelmingly meant the values and process ofthe market in the form of competition, choice andconsumerism. As such New Labour is fatalisticabout the context in which we find ourselves. AlanMilburn, the former Secretary of State for Health,said ‘Like it or not, this is a consumer age.’6 Suchfatalism then directs political strategy as Milburnlater went on to argue in an article for theGuardian that unless Labour made public servicesmore like the market first, the Tories would just doit on their terms. So Labour members andsupporters are left having to support policies theTories would have enacted .

WWhhaatt aarree wwee ccrreeaattiinngg,, cciittiizzeennss oorr ccoonnssuummeerrss??But the ideological question is: What are wecreating, citizens or consumers? This is the centralrift within Labour’s rank; between those who thinkthat essentially it is the values of the market that cansave the public sector and in particular the NHS,and those who think that individualistic meanscannot create what is essentially a service ofsolidarity. Both sides would argue that they areremaining true to the mantra of ‘traditional valuesin a modern setting’. The Blairite view is that wemust accommodate to the modern setting of theconsumer age and global markets, without betrayingtraditional values, which in the case of the NHSrests on being ‘free at the point of need’ and paid forout of general taxation. But ‘free at the point ofneed’ is a necessary but insufficient slogan for theNHS if the values and culture of the service are

Introduction

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being undermined by a mix of markets andoverbearing centralism. The soothing mantra isbeing broken de facto if not de jure. Prescriptionand now dental charges mean there is no line in thesand. As social care is taken down the route ofindividualised budgets, co-payments and top ups arebound to feature. Under an increasinglycommercialised NHS the determination of what isprovided ‘free’ and at what ‘point of need’ andtherefore for whom has become gradually more andmore distorted through growing health inequalities.Work by Danny Dorling shows that the relative gapbetween the mortality rates of infants in thedifferent social classes and life expectancy ratesamong upper and lower social classes is widening.7Whatever imaginative attempts are made to arguethat some ideal version of the market could actuallyredress such inequalities,8 all evidence and analysisshows that the actually existing health servicemarket being created by New Labour is likely toexacerbate the terrible social injustices of unequalaccess to health care and unequal health outcomes.9

The argument of this pamphlet is that means alwaysshape ends and that we must stop running frommarket forces and start building an alternativemodel of personalised, responsive, efficient anddemocratic public services, starting with the NHS.By deploying the processes of choice, competitionand consumerism, what you end up with looks andfeels more like the market than a democratised state.Then we breed only selfishness and cynicism. NewLabour’s strategy is akin to the GIs in Vietnamwhose approach was to ‘burn the village to save thevillage’. Even on strict instrumental grounds there islittle evidence of success when it comes to greaterefficiency.

In rejecting the old centralising state we don’t haveto accept the market as the only alternative. If wedo, then we corrode the purpose of politics itself. Ifdemocracy is not for a higher social good, then whatis it for? People start to switch off. It is nocoincidence that the high water mark of electoralpolitics in the UK matched the high water mark ofequality in our society. We can’t debate tax anymorefor offending Rupert Murdoch and the Daily Mail

and therefore will find it impossible to sustain highinvestment in the NHS. So spending declines orrelies on private finance initiative. Both re-enforce asense of political disconnection and the ratchet slipsanother notch tighter. The danger is that a viciouscycle is created whereby politics close down and weare left with competing technocrats arguing aboutwho can best manage public service deliverythrough a hybrid system of commercialisation andcentralisation.

New Labour has taken a huge gamble with theNHS. It thinks that an instrumental, individualisticand mechanical view of reform will bind in themiddle classes and show that all the investment ispaying off. But the evidence and public sentiment isbeginning to run against the government. Cries ofmore time and more reform – worryingly close toNo Turning Back – inspire less and less confidence.

The key problem is the mix of commercialisationand centralisation. This view of the NHS as partmachine and part market denies the possibility ofself-sustaining reforms in which professions,producers and users are key. Instead we should lookat the NHS and our requirements of it as essentiallyparadoxical. There are tensions within the NHS,primarily between the desire for diversity and theneed for equality, that cannot be solved – onlybetter managed. The tensions emerge when cabinetmembers campaign locally against hospital cuts thatare the product of decisions made round the cabinettable and in the anxiety caused by the availability ofdrugs like Herceptin in one postcode but notanother. The pamphlet therefore describes ways inwhich four governance tools – professionalism,commercialisation, centralisation and regulation,and most importantly participation – can createbetter outcomes and sustainable improvements inthe NHS.

I came at this whole issue thinking a new blueprintfor the NHS could be applied and the problemcould be fixed. I know now this is clearlyimpossible. What matters are the processes, spaces,practices and institutions through which all NHSstakeholders can own the debate and determine the

Introduction



direction of this enormous, complex and pricelesspublic service. Means always shape ends – that iswhy democracy and socialism are two sides of thesame coin.

The pamphlet starts by contextualising the NHSwithin the market society in which it operates. Thesecond chapter critically analyses the machine

model that has dominated NHS thinking; the thirdchapter is on the market model and thecommercialisation of the NHS. The final chaptersexamine the NHS as a paradox and the democraticmeans needed to manage this contradictory, difficultbut hugely significant beast in a way that maintainsits political role and values but modernises itsapproach.

Introduction



The NHS as a political entity

BBeettwweeeenn ttwwoo rriigghhttss ffoorrccee ddeecciiddeessKarl Marx10

To understand the politics of the NHS we mustunderstand the context it operates in. The reason whythe left supports the NHS is that the principles thatunderpin the NHS are those of the left. It aspires totreat everyone equally on the basis of need, not abilityto pay. It is an institution that provides collectiveinsurance against ill health and therefore is a site ofsocial solidarity. Its professionals and staff work notonly for personal monetary reward but from the senseof pride and purpose that comes from serving thepublic good. And, nominally at least, it is controlledand managed democratically by us through the state.As we will see later, the reality of an undemocratic,bureaucratic and rather paternalistic NHS has provedto be its weakness in changing times.

The NHS by definition is not owned privately. It isnot run for a profit. The products and services arenot commoditised for individual payment andprivate consumption. There is only a limited marketfor health care with providers such as BUPA andprivate nursing homes, and the market for cosmeticsurgery and alternative medicines which is growingfast. But that doesn’t make the NHS wholly public.The NHS is not purely anything. It was founded onthe ideals of the left but does so as a bubble orbridgehead within a broadly capitalist society wherethe values, practices and institutions of the marketare dominant.

Mike Prior and Dave Purdy have described the conflictbetween the egalitarian and collectivist ‘socialisingfactors’ of the NHS with a market society thatdominates and contains it as ‘the most fundamentalprinciples of social organisation and action … lockedin combat’.11 Crucially general practices remainedprivate small businesses and consultants retained theright to practise privately. Public health policyremained vulnerable to the distorting influence of anexpanding and increasingly powerful privatepharmaceutical industry. An uneasy compromise withprivate interest was therefore part of the NHS DNA.The funding of the NHS depends, in part, on theperformance of the capitalist economy and it is income

and wealth inequalities that largely determineinequalities in health.

The NHS is not just a creature of the largely capitalisteconomy in which it was created but was also acreature of its time. The dominant model of publicadministration in 1948 was a centralising cocktail ofFabiansim and Leninism. Aneurin Bevan wanted aregional model for the NHS to increase accountabilitybut much like today none was available. So it took onthe form of a top down and therefore centralisedbureaucracy.

The NHS like most political entities was and is apragmatic fudge. It reflects the competing ideologicalforces of political interests of the day. It is a paradoxicaland contradictory entity; founded on values of equalityand solidarity but operating in a capitalist economy.

Capitalism is a restless and dynamic beast. It does notsit still but endlessly searches for new places to makeprofits. Whether it retreats or advances depends on thestrength of its ideas and forces compared with those ofsociety. The forces can balance out and then we live inrelatively harmonious circumstances. But this neverlasts. The search for new profits from ‘common goods’like public services means the market will try to find away to commoditise those services or products.

If we understand the relationship between the marketand society as one of an evolving and fluid contestbetween competing public and private sets of forces,institutions and values then the NHS becomes a primesite of political contestability. Below the surface calmour world is shaped in large part by the ebb and flowof the interests of markets versus the interests of society.Often those interests can coincide, but not always.

The NHS was a product of the socialising wave thatswept the globe in the middle of the last century. Afterthe horrors of mass wars and the depression years ofthe 1930s the forces of social advance held the upperhand. Intellectuals, like Keynes and Beveridge,illuminated the way and showed that not only couldcapitalism be managed in the interests of society butalso institutions could be founded that provided analternative to the market. The growing and vociferous



working class, organised through the trade unionmovement, provided resources and electoral strength.And the Labour Party acted as the political wing ofthat movement. The market was in retreat and had toaccept a new settlement with these socialising forces,which led to the mixed economy of the post war years.The forces of the right had also seen what hadhappened in Russia and knew they had to concedeground to ‘buy-off ’ the working class in the West. Thejewel in crown of this post-war settlement between themarket and society was the NHS.

We should remember though that the very notion ofpublic services are not a twentieth-century socialdemocratic creation but Victorian. These early highpriests of capitalism understood that the businessworld could corrupt politics and society just as thepolitical and social world could corrupt that ofbusiness. What was needed was a balance between thetwo. Indeed when it came to issues like sanitation andthe mobilisation of mass participation in the workforceor for war, their enlightened self-interests led them tothe path of municipalism and public services.

But times and social forces change. The market is onceagain on the front foot. In part this is because the topdown welfarism of the post war years, including theNHS, lost democratic legitimacy and was thereforealways vulnerable to renewed attack by the market.The failure to adapt to new times and new demandsopened the door to the already growing ideologicalrevival of the right in the guise of free market neo-liberalism.

The setbacks suffered by the organised working classand the intellectual disarray on the left – following theabsolute collapse of socialism in the East and its relativedecline as a reformist force in the west – meant therewas no counter charge to defend public goods like theNHS. According to David Marquand, ‘On strict neo-liberal assumptions, the NHS was ... unashamedlycollectivist, not to say socialist: it was run byprofessionals whose ethic ran counter to theshibboleths of the free market.’12 The right hate theNHS because it treats people as equals not as rationalchoice makers, because people are treated on the basisof need not wealth, and most of all because it is a

challenge to their fundamentally held belief thatcompetition and individualism is better thancooperation and collectivism. In the battle for politicalideas and institution, the NHS is an arrow aimed atthe heart of neo-liberalism.

But the NHS was, inthe words of NigelLawson, close to being ‘anational religion’. Itmeant that MrsThatcher, she of ThereIs No Alternative, orTINA, had to admitthat ‘the NHS was safein her hands’. She trodcarefully. There wouldbe no wholesaleprivatisation. Instead shesnipped at the edgeswith the contracting out

of ancillary services while only dentistry was effectivelyprivatised. Eventually the purchaser–provider split wasintroduced and with it the creation of an internalmarket and the beginnings of shadow or quasi marketto try and make the service more cost conscious andresponsive. She also starved health of funds. This led toa deteriorating service, low morale among staff and aflight to the private sector by those who could afford it.The notion of the NHS as a contradictory entity wastherefore further embedded.

HHooww aanndd wwhheerree ttoo ccoorrrraall tthhee ffoorrcceess ooff tthhee mmaarrkkeett iinntthhee iinntteerreessttss ooff ssoocciieettyyThe issue for the left is always how and where to corralthe forces of the market in the interests of society. Thecentral problem of New Labour was not the feasibilityto manage capitalism more effectively but thedesirability of such a challenge. The central tenet ofNew Labour is that the forces of globalisation are to beadapted to, not managed and regulated for the good ofsociety. Once we give up this central political strugglethen the unconstrained market floods into every cornerof the once public realm. Alan Finlayson, a particularlyastute observer of New Labour, has written, ‘The spacebetween the private activity of market exchange (self-oriented and instrumental in its approach to the


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world) and the public activity of society-making(other-oriented and ethical in approach) is becominglost. Society as a whole needs the dynamism of selfishmarket activity, but if left unconstrained this hascorrosive effects.’13

One of the problems of the old NHS is that it wasbased on a purely mechanical notion of reform. Itsvalue was instrumental. Either it did the job or itdidn’t. As such New Labour is much like Old Labourbased on the concept of ‘socialism is what Labourgovernment do’ or in the modern vernacular ‘whatworks’. But ‘what works’ is a moral question. Whodefines ‘what works’? Works for whom and how? Forthe interests of society, the market or the individual?Now or in the future? The left never placed enoughvalue on the morality of the service or the reformprocess. This is the intrinsic value of being served as anequal, through the forces of solidarity and democracy.We forgot or never realised that such values could benot only be more ‘efficient’ but could also make us feelbetter about our lives and our place in the world.

If forms follows function, and the function of theNHS is to make people well regardless of their wealth,then the form the NHS should take should bedifferent from profit-maximising enterprises. Walkinginto an NHS hospital or a community health centreshould feel uplifting – like walking into a cathedral orchapel. The NHS is a very special social space. Theoxygen, the ambience, the culture should feel differentfrom the high street. Unless it does it will be judged onthe same instrumental grounds of consumer stylesatisfaction.

Too often, though, the reality was that patients didn’tfeel special or equal. They might not have to worryabout paying the bills like they did before 1948, but theNHS failed to engage them as citizens. It was toobureaucratic and paternalistic. But it was the absence ofa moral case for the welfare state that precipitated itsdecline in the 1970s. If institutions like the NHS areonly valued on the narrow basis of what works thenwhat happens if for some reason it stops working? Ifthere is an external economic shock like an oil crisis orrampant inflation then there is no public support to fallback onto – no other value or reason for its existence.

The politics of ‘what works’ always begs the question:What happens when things don’t work? This is whathappened in the 1970s and resulted in the death of thepost war settlement and the rise of neo-liberalism. If wedon’t want to repeat that era then the moral case forsociety over the market needs to be put. Of course theNHS has to provide a brilliant service but not only isthat not enough, we must also make the case that abrilliant service can only be based on the values ofequality and solidarity and organised in a way that is intune with such values. The NHS can only be brillianton terms that embed long-term legitimacy andpopularity. Neither the machine model nor the marketcan do this.

TThhee lliimmiittss ttoo tthhee ssccooppee ooff tthhee mmaarrkkeett iinn tthhee NNHHSSIn a speech to the Social Market Foundation (SMF) in2003 Gordon Brown quoted the economist ArthurOkun as saying ‘the market needs a place and themarket needs to be kept in place’.14 It is worth goingback to this speech in some detail as it spells out why,for the left, there should be limits to the scope of themarket in the NHS. In the speech Brown said:

In healthcare we know that the consumer is notsovereign: use of healthcare is unpredictable and cannever be planned by the consumer in the way that, forexample, weekly food consumption can. So we know…. that the ordinary market simply cannot functionand because nobody can be sure whether they needmedicinal treatment and if so when and what,individuals, families and entire societies will seek toinsure themselves against the eventuality of being ill …that in every society, this uncertainty leads to thepooling of risks.

Take the asymmetry of information between theconsumer as patient – who may, for example, beunknowingly ill, poorly informed of availabletreatments, reliant on others to understand thediagnosis, uncertain about the effectiveness of differentmedical interventions and thus is not sovereign – andthe producer’.

With the consumer unable – as in a conventionalmarket – to seek out the best product at the lowestprice, and information gaps that cannot – even over




the long term – be satisfactorily bridged, the results ofa market failure for the patient can be long-term,catastrophic and irreversible. So even if there are risksof state failure, there is a clear market failure.15

Brown went on to describe the features of the NHSthat make it difficult to commercialise, namely:

! the need for guaranteed security of supply, whichmeans that, generally, a local hospital could not beallowed to go out of business

! the need also for clusters of mutually reinforcingspecialities (trauma, pathology and emergencymedicine for example)

! a high volume of work to guarantee quality ofservice

! the economies of scale and scope making itdifficult to tackle these market failures by marketsolutions

! and – as the US system has also demonstrated –the difficulty for private sector contracts to anticipateand specify the range of essential characteristics wedemand of a health care system.

He summarised that in health:

! Price signals don’t always work.! The consumer is not sovereign.! There is potential abuse of monopoly power.! It is hard to write and enforce contracts.! It is difficult to let a hospital go bust.! We risk supplier induced demand.

But the enlightened progressive economic analysis ofGordon Brown or anyone else, while a necessarystarting point, is not sufficient to hold back theadvancing tide of the market. Huge private profits areat stake from the commodification of NHS services.Against the backdrop of the perceived superior logic ofthe market – that inefficient organisations fail whilethe efficient succeed – the floodgates to thecommercialisation of public services like health andeducation are being pushed open. It is not just theory

that closes these gates but active and organisedcountervailing social forces and interests.

TThhee iiccoonniicc ssttaattuuss ooff tthhee NNHHSS aanndd tthhee bbaarrrriieerr ooff ddeemmooccrraaccyyThere is a further big political problem that hasimplications for the NHS and those who work in itand rely on it. As politicians withdraw from the bigdecisions that shape our society – about therelationship between the market and the state –because they feel there is nothing they can or shoulddo about regulating global capitalism, they focusinstead on what they feel they can do to both justifytheir high position and to exaggerate the managerialdistinction between themselves and their politicalopponents. So the management of the NHS isanalysed, reviewed and reformed again and again. ForNew Labour and its attachment to modernism theurge to quicken the pace of renewal by a constantcritique of what exists is irresistible. Good or bad, whatmatters is showing who is ‘in control’ of themodernisation process being enacted and then re-enacted. It is a permanent revolution of upheaval onwhich no lasting basis of reform can be laid. AnnaCoote has explained the importance of the NHS to usin these terms:

The NHS has taken on an iconic status – in the eyes ofgovernment and electorate – as politics have becomeless readily defined by ideology. We may not want tobelieve in the market or the state any more, or insocialism or capitalism, but it seems we can all believein the NHS. It defines and unites us as a nation. Itshows that we can all pull together and look after eachother, but it does reassuringly practical things and doesnot threaten existing power relations. Very tempting,then, for ministers and prime ministers (whatever theirpolitical complexion) to pin their colours to the NHSmast, to promise to rescue and improve it, and to askto be judged accordingly – without looking beyond themechanisms of service delivery.16

Have we gone beyond the point of no-return? Are thevalues and institutions of the society so weak,demoralised and incoherent that there is no defenceagainst the market? The final barrier is democracy itself.Democracy has flourished in an era not just of amazing




economic growth but huge advances in equality. This isno coincidence. Equality as voting citizens only has anymeaning if we are relatively equal in economic andsocial terms as well. The high point of democracy – asmeasured by electoral turnout in the 1950s and 1960s– matched the era when Britain was the most equal ithas ever been. As Britain has become steadily less equal– as a direct consequence of the spread of the market –democracy itself has lost its value. What is the point ofvoting if all parties converge around a largely neo-liberalagenda that leaves too many in greater relative poverty?It is not just the frontiers of the state that the marketwants to roll back but the frontiers of democracy itself.In the market you can vote with your trolley everydayfor what you want as a consumer. The march of themarket means that democracy itself is being broughtinto question if there are not enough common bonds tosustain the purpose of democratic action. The NHS isan institution that makes democracy worthwhile – butin turn requires a healthy democracy to sustain it.Zygmunt Bauman, the eminent sociologist, has written:‘Without collective insurance, there is no stimulus forpolitical engagement – and certainly not forparticipation in a democratic game of election.’17 Theexodus from politics becomes almost complete as localsolutions cannot compensate for global problems. JohnGray encapsulates the downward spiral when he writes‘We lack the common values that would allow acollective choice to be made on the boundaries of themarket. In these circumstances, the idea that publicservices will be improved by the introduction of marketforces is practically irresistible, for it trades on one of thefew common values to which we cling – the sanctity ofconsumer choice.’18

The depth of the retreat is made clear by the formerLabour health adviser and academic Julian LeGrand: ‘As a public sector professional myself, Iwould far prefer to work in the context of a quasi-market than under the dead hand of command andcontrol.’19 We should refuse to accept such a falseand unedifying dichotomy as if it’s some simplisticforward or backward choice we face – whereforward means swallow the market and backwardmeans be a dinosaur. There is more than one routeto the modernisation of the NHS. We can decide tomove on from the past without accepting the

straight jacket of globalisation, commercialisationand quasi-markets.

To restate: the issue is not one of absolutes, the marketor society but of finding a better balance between thetwo. Markets don’t volunteer balance – they just take.Only a democratic society can determine where thepoints of balance should be but it needs to tools andforces to do so. How can we effect a balance betweenthe dynamism of the market and the needs of society?This does not preclude progressives using the market.Ken Livingstone took the brave decision throughcongestion charging in London to show that the marketcan be used for progressive ends, as it potentially can forcarbon trading. But what is important is that themarket is not enshrined as a matter of doctrine anddogma and that there are the means to correct itsfailures and circumscribe its application.

The point is that we have to be constantly on ourguard attending to the vitality of non-market spacesthrough the values, institutions and tax base to pay forthem. But to do this we must value the kind of publicrealm the NHS represents. That is tough when thefortress of the public realm has become tooundemocratic, unresponsive and unaccountable. Butthe answer is never less democracy, but more!

HHooww iinnssttiittuuttiioonnss sshhaappee ppoolliittiiccaall pprreeffeerreenncceess aanndd ddeessiirreessWhat the centre-left has to understand is theimportance of institutions in shaping politicalpreferences and desires. These are the sites in whichpolitics is played out. Their nature, form andpurpose shape and determine the politicalbattleground. Politicians through the ages have beenaware of this. The Fabian view was that publicadministration builds socialism. And so it did in itsday. Only the mass, bureaucratic, centralising andpaternalist Fabian model ran its course some timeago. There is no turning back. Thatcher insisted on anew model – that of the market. Civil servants underher jurisdiction famously remarked that whatever thequestion the answer was always the same – create amarket. The market is the institution of the right. Inpart the argument is about efficiency – but only thebean counting efficiency of profit. Markets sort the




winning wheat from the losing chaff. But the marketcase for efficiency is a profoundly anti-democraticproject. Markets work best by closing down the spacebetween individual consumers and producers. Onlythen can signals between the two be easily and cheaplytransferred. Democracy and democratic institutions, inthis light, are viewed as inherently inefficient andtherefore eminently disposable. Local government,unions, corporatist forums, even political partiesthemselves are disposable because they take time andenergy to discuss, debate and find answers. For theright the ‘invisible hand’ of the market is all we needfor moral guidance and operational efficiency.

In such a world view the welfare state and in particularthe NHS is relegated to a second order value behindthe needs of the economy. It becomes not a site ofwelfare, protection and social citizenship but part ofthe support economy. It exists not just to ensure peopleare fit for work but must do so on the basis of theefficiency of the market by mimicking it. In this way itplays a duel purpose for the market: it is a site for theexpansion of profits through privatisation but cruciallyconditions people to become global consumers bypromoting choice, competition and individualism. Welearn through the increasingly commercialised NHSnot how to be citizens, in it together, but how to beconsumers, in it on our own. Managers learn tocompete and become businessmen; patients learn tochose and become consumers. So we have a new onesize that fits all: the market.

We are left with a ‘permanent revolution’ – definingourselves against the past and our own people, copyingthe market’s desire endlessly to renew and re-engineer.For New Labour the historic struggle to make societythe master of the market is over. That is why ‘It’salways the economy stupid.’ All we can do is morehumanly help individuals stand on their own two feetin a world where everything can be reduced to rationalchoice theory. In such circumstances the prophecy that‘there is no such thing as society’ can become a self-fulfilling.

We are in danger of shifting from an ‘age of equality’ toan ‘age of ego’. This is the Hobbesian ‘war of all againstall’ where a strong state is used to police a free market,

unless of course the left does its job of building thedefences against the market to create the space within apublic realm where people can be truly free. This iswhat the Ancient Greeks called the ‘agora’, the territoryin which we encourage people to be compassionate,caring and cooperative. It is institutions like the NHSthat facilitate such beliefs. The agora is the space wherefirst and foremost we can be citizens. Those whowould bring it down and put the market in its place,those who wish to destroy these public spaces for fearthey will stand before the market, are the agoraphobics.

For his 2004 Labour Conference speech GordonBrown went beyond the mechanical reasons for thelimits of the private sector in the public realm he setout in the SMF speech the year before. This time hespoke about the moral difference between the marketand society:

I have seen this ethic of public service at work. I haveseen doctors and nurses who show not onlyexceptional skill and professionalism but extraordinarycare and friendship; carers whose unbelievablecompassion and support can transform despair intohope; home helps and support staff whose dedication,commitment and humanity show that there are valuesfar beyond those of contracts, markets and exchangeand that public service can be a calling and not just acareer. The ethic of public service summed up best inpoetry:

‘It is the hands of others who grow the food we eat,who sew the clothes we wear, who build the houses weinhabit;

‘It is the hands of others who tend us when we’re sickand lift us up when we fall;

‘It is the hands of others who bring us into the worldand who lower us into the earth.’

So we are not isolated individuals but we depend oneach other.20

But to make this happen we have to recognise thatmachines and markets are largely inappropriate asreform models for the NHS.




The NHS as a machine

If we understand theNHS as a site ofpolitical contestabilitybetween left and rightthen what of the formit takes? The NHS isstill the product of theera in which it wasborn – the era ofcentralisation. KarlMarx had a point. Theeconomic base doeshave at least someinfluence on the super-structure of society.The height of masscentralised productionwas perhaps in 1948.The top downmobilisation for the

war, Henry Ford’s mass production, Lenin-inspiredSoviets and paternalistic Fabianism defined an ageof the centralised machine and the administration ofthe world from above.

In this era the NHS was only ever going to follow amechanical metaphor – defined by an all knowing,seeing and controlling centre. Politics itself couldnot escape the same fate. Labourism became cultureof the party and still largely is now. This basedeverything on one party winning elections and thendirecting state power, and through publicadministration. Socialism was what a Labourgovernment did. Democracy was therefore just ameans to an end – the end being the control of thestate machine.

The language of the machine seeps into the phrasesof post war politics – of delivery, levers of power,stepping up a gear and having no reverse gear. Thejob of the party was to be the delivery mechanismthat won power for an elite to make the rightdecisions and bestow their enlightened magnificenceon those below them.

Jake Chapman, who has written extensively onsystems theory, has said, ‘At the heart of the

mechanical world view is the presumption thatcontrol is possible and that if you can controlcauses you can have predictable effects.’21 It is thisbelief in predictability and order through acontrollable machine that still defines how theNHS is run.

New Labour in all its control freakery anddesperation to show ‘it is in charge’ and ‘can deliver’has taken centralisation and the machine metaphorto new heights. More power than ever has beenfocused around the office of the prime minister. Inpart this is because few others could be trusted.Blairism was always a vanguard. Only a few truebelievers understood the modernisation revolution –the ‘project’. The majority had to be defined as OldLabour to prove the contrast and willingness tochange to New Labour. A small magic circleendlessly debated and decided the new course.Everyone else had to follow or be defined andcrushed as dinosaurs. But the urge to controlextended to much more than style. Where Stalinwould only dare to have five-year tractor plans NewLabour would settle for nothing less than a ten-yearplan for its NHS. Simon Caulkin, the Observer’sastute management columnist, has written: ‘Despiteits professed dedication to market disciplines, NewLabour is the most micro-meddling administrationin history, creating detailed specialisations andprescriptions for everything.’22

But the machine model and in particular the targetsthat now go with it is deeply flawed. It can work fora while – for a war when people are prepared tosacrifice themselves for a bigger cause or for somecontained production processes like making cars.But across increasingly complex, less deferential anddecentralised organisations and societies themachine model is too inflexible and leads to toomany unintended consequences. The £6 billionspent on IT systems is a classic example of acentrally driven approach that has failed to delivervalue for money according to industry experts.23

Targets are the reason the Soviet Union collapsed. Ifit couldn’t work in Minsk in 1950, why on earthdoes anyone think it will work in Manchester in2007?

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AAppppllyyiinngg ssyysstteemmss tthheeoorryy ttoo tthhee NNHHSSInstead of a machine model based on levers ofcontrol we need to adopt the more organic model ofsystems theory. This sees entities like the NHS notas a machine with separate cogs that can be directedfrom the centre but as a whole organism wherebyactivity in any one part of the system inevitablyaffects all other parts. Take the target of ensuringthat 100 per cent of A&E patients are seen withinfour hours. The cost is huge and the total probablyunknown. Derek Wanless in his review of progresson the NHS recently described it as ‘daft’. In hisreport for the King’s Fund, Wanless accused thegovernment of failing to recognise the complexity ofthe service and how various elements fit togetherand also condemned the repeated re-organisationsthat are costly not just in terms of finance butdisruption.24 He concluded that the additionalfunding of health services is not having the impact itshould. This is politically very worrying.

Organisations like theNHS are by necessitycomplex, often withcontradictory elementsand goals and thereforeby definition cannot becontrolled from thecentre or anywhereelse. Even recordamounts of spendingand more targets thanan army rifle rangecannot save a system

based on the myth of the machine. The keyproblem is targets and how they fit with humannature and the law of unintended consequences. Assoon as the centre decries that one outcome is moreimportant than any other things start to breakdown. This is especially true if people areincentivised to meet the target. As soon as there isany kind of reward, especially financial, for hitting atarget you can bet anything that NHS managers willstart to hit the target. Whether it’s in the ‘right’ wayand what else may be sacrificed along the way isanother matter. Managers will strive to meet a targeteven if it means destroying the organisation in the

process. People can only manage what is in theirpower to control. This is what distorts the rest of theorganisation in the struggle to meet their targets.

There is more than one kind of target. Thesimplistic ones that have numbers attached tothem, like waiting times, are good for mediaheadlines but distort healthcare priorities.However, there were some excellent targetsproposed by National Service Frameworks. Theseincluded structural recommendations and bestpractice examples to be emulated. And they werecreated by consensus groups of healthprofessionals, social workers, patients and carersworking together for months, and both voluntaryand professional bodies contributed the results ofsurveys and consultations.

It is the use of crude targets that is in part creatingthe current financial crisis in the NHS despite therecord investment. Simon Caulkin has written,‘How can the organisation be meeting all itsperformance targets and be in financial crisis,despite absorbing record amounts of money?Because in the absence of a systems view ofimprovement, performance goals can be met only atthe expense of missing others, in this case financialones.’25 The machine decides what targets to hit butcan’t account for what goes wrong in the process.So, for instance, waiting times become a politicalpriority but without sufficient cost–benefit analysisto understand what the true impact is. Frontlinestaff meet the political imperative of reducingwaiting lists but the resource input required isunknown and unquantified.

Jake Chapman has identified four problems withtargets: first, people face the wrong way – the targetnot the citizen becomes the focus of all activity;second, the goal becomes achieving the target, notimproving the quality of the service; third, data ismanipulated to meet the target or gaming takes place(an example of which is being passed around thehealth system because no one wants you to mess uptheir figures); and finally, collecting data takes timeand resources and detracts from the real job of carefor patients.

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Whatever targets are set there will always beunintended consequences. If trusts are given a targetto reduce waiting lists then low priority cases will begiven immediate priority and there will be a lack offollow up because there is no target for this. If youenforce a target for fewer deaths during operationsdoctors just stop doing riskier operations.

Consultants end up with a 25 per cent pay increasefor doing less work because the centre doesn’t andcan’t have all the necessary information about theirprevious workload. If trusts are given targets toreduce deficits then corners will be cut, leading toproblems such as more patients bring sent homeprematurely and the rise in MRSA. Of course thegovernment’s target to cut MRSA was missed. The50 per cent reduction was deemed unachievable byscience researchers. But even if the target had havebeen met it would have led to a drain in resourcesand attention elsewhere. It’s the classic water bedeffect. Pressure exerted in one spot always leads to areaction somewhere else.

The psychological basis for the machine model iselitism. Essentially what the politicians are saying isthat they don’t or can’t trust people to provide apopular and responsive service and therefore they mustbe directed and controlled. But mistrust is always aself-filling prophecy. If you treat people as if they can’tbe trusted then they will act in a way that proves theycan’t be trusted. Tighter control mechanisms are put inplace to rectify the ‘lack of control problem’ and weend up with a fully fledged vicious cycle. This destroysmorale still further and leads to the growth of aclunking big government machine as the process oftinkering and meddling takes on a life of its own. Thedefinition of madness is doing the same thing againand again and expecting a different outcome. SimonJenkins, the staunch proponent of localism, says this:‘To Thatcher, as to Blair, government was the agent ofperpetual change. It was Lenin’s light burning bright inthe Kremlin turret, never sleeping, ever planning, everdriving forward, always frustrated by the crookedtimber of mankind.’26

The machine mindset, in part, is the reason whyNew Labour has never won the cooperation and

support of those at the heart of the system; thosewho work in it. At best reforms have been carriedout to those in the service – at worst they have beendone against them. The workforce cannot be trustedother than as tightly organised cogs in the machine.They need to be controlled, disciplined and ifnecessary incentivised to ‘deliver’. Whereperformance is improved it is the victory of thecentre.

The machine was the only model available at thebirth of the NHS. Sixty years on the world haschanged. What makes us healthy, or not, isincredibly complex and getting more so. Once itwas chronic disease that could be treated throughmore straightforward delivery systems.Increasingly it is the environment we live in, ourdiet and the fact that we live in an ever moreunequal society that determines how healthy weare. In the world of prevention, where the NHSshould be focused, the machine breaks down. Onesize doesn’t fit all. Services can and must bepersonalised wherever possible. Machines are badat personalisation.

It’s not just that machines don’t work on their ownterms – they rule out better options. If all thatmatters is what can be counted, measured andaudited then what can’t be captured in raw figures isdisregarded and devalued. Any notion of publicvalue and the intrinsic benefits of a collectivist NHSare forgotten in the rush to win the battle of thetargets. As soon as you try to measure quality itbecomes quantity. The government is using one-dimensional measures like financial performance toaccount for multi-dimensional value.

Of course people need to be held to account in theNHS and across the all of the public and privatesectors. But targets aren’t the way to do it. JamesStrachen, the chair of the Audit Commission, hassaid: ‘Sticks will not promote excellence. They willmerely discourage failure, which is not enough.’27

FFiinnddiinngg aalltteerrnnaattiivveess ttoo ttaarrggeett sseettttiinnggPoliticians are going to have to learn that theanswer to better services is not target setting but




hard continuousreform, feedback loopsand producer and userengagement in a slowbut purposefulmovement towardssystemicimprovement. There isno instant fix for theNHS so that come anelection the politicianscan say they did it.The cult of the heroic

leader must die. The future of the NHS must be acollective. Neither workers nor users should beviewed as passive receipts of the service. Insteadthey must be engaged and consulted. The mostefficient organisation in the world is deemed to beToyota. Year in and year out they refine theirproduction system to increase efficiency andinnovation. Patients would benefit from suchpatience.

We need to find new ways to deal with complexity,accountability and responsiveness. New Labour thinksit has found the answer – the commercialisation of theNHS. But just because the Soviet Union failed itdoesn’t mean that the USA is the answer. Enron, don’tforget, was the most target-orientated organisation onearth.

The new Brown administration has promised a‘bonfire of government targets’28 with all but a handfulof priority targets being superseded by local agreementsdetermined by councils and PCTs. But whether theinstinct to meddle and a new culture of pluralism is tobe allowed to take root only time will tell. Perhaps weneed to go as far as the Canadians who haveabandoned all measurements except one: raisingsatisfaction among the public about the services theyreceive by 10 per cent – which they duly did. Sometargets, some of the time, can help develop a stepchange in services but they are not a recipe for the kindof continuous in-built performance and moralimprovement the NHS needs.

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The NHS as a market

One of the key reasons why New Labour centralisedcontrol over the NHS was to use its increasedpowers to usher in market orientated reforms. Thiswas the one way in which Blairism was willing to letgo: to the private sector. It is only a strong centrethat can dictate the terms of the commercialisationrevolution taking place in the NHS. But before2001 there was little evidence that future terms ofdebate about the NHS would be the extent ofprivate sector involvement and the three Cs itimplied: choice, competition and consumerisation.

Let’s be clear. It is not privatisation in the sense ofselling off wholesale the service to the private sector.But it has meant a growing share of the servicebeing provided by the private sector, with the publicsector increasingly forced to compete with privateproviders by mimicking them. The overall effect hasbeen the commercialisation of the service and thetreatment of patients as consumers.29

The central argument of the commercialisers is thatneither professionalism nor producer interest can betrusted to make the system efficient or responsive.Only competition forces managers to be held toaccount through the rigours of the market ashospitals fight for resources and ‘customers’ aregiven a wider range of choices about the service onoffer. The threat of ‘exit’ is everything.

The key driver is the use of market forces or theclosest approximation that is possible. Here there issome confusion at the heart of government. In 2005Patricia Hewitt, then Secretary of State for Health,said, ‘I do not believe we are turning the NHS intoa market, and nor do I think we should, it would bea pretty odd market where the user cannot pay andthe providers cannot compete on price.’30 But TonyBlair told the BBC’s programme Breakfast withFrost in December 2004 that Labour electionmanifesto would ‘drive through market-basedreforms in the health service’. The truth is thatbecause no payment actually changes hands theNHS can’t be called a market but the mix ofincentives, competition, choice and private sectorcompanies takes us to a world of at the very leastquasi markets.

But the evidence that commercialisation eithercreates increased efficiency or is in any way aresponse to public demand for increased choice ishard to find. A YouGov poll for UNISON inFebruary 2006 found that 61 per cent of patientswant providers to cooperate rather than compete.Only 19 per cent wanted competition. They areright to be concerned.

Competing institutions lies at the heart of NewLabour’s NHS reform; either trust against trust orpublic providers versus private companies. At leastthe government is now being honest about itssupport for an NHS based on competition. Soonafter the last election Patricia Hewitt said it wascompetition rather than the popular New Laboureuphemism of ‘contestability’ they were aiming for.She memorably remarked that the ‘instability’caused by competition was ‘not only inevitable butessential’. She developed the argument by saying,‘Yes, money will follow the patient. But why shouldchoice, innovation, competition and financialdiscipline be confined to private markets?’31 In apamphlet for the New Health Network Hewittwrote, ‘We are bringing greater risk into the systemby challenging the NHS monopoly and creatingincentives for providers to meet patient’s needs.’32

The risk she is talking about is the closures ofservices based not on public need but market stylerigour.

To achieve a system of quasi-markets Labour hasbuilt on the Tories’ internal market and turned itinto an open market. Often the market is rigged infavour of private providers. For instanceindependent sector treatment centres (ISTCs) arebeing paid long-term contracts at a premium abovethe rest of the NHS, which is struggling to copewith the replacement of block contracts with moreunpredictable payments procedures. Privatetreatment centres were not supposed to be able topoach NHS staff – now they can poach staff andpremises. Rules are bent and broken but only infavour of private providers. The presumption isalways in favour of profit maximisers. And theproblem with profit maximisation is just that – itputs money before need. Here is one interpretation



The NHS as a market

of the impact from the British Medical Association(BMA): ‘A system of winners and losers seemsinevitable, in which funding flows away fromunpopular providers, possibly trapping them in acycle of decline in which they have a higherproportion of the more complex and “unprofitable”cases but fewer staff.’33 In 2004 Professor PeterSmith from the Centre for Health Economics atYork argued that the effect of these quasi-marketswill mean that ‘providers tend to pick patients ratherthan the other way around. They pick those thatwill be most profitable and the least trouble – justlike schools.’34

Competition betweeninstitutions in theNHS has hugeimplications for theprovision of servicesand their financialstability. While servicesin such a hugeorganisation clearlyneed to be rationalised,this should be securedthrough proper long-term management ofresources, consultation

and, where possible, democratic agreement. Not theforces of the market. The current wave of unrestabout hospital, ward and specialism closures is fedby the lack of any discernable decision-makingprocess the public can access. This is not to argueagainst rationalisation but against imposed decisionseither from the centre or based on quasi markets.Much of this ‘instability’ is starting to be driven byshifting consumption patterns. Now that patientscan choose their hospital small shifts in patientchoices that see money follow the patient can havedramatic effects on hospitals, all of which have veryhigh fixed costs. This is why supermarkets, whichalso have high fixed costs, fight so fiercely forcustomer loyalty and are vulnerable to that loyaltyswitching.

As money and patients shift around following therules of the market the notion of an integrated and

holistic system starts to fall apart. Cross subsidies canno longer flow from those with surpluses to those indeficit. We might not want cross-subsidies to takeplace – but it is a complicated issue that requires anegotiated outcome. As specialisms close, the needfor shared services like cleaning can become harder tosupport threatening the viability of the whole hospitalunit. Unintended consequences of the market’s‘invisible hand’ abound. Public servants losecompetences as they get cherry picked by the privatesector, who by definition don’t have their experienceto do the job. They then get charged back to theNHS at a higher rate in the name of efficiency. InApril 2006 the Royal College of Nursing (RCN)threatened to withdraw unpaid overtime – anexample of dedicated staff acting on the basis ofrational choice theory and not public service ethos.The NHS itself turns into a brand like Nike, whichwas the claim that led to the resignation of JohnAshton the regional director of public health in thenorth west. He said we were heading towards a two-tier system after the fifth re-organisation he hadfaced. Hospitals are developing their own brands andstrap-lines and will inevitable start advertising forpatients.

The problem with choice is that in an unequalsociety some can always make better choices thanothers thus paving the way for greater inequality.New Labour ministers argue that the system wasalready unequal and they are only trying to create alevel playing field where all have choice. But thisreally is a baby and bathwater issue. Just becauseinequalities in health exist doesn’t mean we shouldadopt a market-based system that is bound toexacerbate the gap between winners and losers.Health inequalities exist primarily because ofincome inequalities. The real answer is to close theincome inequality gap. Second, inequalities existbecause the middle classes play the system better. Bycreating more choice it just provides the space forgreater middle class advantage. That is why theNHS must be a haven away from some people’sability to make better choices than others.

The New Labour argument is that choice isinevitable in the NHS because it is the meta-value

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The NHS as a market

for the rest of the society. You can’t stop peoplegoing on the internet to find out about what thebest hospital might be or what new services andcures there are. Indeed you can’t and neither shouldwe try. We should welcome a more personalisedNHS and encourage patient interest andresponsibility for their health. If this is whatministers mean by choice then fine. But up untilnow it wasn’t. It is the elevation of choice as a keydriver of policy and practice we should object to –at least in terms of it being a proxy for the market.Choice in terms of an abundant range of actualsuppliers of health care, like the choice of asupermarket, is just not feasible. Nor is it desirablebecause of its distorting impact on the public serviceethos of equality and citizenship. The thing we mustdistinguish is choice of provider (which most peopledon’t want unless it is the only way off a longwaiting list) from ‘shared decision making’ betweenhealth professional and patient. The latter is not anew thing, but has got more sophisticated as thepatient has access to more information. But even inshared decision making, we mustn’t forget thepeople who want the doctor to decide for them.

By establishing a set of superior and inferiorproviders inequality becomes systemic. King’s Fundresearch in May 2006 found that those with formaleducation chose the best hospital and those leastwell educated opted for the local hospital. JohnAppleby of the King’s Fund has argued that there isa parallel with schools – the middle classes tend togravitate towards what they perceive as the bestschools. If this happens in health care we couldpotentially see a widening of health and healthinequalities between those with formal educationand those without.

In a speech to the Fabian Society Patricia Hewitt in2005 said, ‘Far from entrenching inequality – it(choice) will help us create a more equal society.’35

This is Orwellian double speak. Just because thepoor can go to Matalan to buy cheap designerclothes doesn’t make it a more equal society if therich get to make even more extravagant purchaseson Bond Street. It just legitimises the market systemin a place it doesn’t belong. In echoes of Alan

Milburn, she went on to say, ‘It would be a majormistake – a mistake the Conservatives are justwaiting for us to make – to deny people choices overtheir health and health care, leaving us out of stepwith irreversible changes in society and out of touchwith the people we seek to serve ... people want areally good local hospital: but more choice meansmore chance of having a good local hospital.’36

Choice for James Purnell, another New Labourminister, is ‘an end in itself ’.37 So we tell people thatchoice will give them a good hospital when thereality around the country is that it leads to theclosure of services and provision. Hewitt finishedher speech in a flourish, ‘My appeal to progressivesand supporters of the NHS is: don’t oppose greaterchoice and control for individuals and communities;don’t just grudgingly go along with it; but embraceit as part of the way in which we renew the values ofthe NHS for modern times.’38

The elevation of choice to the high principle in theNHS opens up a can of worms in which individualadvancement is prioritised above collective interest,which brings about market failure as a few patientswitchers cause chaos to highly geared-up serviceslike big hospitals. The objective of the democraticleft should not be to deny personalisation but toexplore how much more meaningful collectivechoices can and should be made about the nature ofthe service. The NHS should primarily be aninstitution that promotes equality, liberty andsolidarity. Of course in a largely capitalist society itwill also reflect some of the dominant values of thatsociety, like choice, but they cannot be the metavalues of the service without the NHS losing itsrationale as a socialising force. This is not just myview but also that of Robert Hill, a former healthand public services adviser at Downing Street. Hehas written recently: ‘Choice and markets arepowerful agents for change. But they are not theonly club in the modernisers bag.’39 John DenhamMP, now Secretary of State for Higher Education,endorsed this view when he wrote, ‘Choice,diversity and contestability should be in any modelof public service reform, but they do not define theideal approach.’40 Choice in the NHS inevitablygives some more of what is ‘free at the point of need’



The NHS as a market

than others. It is little surprise that New Labour’sown Healthcare Commission recently reported thatthe choice of hospital is irrelevant to patients. Whatmattered was the quality of care.41

But choice is also difficult to argue for on groundsof efficiency. By definition to offer a meaningfulchoice supply must outstrip demand, which leads towaste. This is why the supermarkets throw away somuch of their stock every night – by pricing in thecost of such waste. This cannot be a model for theNHS.

But we are not given a choice about choice. TheDepartment of Health appears to have removedresearch from its website that showed there was noappetite for the choice agenda. The researchcommissioned by the Department found thatpeople did not want to select a hospital while theywere ill, preferring to trust their GP. The researchalso said there was no evidence that greater choicewould improve the quality of care, and good reasonto fear it would only benefit the wealthy andarticulate.42

These findings fit with other research. JohnstonBirchall and Richard Simmons in a paper to theTreasury in June 2005 wrote that ‘service users didnot want their own preferences to take priority overthe preferences of others if this was going to lead toan “unfair” outcome’. They went on: ‘Choice simplyrepresents a measure of rational preferences made onthe basis of available options. The aggregation ofthese choices may or may not add up to the publicgood… Choice appears to have a more limitedrange than voice; it is based on a more limited set ofassumptions.’43

In complex systems where there are clearasymmetries of information between producers andpatients simple versions of top down choice areinsufficient to empower citizens. It is not passiveand individualised consumers that will transformthe efficiency and quality of the NHS but activecitizens. Consumerism is just about the right to pickand choose and exit if you don’t like it. Publicservices and especially health can’t work like this.They are about rights and responsibilities. Theodore

Dalrymple wrote, ‘To be a customer without theresponsibility of paying for goods or benefitsreceived is to be an egotist permanently resentful atnot getting what you want immediately, whichbecomes the only criteria for satisfaction. To be adoctor constantly confronted by such customers isto wish to have chosen another career.’44 You cannotcontract your way out of chronic diseases as aconsumer. Consumerism encourages the view thatproblems can be fixed by over the counter drugswith no input or effort. According to David Walkerof the Guardian, ‘The very basis of social policy isassessment of need, followed by distributivedecisions that give relatively more to one group thananother. This isn’t like consumption in the marketfor retail groceries.’45

But if people are treatedlike consumers thenthat is how they startbehaving. It is onereason why there hasbeen a 75 per centincrease in the numberof emergency calls inthe last decade. It is nowpeople’s right asconsumers to demandan ambulance even forthe most frivolous ofcases. Like frenziedconsumers, people wantit all and they want itnow. The new

generation in particular feel no obligation to conformor wait it line. But we aren’t consumers of the NHSbut citizens. The NHS is not like shopping. Peopledon’t consume more health than they need.

For David Marquand the implications of thiscommercialisation agenda are profound. He writes,‘Incessant marketisation, pushed forward by the coreexecutive at the head of the most centralized states inWestern Europe, has done more damage to the publicdomain than low taxation and resource starvation. Ithas generated a culture of distrust, which is corrodingthe values of professionalism, citizenship, equity and

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The NHS as a market

service like acid in the water supply.’46 A little laterMarquand continues:

New Labour has pushed marketisation andprivatisation forward, at least as zealously as theConservatives did, narrowing the frontiers of thepublic domain in the process… Though it sometimestalks the language of community, it refuses toacknowledge that community loyalties can be forgedonly is a social realm protected from market power...When they say they are new, they (New Labour)mean they have abandoned the old social-democraticdream of mastering or remodelling capitalism.47

Patricia Hewitt called for choice and competition butsays in the same breath that the NHS is ‘a beacon ofcompassion and an ethic of care, of fairness and socialsolidarity, mutual responsibility one for one another,in times that so often feel harsh and individualistic. Ineverything we do, in every change we make, we willnot compromise those values.’48 But she advocatedpractices and processes that are antithetical tocompassion and care. Competition is not aboutcompassion but the survival of the fittest. Oppositionto such values is not about being anti-market butknowing when and where they can work best.

The new Brown administration has applied the brakesto some aspects of the commercialisation of the NHS.The next wave of ISTCs are being halted in theirtracks. But the signals are mixed. There are plans toask Virgin and Tesco to offer rival services to generalpractices and private companies are being asked in tolook at the takeover of the management andcommissioning functions of PCTs.49 The privatesector is expected to have a key role to play indelivering new general practices and health centres,and there are moves under way to induce greatercompetition for patients.50 Primary care could beturning into the new frontier for the marketisationand privatisation of the NHS, a process that coulddisrupt the continuity and engagement that will be soessential to tackling new health challenges, andundermine the integrity and equity of the entiresystem. The potential takeover of PCTcommissioning by the private sector opens the systemup to wholesale influence by market forces and

competition. Companies like UnitedHealth andMcKinsey will be able to access sensitive andprivileged date and be able to extend their influenceinto more profitable areas of health. This could becontracting out on a grand scale. Suspicion andmistrust in the search for profit will then replacegoodwill and cooperation. The patient pathwaythrough the system may become a vicious minefield ofcompeting interests.

Another worry is the growing support forindividualised budgets in social care in particular.Again the issue is one of emphasis. While there maybe a role for people to make more personaliseddecisions there are problems. On a practical level, ifpeople become their own commissions then the scopefor inefficiency, duplication and fraud grow – as wesaw with individual learning accounts. The system willfind it harder to plan and patients are faced with whatcan become the tyranny of choice. At an intrinsic levelwe should be concerned about a step towards Toryvouchers for public services and the implications forthe individualisation and consumerisation of services.And some will always make better choices than others.That’s fine on the high street but shouldn’t be the casein public services where top up payments could easilytake us towards a two tier service.

We are ending up in the worst of all words, with anNHS that is part machine and part market. It’s neitherunder tight central control nor is it subject to the realrigours of the market based on price competition.New Labour has not gone beyond the old left and thenew right into some new synthesis but has simplycombined the two into a disfigured hybrid. Above allthe guiding philosophy of New Labour is that peoplecan either be bossed or bribed into accepting theirreform agenda. Simon Jenkins has called it regulatedprivatisation. The big stick of the centralised state isbeing used to force people into the ‘freedom’ of themarket. Under New Labour to be ‘successful’ theNHS must increasingly behave like the thing it wascreated to replace – the vagaries and injustice of amarket-based system of health provision. It’s littlewonder that in 2006 the then Secretary of State forHealth announced that ‘there is a sense that the serviceno longer knows where it is going’.51



The NHS as paradox

The brilliance of capitalism is its single mindedpursuit of profit. That’s all it knows how to do. Ifit is given the chance to profit from hip operationsthan it will try to make a profit from knees next.It is irrepressible unless we decide collectivelywhere it is morally and practically right and wrongto go.

As Alan Finlayson argued in 2004: ‘True choice,unlike market choice, requires the possibility thatwe might change the terms on which choices areoffered to us.’52 Public services like the NHS areinherently political and cannot be reduced to theself-interested decisions of individuals. This isimportant because the market doesn’t just corruptand corrode the NHS; it also makes us ill. Obesity,diabetes, drug abuse and mental illness are all inpart a result of the market madness that consumesour society and creates the social recession. Themarket is not the answer to the future of the NHS;it is part of the problem. We are not just rationalchoice theorists working purely for money or self-interest. People working in the NHS – doctors,

nurses, ancillary staff, therapists, porters, cleaners,cooks, receptionists – have many motives for whatthey do, like pride in the job, or working in a placethat has a remarkable ethos. Patients and the widerpublic don’t want just what is best for them butknow that need comes before greed. This is not howmarkets function.

If the commercialisation of markets andcentralisation of the machine are of limited value tothe mechanical and moral development of theNHS, then what? Before we attempt to answer thisquestion it is vital that we examine and understandthe NHS as a paradox. It has already beenestablished that the NHS is riven by tensions due tothe fact that it is a social democratic bubble in a seaof capitalist values, institutions and forces. A furthertension arises over the pretence that rationingdoesn’t exist. It clearly does, and is either beingsolved by professional decisions or by yourpostcode. But there is a wider and irresolvabletension at the heart of the NHS: between our desirefor equity and our need for diversity.

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CCEENNTTRRAALLIISSAATTIIOONNWhat: Targets, plans and regulationWhy: Important because it is the basis ofequality; those who get the worst services wouldlove a big dose of uniformity if it meant theirservices were raised to the standards of the bestHow: As little as possible to ensure the maximumamount of equality

DDIIVVEERRSSIITTYYWhat: localism, working with or learning fromprivate and third sectors, organisational autonomy,challenge, contestability and choiceWhy: Important for innovation and localinvolvement and freedom to experiment, to learnfrom best practice and from mistakes; localismalso allows for setting of local prioritiesHow: As much as possible commensurate with thedemands of equality

PPRROOFFEESSSSIIOONNAALLIISSMMWhat: Ethos, training, judgement and experienceWhy: Because doctors, nurses and other staff haveunique expertise and experience that will always bean essential ingredient of any successful programmeof modernisation, and can work on long-term goalsHow: As much as possible while ensuring it isaccountable and responsive

VVOOIICCEEWhat: Participation, democracy and co-productionWhy: Because it is the only route to sustainablereform improvementsHow: As much as possible, in all circumstances and atall times up to the point that citizens and workerswant no more of it; care must be taken to ensure allvoices are heard otherwise there can be a clash withequality.



The NHS as paradox

This is a paradox and as such holds within itfundamental contradictory forces that cannot beresolved; only managed to the best of our ability.The fundamental paradox at the heart of the NHSis that we want health equality, as nothing can bemore fundamental than the right to live as long andas well as anyone else. The accident of birth, bothwho you are born to and how healthy your body is,cannot be allowed to shape the quality of your life.Health equality demands state intervention throughan institution like the NHS. But as pluralists anddemocrats we know that local decisions are crucialto build buy-in and support for the NHS and thatdiversity and experimentation are essential toinnovation and the kind of creativity that will seethe service modernise to meet new demands andchallenges.

In essence the paradox between equity and diversityspeaks to a deeper tension that is the driver of humandevelopment and progress – between our need forsecurity and our desire for freedom. We want certaintyand to be free of anxiety and insecurity but we alsowant to be liberated to ‘do our own thing’. Thesecompeting desires are engine that fires our restlessnature as we struggle to satisfy both competinginstincts.

However, diversity, the freedom side of our dualnature, leads to difference and difference can sit inconflict with equality, at least some of time. This is aproblem because we know that the centralisingmachine metaphor doesn’t work: it neither controls,because control is impossible, nor – as history hasshown – does it sufficiently equalise. If we imposerigid standards from the centre on everything thenthere is no space for local input or innovation. Wealso know that just letting go is a recipe forunacceptable inequity. The areas with the richestpeople will inevitably end up getting the best serviceand private providers will cherry pick the mostprofitable procedures and patients. Poor peoplealways get the poorest service without active stateintervention to ensure greater equality.

However, the big problem is not the paradox butthe refusal to admit it exists. Politicians refuse to

accept there is a core tension that cannot be resolvedand so end up going through endless rounds ofreforms to try and do the impossible:simultaneously to satisfy the need for diversity andequality. The result is wasted time, resource and thefrustration of not being able to square such a circle.Polly Toynbee has written that ‘Tony Blair hasalready reorganised the NHS three times: this fourthattempt now puts back and sharpens the Toryinternal market he dismantled’.53 This inevitablyundermines the popularity of the service.

Arguing that you can have both equity and diversitywithout any tensions or trade offs is just misleadingspin. Instead, we have to find a means by which theparadox can best be managed. The issue is how?There are in essence four basic systems ofgovernance for the NHS, which need to bemediated and determined via democratic decisionswherever possible. The following matrix sets out thefour broad governance methods:

PPlluurraalliissmmThe battle between localisers and centralisers mustcome to an end. We need both. But both must bedemocratically accountable. Equality for the left issacrosanct because it provides the resources forpeople to express their freedom. But the non-marketimprovements being made in Scotland and Walesshow why diversity is also important. Scotland isdeveloping the concept of patients as partners indecision making and empowering and equippingstaff. The Scottish Parliament’s Health Committeehas come out in favour of direct elections forScotland’s area health boards. The war againstprofessionals must stop but the way professionalsoperate must be brought in line with the lessdeferential age we live in. Voice must be given thepriority of resources and time it needs to work.Instant fixes, blame and the extremes of the freemarket or top down targets must take a back seat.

John Kay has written about an approach called‘disciplined pluralism’, which he describes as‘decentralised choices with accountability’.54 Theobjective is to replicate the more complex and fluidoperation of teams who achieve common goals via



The NHS as paradox

cooperative activityeffected throughindividual decisions.The centre-left has sofar failed to come toterms with the needfor diversity andpluralism. This isprimarily because ofthe clash with equity.It is, however, morehelpful to identifyequality as a means toan end rather than anend itself. The end forthe left should be the

ability of people collectively to manage their livesand the institutions around them, especiallyimportant ones like the NHS.55

A crucial component of such liberty or autonomy isgreater equality. To be free agents we need theresources to put the theory of freedom into practice.I’m free to go to the best doctor on Harley Streetbut in practice I don’t have the money. Equality isone route to freedom. The second is solidarity. Wecan only self-manage our world when we do ittogether. Most of the big issues are impossible for usto address acting as individuals. Without sufficient

equality and solidarity as expressed through new anddemocratic forms of collectivism we are just leftwith the pseudo freedom of the neo-liberal right.What we cannot do is deny the human need andability to create, experiment and innovate. Thisdemands diversity and the space to be free.Diversity, by definition, comes up with differentand therefore unequal outcomes. This is made moreproblematic by the notion of diversity as a form ofcontestability or competition, although we have toaccept that public service institutions must be opento challenge and that quite rightly there is opencompetition for job vacancies in the NHS. The issueis how they should be challenged. Competitionbetween providers in health is not the answer, butdiversity does not necessarily equate to the profitmotive. It can and should mean the democratisationand decentralisation of the state as well as otherservice providers, as long as employment standardsand other egalitarian regulatory benchmarks areenforced. Ways of working need to be challenged toensure that the quality of service doesn’t deteriorate.Much of that could happen through bettermanagement, sufficient resources and politicalleadership that builds rather than undermines staffmorale.

As Compass has consistently argued, the answer isto dare more democracy.56

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The NHS as a democracy

The solution to the equity–diversity paradox of theNHS lies in giving the people who work in and use theservice the ability to help determine the trade offs andcompromises that inevitably have to be made. There isa limit to how meaningful participation can beeffectively enacted through individual choice.Individuals can only pick different services that areright for them. They cannot try and determine theoverall nature of the service. This is a political andtherefore a democratic demand. It is collective voice ofusers and producers that can allow the problems of theequality–diversity paradox to be owned, shared,understood and acted upon. Any externally imposed‘solution’ is only ever going to exacerbate thefrustration and tensions inherent in the system. Themarket’s invisible hand cannot resolve such tensions;nor can another round of top down reforms. Thepossibility of exit just provides a temporary safety valve,which allows some ‘consumers’ to make a limited rangeof choices. A target culture is fundamentallydisempowering. The reform solution will not comefrom without, but only from within the system.

By helping us manage the paradox, democracy andvoice provide ways of making the service moreresponsive, trusted, efficient and productive. Andthrough active engagement the ethos of the NHS isreinforced, and the willingness to pay for it throughprogressive taxation is underpinned. Throughdemocracy and voice we create the conditions for avirtuous cycle of sustainable improvement in the NHS.The value is instrumental, in that it makes the systemwork, and also intrinsic, as it builds the moral fabricthat underpins the NHS and therefore collectivismmore widely in society.

But to date democracy and wider participation hasbeen largely absent from the NHS as voice doesn’t fitwith either the machine or market models. There arefew democratic structures within the NHS. Indeed theSecretary of State is still the first elected representativeyou meet in the service – and the last. This is largelythe fault of a Labour movement that has neverrecognised nor cherished the role of democracy inpublic service delivery and always preferred to trumpaccountability and participation with elitism. That waspossible in 1948. It is impossible now. The age of blindloyalty and deference has gone. Public servants cannot

act just how they want – although as we shall see thereis a role for professional discretion, which should notbe obliterated by the force of markets or targets. Theprivilege of being backed and resourced by the publicmust be associated with public accountability andwhere possible collective participation in shapingpreferences.

Jack Stilgoe and Faizal Farook have argued that ‘whilepeople are imagined as consumers sending signals tothe health service through their choices, they areseldom seen as having much of a role to play once theirchoice has been made’,57 while the BMA has suggestedthat ‘the democratic deficit in the NHS’ has been oneof its key weakness since its inception, and that ‘findingways of strengthening local accountability’ may be ‘thekey challenge ahead of us’.58

It is the superiority in the NHS and other publicservices of voice above choice that the left mustdevelop and champion. Johnston Birchall and RichardSimmons wrote: ‘Voice acknowledges the complexityand political nature of public services … it recognisesthat there is often a need for (i) negotiation oversensitive political issues and (ii) trust-basedmechanisms of control. This means give and take onboth sides, which in turn depends on the resolution ofstructural and cultural differences… It (voice) is morefluid and flexible.’59

Choice assumes only a limited set of pre-determinedoptions. Voice is not pre-determined; everything andanything is possible. And collective voice can be amuch stronger driver of change and improvement thanindividual exit. Take your local general practice. If youare unhappy with the service your doctor’s surgery isproviding the answer now is to move somewhere else.But this is not easy. First you have to find an alternativepractice with the space for you. If you can you mightbenefit from this move but you are taking a risk. It’snot like switching from Tesco to Asda or making easyprice comparisons. It takes time and you can’t easilyswitch back. Information on what general practicemight be best is available but it’s not very revealing.Pro-market reforms would call for more information,but that means more bureaucracy. Anyway, if there ismore information it will be exploited more thoroughlyby those most able to do so: the better off.




But what does this kind of switching do to theservice as a whole? Does it send a signal to generalpractices to make them sharpen up their act andbecome more efficient and user friendly? Well, overtime perhaps, but only if enough people leave theirsurgery. But more will join just because of localdemographic changes. So the signals to the generalpractice will be very unclear. If there are anycontestability impacts they are likely to be messyand very slow. As the practice loses its most mobileand articulate patients the service is likely todeteriorate. But what if the full logic ofcontestability is realised and exit leads to the closureof the surgery? Those with cars might be fine, evenif other surgeries can soak up the new demand. Asever, it will be the poor who will suffer most.

But wouldn’t it be quicker and more efficient ifthere was a form of collective voice which allowedproblems and potential solutions to be raised,discussed and actioned before anyone had to thinkabout leaving? If one patient leaves a generalpractice the signal is minuscule. But if twenty or ahundred say they are unhappy about someone orsomething, or want different opening hours or morespecialist nurses, and say so through a collectiveaction like sending a mass email or signing apetition, then the signal would be loud and clear. Itis worth considering whether the Child SupportAgency fiasco would have lasted so long if thoseentitled to payments could have dismissed its chair.Would farm subsidies have been paid more quicklyif the Payments Agency Board was elected byfarmers? Voice is a more effective system ofaccountability than exit in the NHS.

Voice allows difficult decisions to be determined bydeliberation and consensus. Hospital closures andother forms of rationalising and good planning maywell be justified but they need to be explained toworkers and to local users if protest campaigns andgeneral disillusionment are going to be avoided. It istheir hospital or social care centre and they must havesome say over its future. If it is the public’s service thenthe public must be part of its governance. A serviceprovided with them, not just done to them. Ultimatelywe need a choice about the balance between choiceand voice.

The government can talk a good fight on voice but dothey deliver? The Picker Institute think not. A reportin October 2007 claimed that a £43 billion increase inNHS spending over the past five years has failed tocreate the patient-centred service that everyone claimsthey want. The Institute found that almost half ofhospital patients were not as involved as they wantedto be in decisions about their care, with no change inviews since 2004.60 A similar report from Which?found that half the patents treated in NHS hospitalsare unhappy with aspects of their care but few thoughtit worth complaining, and of those who did complain,only a quarter felt their complaints were wellhandled.61

CCoommpplleexxiittyy,, ttrruusstt aanndd bbeetttteerr hheeaalltthhThe case for voice over choice is made by thecomplexity of the NHS and the inability of eithercontrol or commercialisation to manage satisfactorily asystem where, according to Hilary Cottam and CharlieLeadbeater, ‘innovation is widespread but difficult topropagate’.62 In the NHS, know-how, effort andexpertise are distributed resources that requirecollaboration, co-creation and constant innovation. Forexample, to deal with chronic rather than infectiousdiseases requires continuous support close to users thatis adaptable, joined up and ‘assembled round people’63

and their distinctive needs. A machine can’t do this anda market leads to unacceptable levels of inequality. Butit is also the case that you can’t transact your way out ofchronic diseases. There are no over-the-counteranswers that can be bought. It’s about behaviour,environment, culture, family, diet, happiness andpoverty. The issue is not just to dispense health in somesimple top down system but how to run what isinevitably a complex process where people can behelped to manage their own health better throughmentors, facilitators, improved knowledge, coachingand feedback.

Cottam and Leadbeater see the NHS as akin to e-Bay– a mass peer-to-peer complex system that is highlydistributed but popular and effective. It is an involvedprocess where people learn through participation,sharing, co-operating, talking and listening. In thesame paper they argued: ‘In the 20th century, publicgoods were created by professionals working indedicated, hierarchical organisations, delivering packets




of services to waiting, deferential users; doctors madeyou better… In the 21st century, public goods andservices will be crated interactively, throughpartnerships between professionals and users and byuser collaboration. These alliances, partnerships andcommunities will co-create new services.’64

The trust required of the NHS is different from trustafforded to a private company like an airline. We maytrust BA to fly us safely to New York but that doesn’tmean we trust them to serve our interests all of thetime or know how to balance our interest against thelegitimate interest of others. They will charge us asmuch as they can to take the trip regardless of ourability to pay. With a GP, surgeon, nurse or careworker we have to have absolute trust that they areacting fully in our interests, although that doesn’t meanwe don’t ask questions and push for what we think isbest for us. Peter Taylor-Gooby argues: ‘Work inpsychology and sociology indicates that trust has twomain components – a cognitive judgement that anagency is competent and efficient, but also anemotional belief that it operates in one’s interest – thereis little point in putting ones trust in a health servicewhich has the highest standards of expertise, but whichcan’t be relied on to use it when you need it.’65

Commercialisation undermines trust because it isbased on vested interest and therefore suspicion.Market systems detest professionals and try either toeradicate them or to tie them down through audit,regulation or consumer power. This replaces trust withthe threat of exit or competition and fuels thelegitimation crisis within the NHS. As DavidMarquand has said: ‘The market domain consumestrust; it does not produce it.’66

The NHS could be transformed on the basis of trustrelationships that come from debate, dissent,consensus and, yes, difference. It is a maturecitizenship we should be aiming for, which is thevery opposite of the widespread cynicism we seetoday in our commercialised world because peopleare either treated as passive targets or consumers.

VVooiiccee aanndd eeffffiicciieennccyyTrust born of voice and participation is not just anintrinsic good but an instrumental one. Trust cutstransaction costs. Productivity in the NHS, despite

the claims of the commercialisers that only marketsare efficient, is flat or falling. Neo-liberalism willalways argue that the problem is that markets aren’tfree enough. Experience to date would suggest thisis not an argument we should entertain. Because thegovernment piles reform on top of reform,undermining improvements that have just beenmade, the idea that the system is inherentlyinefficient is now widespread. When asked whatthey think of the extra spending on the NHS since1997, 72 per cent of the public think ‘a lot has beenwasted’.67 Like any organisation some money will bewasted. ‘Choose and book’ should have cost £65million and now stands at £200 million and theystill can’t get it to work. Millions are paid in fines tosuppliers because of the delayed IT system; £2billion worth of cuts per year have only recentlybeen identified by ministers when the system shouldbe getting more productive through new technologylike new replacement hips that last much longerthan the old ones.

A report by the TUC shows that the commonjustification of market efficiency and public waste forcuts and savings is unfounded. In fact the public sectordelivers services with far fewer managers than theprivate sector. It also has fewer administrative jobs thanfinancial services, including the City. The report,drawing from the Labour Force Survey, draws thefollowing conclusions:

! Managers make up 7.5 per cent of the publicsector employee workforce compared with 17.2 percent of the private sector employee workforce.

! There are roughly 6 employees for every managerin the private sector compared with roughly 14employees for every manager in the public sector.

! In large workplaces employing 250 or moreemployees, 9.6 per cent of the public sector employeeworkforce are managers compared with 18.7 per centin the private sector.

! Managers make up 27 per cent of the private sectorfinancial services employee workforce and 21 per centof business services compared with 12 per cent inpublic administration.




! Private financial services also employ the mostadministrative workers, at 34 per cent, compared withpublic ‘administration’ at 26 per cent.68

The democratic left must start to make the case thatvoice and participation increase not only fairness butalso efficiency in complex public services like theNHS. This view of the creation of ‘public value’ is intune with the basic progressive belief that given theright inputs of time and resource people who deliverand use a service can make the right long-termdecisions about its effectiveness. Lasting efficiency andproductivity gains built into the system cannot beimposed externally through the bullying of themachine or the bribery of the market. Voice can createa virtuous cycle of efficiency. According to SimonCaulkin, ‘Organisations that treat people as optimistswho want to do a good job can create the conditions inwhich creative optimists succeed, abolishing the needfor expensive control… A company that functions onthe basis of trust and co-operation creates a system, inwhich co-operating people flourish. The more itflourishes, the more the norm is reinforced. The self-fulfilling prophecy makes the company quite literallyinto a force for good.’69

Greater user involvement can also help us seebeyond crude targets to ways of maximising truepublic value, which is always more complex and hasan irreducibly experiential dimension. New thinkingabout patient and public involvement is looking athow the notion of ‘experience-based design’ can bebrought into the NHS; finding out about howpatients experience the service and using this to ‘co-design’ services. Paul Bate and Glen Robert havepointed out that the NHS has focused on designingprocesses and pathways, but less on patientexperiences: ‘one can have the perfect process (fast,efficient, not bottlenecks) or pathway (evidence-based) but an incredibly poor experience’. Inexperience-based design ‘the traditional view of theuser as a passive recipient of a product or servicegives way to the new view of users as the co-designers of that product or service, and integral tothe improvement and innovation process’.70 Thiscould be an important part of the solution to whatMadeleine Bunting and Simon Parker have called‘the tragedy of the call centre’ – reforms that might

on paper seem to help a service meet efficiency orperformance targets but which actually result in animpersonal, frustrating and alienating experience forthe user that erodes trust and loyalty.71 There aremany examples of patients being involved inredesigning ‘patient pathways’ – to stop peoplegoing round in circles, which wastes their time andthat of the health professionals; often it means thereare more local decisions and delivery.

Finally, voice and participation through a democratisedNHS helps make the case for funding and the sensibleallocation of resources. Through greater involvementand participation the criteria for setting prioritiesbecomes more transparent. People learn that noteverything can be funded – what they want to know iswhat can be funded and whether they can influencefunding decisions. A more deliberative process makesthe case for taxes to increase for the NHS because itbecomes ‘our’ service and allows consensus about thetrade offs that have to be made. In a report for theNational Consumer Council Johnston Birchall andRichard Simmons72 summed up some of the benefitsof voice in this way:

! Public service participation engages the less well offin society.

! Time constraints are an initial barrier but once theystart people find the time to participate.

! Users are often motivated to participate throughconcern about issues such as poor quality or ‘puttingsomething back in’.

! People say they participate for others, not primarilyfor themselves – collectivist incentives are the mostimportant at all points of participation.

! The longer their participation the more peoplealign themselves to collectivist rather thanindividualistic factors.

! Loyalty was strongest if it was felt providers werereceptive.

! Knowing the option of voice was available even ifthey didn’t use it was important.




SSttaarrttiinngg tthhee ddeemmooccrraattiicc ttrraannssffoorrmmaattiioonn ooff tthhee NNHHSSThe transformation of the NHS into a more self-sustaining and self-managed entity must be based onproducer and user participation and voice in shapingthe nature of the service and managing theequity–diversity paradox. There should be an easilyaccessible menu of democratic and participatoryoptions so people can use voice when and where theywant. They would be ladders of participation whichtake people onto the next stage of engagement if that iswhere they want to go. Often people first engage onissues about the structure of the service but end upfocusing on values. It cannot be about spin. Voice mustbe a meaningful system of control accountability andmotivation – not just about what the service is doingbut what it should be doing.73 If people perceive it asjust a PR exercise with no resulting shift in power theywill quickly withdraw and are unlikely to return – theninstead of a constituency of concern there will be aconstituency of cynicism.

To date the government’s major focus has been a mixof centralisation and targets alongsidecommercialisation and marketisation. Both areanathema to voice and participation. There is afledgling programme of patient and publicinvolvement (PPI) but the systems of voice andparticipation offered by the government since 1997have been confused and ineffectual. Brian Fisher,practising GP and PPI lead for the NHS Alliance, said:‘At present the NHS is not accountable to its users orto the public.’74 The Picker Institute analysed datafrom 2004 and 2005 from Australia, Canada,Germany, New Zealand, the USA and the UK on thequality and extent of patient involvement in theirhealth systems. The UK was lowest on all sixindicators. The NHS came top of a comparativeranking of health systems recently published by theUS-based Commonwealth Fund because of its highlevels of equity, efficiency and quality care, but hereagain the UK scored the lowest on patient engagementmeasures.75

It’s little wonder. In 2000 New Labour abolishedcommunity health councils (CHCs) to replace themwith the Commission for Patient and PublicInvolvement in Health (CPPIH). But this wasabolished before it ever really got going. CHCs were

replaced by the PPI forums but the problem with thePPI forums is that they are under-resourced and ofvery uneven quality. Now the HealthcareCommission has some regulatory responsibility forparticipation and engagement but that is beingmerged with the Commission for Social Care.Adding social care to its responsibilities is not theproblem; the problem is that it doesn’t have teeth.Local Involvement Networks (LINks) are supposedto address the local democratic deficit but no oneknows what impact they will have. It remains to beseen how members of LINks will be recruited,supported and developed in their roles, and how itwill be ensured that disadvantaged groups have a fairopportunity to be involved. There are also concernsthat they will be unable to review contracts drawn upwith independent providers and that their powers toenter and view premises of service providers do notextend to private sector companies. Foundation trustshave over 500,000 members but are little more thanempty vessels when it comes to real accountability asthey are starved of information and focus only onminor issues. The accountability gap in mostfoundation trusts is likely to come back to haunt thesenior managers as soon as there is a financial oroperating crisis. The mutual element of foundationtrusts was a last minute add on to sell the principle ofindependence to sceptical Labour backbench MPs.Patient Opinion, the online forum for feedback onthe quality of service, may be a step in right direct,but again it is based on informal feedback not formalaccountability whereby views translate automaticallyto action. Real power is not transferred to either theworkforce or the people. All the time that eithercommand and control or choice are the meta-valuesof the reform agenda voice cannot be mainstreamed.

There is a clear gap between people’s experience ofinvolvement in local health decisions and what theywant. The Joseph Rowntree Reform Trust AnnualState of the Nation Poll 2006 found when they asked‘How much influence do you think you have affectingpublic services in you local area?’ that when it came tohospitals just 2 per cent thought they had a lot, afurther 6 per cent thought they had a fair amount and57 per cent thought they had none at all. Asked ‘Howmuch influence should you have on hospitals?’, 81 percent thought they should have a great deal or a fair




amount. There is then considerable untappedparticipatory potential.

Not everything could or should be decided by a vote oruser and worker voice. But the broad direction of traveland management, delivery and accountability of theservice should be governed democratically. Thereshould be no big bang to this democratic reformagenda and certainly no imposed solutions. Instead,experimentation and trial should be unleashed andthen mainstreamed over time. Democracy is never aquick fix. It is a complex and time-consuming searchfor ways of making change popular and lasting changehappen that is rooted in values but which allowcontinuous improvements and changes to be made. Atdifferent levels there will be different answers to thedemocratic deficit the NHS faces. There are lots ofways in which voice, participation and democracy canbe established. The following provides an indication ofthe kind of areas that are worth considering in theNHS.

GGeenneerraall pprraaccttiicceessGeneral practices are perhaps the easiest place todevelop greater democratic accountability because likeschools there is a high level of community investmentin the surgery through frequent use, often over timeperiods that are much longer than our temporaryinterest in schools. An annual general meeting ofpatients would be easy to organise as a starting point togenerate ideas for improvement and complaints. Anactual or virtual notice board to trigger issues wouldalso be simple and cheap to set up as would an annualsurvey of patient satisfaction. General practices andgroups, which now have a huge influence because ofpractice-based commissioning, could instigate citizens’juries for major decisions or develop and deepen therole of informal patient participation groups. Perhapsthe biggest and most radical step would be to considermutualising GP services, either through democraticownership by patients or extending the model ofgeneral practice co-operatives developed to provideout-of-hours services to involve all healthcare staff andregistered patients. We could also create opportunitiesfor communities – particularly those communities thathave poor primary health care provision – to employtheir own salaried GPs. Currently only PCTs can dothis but we should seek to create local opportunities for

people to own and shape their own healthcareservices.76 But at the same time as looking for ways ofdecentralising control over services we will need toensure this does not exacerbate inequalities betweendifferent localities or groups of users. This could be aparticular danger where mutualisation is combinedwith patient choice initiatives that create a competitivemarket in which ‘successful’ practices find ways of‘cream-skimming’ the more desirable patients.77

Similar issues arise with the increasing role of socialenterprise in the delivery of primary and communitycare, which has been promoted by the government onthe grounds that mutuals and other ‘third sector’entities are uniquely placed to mobilise staffcommitment and involve patients and communities.78

We need to look at ways of developing models ofprovision that are co-owned by staff and patients as analternative to the profit-seeking multinationals that arenow moving into the primary care sector.79 But it isessential to ensure that such initiatives do not result ina deterioration of employment standards or thedevelopment of a competition for service deliverycontracts that will subordinate social values tocommercial imperatives.80

HHoossppiittaallssHospitals are highly complex organisations, which donot have a long-term client group in the way thatschools and general practices do, which is one reasonwhy current foundation hospital governance, involvingself-selected members, does not yet work. There is nonatural constituency with sufficient interest to vote outan underperforming directorate. General practices andPCTs are hospitals’ long-term clients and so hospitalscould be democratically accountable to localcommissioners, advised by the new health and socialcare regulator to be created from the merger of theHealthcare Commission and the Commission forSocial Care Inspection. If the general practices andPCTs are more accountable to their local communitythen at least some line of indirect accountability thepublic can be maintained.

But the movement is away from big general districthospitals. Micro-surgery, personalised drug treatmentsbased on patients’ genetic make up, and mobile andeasier diagnostics all point towards more local and less




costly treatment outside hospitals. We could see acomplete change in the process of health delivery inthe NHS – moving away from GP consultation,referral, diagnostic, waiting list and eventually hospitaltreatment towards something that is more immediateand engaging – less administered to patients and morecreated by them. The potential of these advances iswhat is fuelling the demise of the district generalhospital and the rise of poly-clinics and primary carecentres. This creates a double opportunity for thegreater development of voice. First, people will want tobe engaged in the decisions about the closure ofhospitals and will rightly be suspicious that theredirection of funding will make services more remoteand inaccessible. Ensuring that changes to the patternof service provision are based on independent clinicalassessment and open to local public scrutiny andchallenge has rightly been raised as a key issue for thecurrent review into the future of the NHS beingconducted by Ara Darzi.81 Second, the benefits of thistechnological change will not be captured for the mostexcluded and disadvantaged unless there is a directinvolvement of citizens in the way resources are used,designed and controlled. This arena could be a newbattleground between the large multinationals that willproduce the equipment and processes that produceand market the technology and the patients and staffthat use it. In effect patients will be confronted directlyby the large private companies delivering these newmethods of treatment much more directly – withoutthe intermediary roles of consultations, commissionersand hospital bureaucracies.

PPrriimmaarryy ccaarree ttrruussttssAt the local or regional level there is huge scope forradical reform. Local authorities could scrutiniseprimary care trusts (PCTs) in the same way that selectcommittees scrutinise government departments. Localcouncil health overview and scrutiny committees couldbe given a more formal role to call witnesses anddemand papers. It is interesting that Hereford islooking to merge the post of chief executive of theirlocal authority and PCT into one. This could be thefirst of a single democratic structure covering localcouncils and local health systems.

Martin Rathfelder of the Socialist Health Associationhas said that the abolition of community health

councils was a mistake and something like themshould be instigated again. This idea should beexamined. Can health boards be transformed intoregionally elected boards and at what level? Muchcould be learnt from the best practices of initiatives likethe New Deal for Communities and Sure Start. Thegovernment has considered allowing localcommunities ‘to choose who runs their PCT’ – whichwould certainly be a better way of ensuring theiraccountability than pitching them into competition forpatients.82 In Scotland there is growing support fordirectly elected seats on health boards alongsiderepresentation for local councillors, patients and staff.The new coalition government in Wales has promisedto ‘reform NHS trusts to improve accountability bothto local communities and to the Assemblygovernment’.83 The BMA has proposed the creation oflocal health councils, elected by and from the public,to represent local views, raise issues and allowcommunity discussion about service development.84

The chief executives of PCTs could be elected as anequivalent to local mayors.

All of this speaks to a deeper democratic issue forthe NHS – that greater local accountability ofhealth is predicated on the revival of localgovernment. Shortly before the formation of thenew Brown administration, Andy Burnham, thethen Health Minister, argued, ‘In this more localworld, a piece of unfinished business is how toensure that powerful commissioners, taking vitaldecisions for the community, have more locallegitimacy and are better held to account… Directelections to PCTs are an option,’ he suggested, ‘butI would prefer a solution that better engagesCouncillors and MPs in the day-to-day work of thePCT.’85 These sentiments have been echoed in anumber of ministerial statements since GordonBrown’s arrival in Number Ten.86 By merging healthinto local government this could be just thekickstart that local democracy in Britain needs.

An important objective must be to ensure that there isadequate public involvement in key decisions aboutcommissioning or service reconfiguration at an earlystage, so that we do not have a repeat of the situationin Derbyshire where a local resident successfully tookthe PCT to the High Court for failing to consult




before handing general practice services to a majormultinational corporation.

Another democratic avenue worth exploring has beensuggested by John Denham MP. He recognises that itcan be hard for elected managers to implement changebecause they know they will have to face the voter’sverdict and could be too prone to caution. Denhamtherefore suggests that inspectors and auditors could beelected.

NNaattiioonnaall ggoovveerrnnaanncceeAt a national level, citizens’ juries or a people’s assemblycould be used to discuss, debate and come toconclusions about the trade offs necessary when itcomes to the postcode lottery or the adoption of newmedicines like Herceptin. But here the government hasto be careful. Citizens’ juries work if their decisions arebinding. They cannot be engagement camouflage fordecisions already taken or being made elsewhere.

The National Institute for Clinical Excellence, whichissues guidelines on the clinical and cost-effectivenessof expensive treatments with the aim of clarifyinguniversal patient entitlements, runs a citizens’ councilmade up of thirty people drawn from all populationgroups to contribute to thinking about the valuejudgements that inevitably influence such decisions.This has been described as ‘a unique experiment indeliberative democracy for the NHS and seemingly foralmost any healthcare system in the world’. But its roleremains marginal and relatively underdeveloped, and itis arguable that much more will be needed along theselines if the NHS is to navigate successfully the crises oflegitimacy that are likely to attend such ‘rationing’decisions.87

One reform being touted as a possible measure for thenew premiership under Gordon Brown is for theexecutive management of the NHS to be floated off toan independent board just like the Bank of EnglandMonetary Policy Committee. The BMA in particularis keen. But this would just signal the political defeat ofthe service. Running the NHS is not just an issue ofensuring there is better management but involvesintensely political decisions about funding and thetrade offs between equality and diversity. It is anadmission that politicians can’t be trusted to take the

right long-term decisions. As Niall Dickson of theKing’s Fund said recently, ‘The trouble is thathealthcare is not just a technical function – it is riddledwith value judgements. It involves balancingcompeting priorities and interests. It is highlypolitical.’88 The idea for an NHS charter is a better idea– but only if it is determined by the public, patientsand NHS workers. Not just by politicians.

CCoo--pprroodduuccttiioonn8899

The democratisation of health is a necessary butinsufficient step towards the purposeful modernisationof the service. The transformation of the NHS also liesin the development of co-production. This is the ideathat all employees and patients should be at the heartof producing and reforming the service. Unlikecustomers in a shop, where all we have to do is chooseand pay, in a hospital or local surgery we are jointlyresponsible for making the service work. We have toturn up on time, take our medicine, provide feedbackand learn to manage our own conditions.

In a recent article Charlie Leadbeater calls this the‘DIY state’. He says, ‘Instead of imposing yet moretargets and performance management, we need adifferent picture of how public services could beorganised. The key to this will be to see service usersnot as consumers but as participants.’90 Leadbeatertalks about an ethic of participation and self-management based on such successful web-based peer-to-peer systems as MySpace, eBay and Wikipedia.These semi-public initiatives provide a glimpse of anew notion of common goods. The problem with theLeadbeater analysis is that it is overly individualised.Instead we should aim for the ‘DIO state’ – the ‘Do ItOurselves state’ – because of the recognition thatindividuals can only change so much – but actingcollectively we can achieve so much more. CabinetOffice Minister Ed Miliband has rightly warned in arecent Demos pamphlet that ‘involving users andcommunities must not be an excuse for the withdrawalof the state – a form of “DIY welfare” in whichpatients get less support and services get less funding’.It must be a progressive vision of co-production thatthe centre-left aspires to.

An example of how comes from RED and what theycall public service ‘mobs’. RED applies the lessons of




design to public service reform. The challenge wasto get patients fit after care. One method was to givethem money or vouchers to spend in a private agym – a classic private sector answer. But gymsrarely work. People usually give up after a month orso. Instead RED encouraged patients who lived neareach other to go out walking or running together.The cost was virtually nil but the peer grouppressure and camaraderie sustained physical outdooractivity that worked. Participation as co-creators ofthe service was better than commercialisation,which would have looked at choice andcommoditisation as the answer. Examples like thisneed to be worked up into a systematic alternativeto the machine or the market. Not least because asRobert Puttnam and others have found,engagement, trust and the building of networks andsocial capital makes us well. People who join andparticipate live longer that those who don’t.

EEmmppoowweerriinngg ssttaaffffPlacing staff at the heart of the reform process is thekey. As the Chartered Institute for PersonnelDevelopment has stressed, successful public servicereform depends on ‘the commitment, motivation andinnovative contributions of all those who work for thepublic’. The key to this will be the ‘quality of therelationship between people and their employer’ andthe government’s ability to ‘energise, enable andempower’ all staff in the cause of serviceimprovement.91

Here is at least one lesson we can learn from the bestof the private sector. Successful companies likeVirgin argue that their most important stakeholderis their staff. If they keep their staff happy andinvolved then they know their customers will besatisfied. Happy customers means happyshareholders. This argument is backed up by TerryLeahy of Tesco, one of the government’s favouriteadvisers on public service reform: ‘The beating heartof Tesco is the checkout assistant and the shelfstacker… What our staff do is determined by howthey feel about the company, not by rules andtargets… We spend most of our time making peoplefeel good about themselves and the job they do. Inthe main they don’t ground with criticism ringing intheir ears.’92

I was struck recently by the BT internet engineer whocame to get me back online after a move. First he saidhow useless BT was now its been broken into differentprofit centres with no one accepting responsibility forthe whole service as the customer falls helplesslybetween the network and the server. But it was the waythey have made the engineers’ working day ‘moreefficient’ that jumped out. Before they would meet in acafé and decide between them who would do whatjobs. It made sense to stick to one area each to cutdown on travelling. These meetings provided theengineers with an opportunity to tell each other aboutparticular issues at certain locations if they had specificknowledge of it. The system worked well and theyenjoyed it. Now they never see each other. The jobscome down the line and sometimes the engineers criss-cross London all day. They never get to discuss localproblems and solutions. Different profit centres meanthey can’t guarantee to customers that they can get theservice to work for them. Morale has dropped. Work isharder and much less rewarding for them, less efficientfor BT and provides a worse service for customers. ButBT, like the NHS, is in the grip of people who haveonly been trained to run machines or markets.

Despite this there are examples to learn from and buildon. The home care workers of the BirminghamUNISON branch won central government funding tofacilitate a new relationship with their managers –primarily over work rosters. Before relations withmanagers were to say the least difficult. The work washard enough and badly paid but inflexible works hoursmade it harder still, especially for parents. Managersspent the bulk of their time trying to sort out thecomplex rostering requirements. Through thepartnership fund the home care workers took completecontrol of their daily work load. They began to managethemselves. They became more flexible but moreefficient and responsive to those they cared for. Themanagers were freed up to take on new tasks and in theprocess the relationship between the two wasconstructively transformed. Everyone was better off.

An NHS Trust delivering mental healthcare andservices to people with learning disabilities inNottinghamshire, Yorkshire and Leicestershire came toa partnership agreement with staff side trade unionswhich included a commitment to develop new ways of




involving employees in reshaping services. Acrossprofessional and ancillary services groups of staff withinterdependent tasks and common goals could applyto become ‘self-directed teams’ (SDTs). Each SDT hada clear mission and relevant partners includingpatients, carers and external agencies. Facilitatorsworked with the teams to help them generate theirown ideas for improving and developing services.Working within policies and procedures established bythe Trust, SDTs were empowered to make manyoperational decisions without having to refer them tosenior management. Team members were given greaterresponsibility for scheduling their own work, lookingfor innovative ways of improving patient care, andcommunicating directly with patients, partners andstakeholders.93 Adeline Hunt, a facilitator and staff siderep, has written that ‘the SDTs promote realinvolvement, deliver flexibility, create a climate ofinnovation and bring decision making closer to thepatient’.94

In Chester a new mental health facility was developedon the basis of full involvement of managers,employees, unions and service users. ‘Building UserGroups’ were brought together to feed into the designspecification for the new building and help withplanning the layout of the wards, reception facilities,dining room and other departments. Involvement atthese early stages ensured the whole building was fit forpurpose and provided for the safety and dignity ofthose using the service. One innovation was theconstruction of a mock-up room to give all staff andusers a clear idea of what the new facilities would looklike. Feedback led to over 100 changes to the layout,including to the location of beds, furniture and lightsto enable nurses to monitor patients effectively. Highlevels of staff involvement have been built on throughbetter communications, involvement in decisionmaking, and enhanced training and personaldevelopment, and staff now feel more confident insuggesting changes to the service knowing that systemsare in place to take those changes forward. Theoutcome is more appropriate care being given to usersand people being put at the heart of the service andtreated with respect.95

And it’s not only localised examples – some of the mostimportant and extensive innovations the NHS has seen

in recent years have been made possible through thevital contribution and involvement of staff committedto the service. NHS Direct, which gives patients directtelephone access to health service professionals, was theresult of a call for new ideas from staff issued by thenew Labour government in 1997.96 The nurse-ledservice has proved hugely popular with users, and hasbeen hailed by UNISON as ‘public services at theirbest’. And trade unions played an absolutely vital rolein the design and implementation of Agenda forChange, a radical redrawing of professional andoccupational boundaries aimed at ensuring the NHShas the right people in place to deliver high-quality,flexible and responsive care to patients.97

Until now these experiences have been the exceptionrather than the rule, and policy makers have yet toseize the opportunities that could be created byempowering and mobilising public service employeesas leading agents of change. Co-production has notbeen mainstreamed. But more recent governmentstatements give some hope that a new start is possible.Earlier this year Andy Burnham, then still minister atthe Department of Health, reported back to PatriciaHewitt on the lessons learned from his days spentshadowing NHS staff. He had realised that ‘the NHSis not good at giving its front-line staff a sense ofempowerment. People with good ideas do not feel thatthey can easily put them into action; there is aprevailing sense that those decisions are taken bysomebody else.’ The future for the NHS lay not withmore targets and top-down management but ‘bottom-up empowerment of not just patients, but staff too’,developing ‘innovative systems – such as the LEANmanagement system – to equip staff with the skills tolead change in their area. Changes instigated anddeveloped by staff are more likely to succeed.’98 Thereis a wealth of international evidence to suggest thatinvolving employees as partners in change could have atransformative effect on levels of productivity andinnovation.99

The NHS Institute for Innovation and Improvementhas suggested that the service needs to move on from‘planned or programmatic approaches to change’ to adeeper engagement of NHS staff.100 Don Berwick ofthe Institute for Healthcare Improvement in Bostonsaid when visiting the NHS: ‘Prevailing strategies rely




largely on outmoded theories of control andstandardisation of work. More modern, and muchmore effective, theories of production seek to harnessthe imagination and participation of the workforce inreinventing the system.’101 On this basis the NHScould come to resemble something akin to a socialmovement – based on the recognition that large-scalechange in organisations relies not only on ‘externaldrivers’ but the ability to connect with and mobilisepeople’s own ‘internal’ energies and drivers for change,in so doing, creating a bottom-up, locally led, ‘grassroots’ movement for improvement and change.102 As avehicle for socialising engagement the NHS could bemuch more open and participative – allowing us all tocontribute in more active ways than simply paying ourNational Insurance and raising money for a newscanner. There is a huge amount of good will to buildon – ranging from volunteers in the WRVS café,volunteer drivers, visitors and so on through to thehuge effort people display in giving blood. Full-timestaff need to be paid properly but additional aspects ofservice and provision could be developed and served bywider social responsibility.

RReenneewwiinngg pprrooffeessssiioonnaalliissmmProfessionals have been under attack since theascendancy of neo-liberalism in the early 1980s.Rational choice theory holds that professionals willonly act in their own best interests and cannot betrusted to serve the public interest. One of the keychallenges for a new left is to re-establish the legitimaterole of professionalism in public services – but in amodernised form that takes into account the end ofthe era of deference and paternalism in whichprofessions once flourished.103

Professionals are defined by their training,independently validated expertise, qualifications andtherefore rules of entry into the profession. They canand must think about the public interest over the longterm for the good of society precisely because they arenot elected and not slaves to the market. Their driver isnot profit but should be pride in a job well done and asense of civic duty. Professionals have to be trusted atthe point of advice or decision. It is an elitist concept.

They know more because they have been trained andeducated in ways the public haven’t. There is a tensionbetween this exclusivity and the rights of citizens toparticipate and have a voice. Better informed citizensbecause of the internet are already producing adifferent relationship with professionals. But it willalways be professional judgement that has a hugebearing on the quality of public service deliveryespecially in health. Their judgement cannot beregulated, audited or commercialised away withoutservices deteriorating. Neo-liberals hate professionalsbecause they represent a ‘rigged market’. According toDavid Marquand, professionalism is not just ‘non-market but anti-market’.104 The underlying premise ofprofessionalism is that society will be better off ifcompetition is not free and prices are fixed.

The democratic left needs to back a modernised formof professionalism in the NHS. It’s not as ifprofessionals are putting up a fight against theinvolvement of the public. In a survey by Involve, 93per cent of health professionals say that ordinarypeople should have a say in how their local healthservice is run and that this would improve theservice.105 But the job of working out howprofessionalism can still fit with our less deferentialtimes is a key task.106

Deepening democracy, empowering staff anddeveloping a new professionalism will not be easy.Building trust, confidence and governance capacitywill take time. We need to acknowledge how difficult itis to get input from citizens and patients from allsections of society. Most forms of public/patient/userinput attract the ‘usual suspects’. One of the reasons forthis is that some of the questions are highly complex,and the formats of consultation assume a level ofeducation (and use of English) that not all possess. Andthen there are the ethical problems: the danger of lackof support for services whose users may be stigmatised.It will take investment and resources to facilitatemeaningful dialogue and decision making. Buteverything else has been tried and has failed to unlockthe systemic and holistic improvement the serviceneeds. Democracy is the last hope.



Conclusion

The left believes in public services because they areone of the most important means of ensuring theredistribution of life chances. After all, ‘we are allequal in our pyjamas’. Since 1997 the NHS hasbecome a better service. Cancer and heart servicesare significantly improved. Staff are better paid andthere are more of them. New institutions like NICEhave proved a success. And the terms of debateabout tax cuts versus public service investment havebeen effectively turned around. The 2001 generalelection campaign around National Insuranceincreases was the high watermark of this progressivetrend. But the space and time that has been won toreform the NHS effectively over the long term isbeing squandered.

The public believe theNHS is now inpermanent chaos.Neither the machine northe market is working. Amix of competition andcontrol is failing todeliver. The worry isthat the improvementsare a one off bought bythe huge increase ininvestment that can’tand won’t be sustainedwithout a change in theculture and operating

practices of the service and those who lead it. DavidCameron, like a benign vulture, is waiting in the wingsif things continue to go wrong.

Politics is about gambles made on values andinstincts. New Labour’s gamble to date has beenthat a mix of commercialisation and centralisationwill keep the middle classes on board through morechoice-driven services. The gamble of thedemocratic left is that democracy and participationis the answer to the paradox at the heart of the NHSand our need for equality and our desire fordiversity.

In choosing choice New Labour has attempted toforce its view of freedom on us. ‘Freedom’ is to be

handed down through targets, bureaucracies,incentives or a limited range of choices that are pre-selected for us. Their goal seems to be a nation ofhealth service switchers, like those who scour theMail on Sunday finance pages for the best deal ontheir mortgage. But markets have no morality, theyare as happy to sell us organic food or chips, dietpills or chocolate, cigarettes or Nicoret patches. Itdoesn’t matter what it is as long as it sells.

Martin Newland, writing in the Guardian, said:‘Despite being in government for nine years, NewLabour has never really learned how to govern. It hasbypassed the boring, methodical process of civilservant-assisted government in favour of eye-catchinginitiatives, quangos and paid advisers. Spending in keyareas has become diverted away from the front-line –away from actually making people healthier.’107

The democratic left have a different conception offreedom. This is not just the freedom to purchasegoods and services as individuals but to be free todetermine what kind of NHS, hospital and socialcare we want. This is freedom based on collectivevoice and is about control over our lives and ourworld. Such freedom can only be won from thebottom up and created by the people who work forthe NHS and use it.

To work, the NHS has to be a family, but after tenyears the staff and patients don’t love thegovernment and the government, at least untilrecently, has shown little appetite to love them. Allthat money spent, all those plans and reforms, allthose speeches and initiatives, and where have theygot us? At best on contested terrain with the Tories.This is not preparing us for the future. The NobelPrize winning scientist Sir Paul Nurse predicts thatthe entire system of private medical and lifeinsurance will shut down in 40 years because ofgenetic predictability. Only the NHS offers a wayforward. Brown offers an opportunity for a freshstart. It is an opportunity that cannot be wastedagain.

The NHS is one of the few remaining places wherethe values of the left resonate. The strength of

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Conclusion

public commitment to be ‘free at the point of need’and therefore notions of social justice have so farweathered the storm of neo-liberalism. But thepatience of the patients is not infinite.

The NHS prefigures the kind of world we want tolive in. The NHS must be a cathedral of socialhealing valued for what it is – not just for what itdoes. The NHS is there to make people better butso is BUPA. For the left there has to be a difference,otherwise the market will rule everything. Wecannot live secure and free private lives withoutpublic services that secure for us economic andsocial rights which make us equal citizens. Equalityis not some Old Labour baggage that we just have tonod to. Rather it is the prerequisite of a modern,open and progressive society in which all benefitand all contribute. Citizens are by definition equaland market rewards are by definition unequal. Thatis why we must fight for a modern NHS built onLabour values.

The left has been in retreat in part because the fearof the unregulated and unaccountable state isgreater than the fear of the unregulated andunaccountable market. Unless we can show that thestate can be democratised and personalised then themarket will continue to win. David Marquand sumsup the challenge well when he writes, ‘The stateceases to be a commander or a controller, andbecomes learner along with other learners – and, ofcourse, a teacher along with other teachers.’108

So the narrative of reform has to be dramaticallychanged. It will take a long time and there is nofinal destination. All of this must be explained andpeople allowed to respond. They are waiting to betreated as responsible grown ups. The starting pointis the observation of Peter Kostenbaum that ‘ourinstitutions are transformed the moment we decidethey are ours to create’.109

In 1946 Bevan sent a pamphlet to every householdabout the future of the NHS. It is time to instigateanother great debate about the most importantinstitution in our society. The moment is right to doit again – only for our age and our time.

On 4 July 2007 thenew Secretary of Statefor Health AlanJohnson announced afundamental review ofthe NHS to be led byProfessor Ara Darzi.The aim, Johnsonsaid, was to have anNHS that was‘clinically led, patient-centred and locallyaccountable’.Encouragingly, herecognised that thiscould not be a matterof imposing anotherblueprint from above:

‘The best of the NHS sits not at the top of theorganisation, but in the millions of complex,diverse relationships which exist across the countrybetween dedicated, devoted professionals and theirpatients. The success of the review will depend ongaining access to these relationships, andstimulating a range of lively, local, provocativedebates.’ The goal: ‘a new, closer, more robustsocial partnership between patients, practitionersand policy makers, based on trust, honesty andrespect’.110 Following the initial publication of aninterim report identifying immediate priorities,111

Lord Darzi is inviting the views of patients, publicand staff through a major online consultation anddebate combined with specialist forums and localevents.112 This will form the basis for thepublication of a new ‘vision for a world class NHS’to be published in June 2008 in time for the 60thanniversary of the NHS. This may be accompaniedby the publication of proposals for a NHSconstitution as part of ‘a new and enduringsettlement for the NHS’ that would ‘enshrine thevalues of the NHS and increase localaccountability to patients and public’.

These aspirations can be seen as continuous withthe broader project that Gordon Brown has begunto sketch in terms of rebuilding public trust andconfidence in state action and social provision by

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Conclusion

finding new ways of democratic engagement aboutthe public good. In his first statement to the Houseof Commons to launch his new programme ofconstitutional reform, the new prime minister setout his goal of forging ‘a stronger shared nationalpurpose – by a new relationship between citizensand government that ensures that Government is abetter servant of the people’.113 In hischaracteristically cautious, incremental, yet strategicway, Brown could be opening the way to a new eraof social democratic advance, by creating newmechanisms that could deepen people’s democraticinvolvement with social issues and social goals. Aninclusive debate about the future of our NationalHealth Service, and a new NHS constitution thatcould secure its values at the same time asembedding democratic deliberation as central to itsday-to-day working, could be a critical element ofthis story. But the success of such an initiative willdepend crucially on the active contributions ofpatients, staff, user groups, trade unions, local

communities and the public at large; and agovernment that is genuinely prepared to listen andbold enough to act on what it hears. If we hadstarted with this sense of purpose and direction tenyears ago then sustainable progress would now bebeing made. But it is never too late to do thingsright.

In September 2007 Gordon Brown made a speechabout democratic renewal in which he said, ‘I don’tagree with the old belief of half a century ago thatwe can issue commands from Whitehall and expectthe world to change. Nor can we leave these greatsocial changes simply to the market alone ... it ispeople who are engaged in changing the world asindividuals, parents, neighbours and activecitizens.’ He went on to say that his vision was ‘apolitics built on engaging with people, notexcluding them’.114 No issue is closer to thepeople’s hearts than the NHS. If they don’t engageon this issue they won’t engage on anything.



Endnotes

1 Department of Health (2007), ‘Shaping Health Care for theNext Decade’, news release, 4 July 2007.

2 www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_079716.

3 Commission on the NHS, New Life for Health, Associationof Community Health Councils, 2000.

4 Margaret Thatcher, interview in Sunday Times, 3 May 1981.5 Tony Blair ‘Europe Moving Forward Again’, Progressive

Politics, Vol. 4, No. 3, 2005.6 Second Reading of Commons debate on the creation of

foundation hospitals.7 See ‘Closer to Equality: Assessing New Labour’s Record

on Equality after 10 Years in Government’,www.Compassonline.org.uk.

8 J. Le Grand ‘Inequality, Choice and Public Services’. In A.Giddens and P. Diamond (eds) The New Egalitarianism,Cambridge: Polity Press, 2005.

9 Rosalind Raine and Martin McIvor, ‘Nine Years On – WhatProgress has been made in Achieving Health CareEquity?’, The Lancet, Vol. 368, No. 9546 (2006), pp1542–5.

10 Karl Marx, Das Kapital, quoted in David Harvey, A BriefHistory of Neo-liberalism, Oxford University Press, 2005,p180.

11 Mike Prior and David Purdy, Out of the Ghetto, Spokesman,1979.

12 Ibid., p113.13 Alan Finlayson, chapter in G. Hassan (ed.), After Blair:

Politics after the New Labour Decade, Lawrence andWishart, 2006.

14 Gordon Brown, ‘A Modern Agenda for Prosperity andSocial Reform’, speech to the SMF at the Cass BusinessSchool, London, 3 February 2003.

15 Ibid.16 Anna Coote, Renewal, Vol. 11, No. 3.17 Zygmunt Bauman, chapter in G. Hassan (ed.), After Blair:

Politics after the New Labour Decade, Lawrence andWishart, 2006.

18 John Gray, Essay, New Statesman, 6 June 2005.19 Julian Le Grand, ‘Healthy Controls’, Prospect, June 2006.20 See http://news.bbc.co.uk/1/hi/uk_politics/3694046.stm.

The poem Gordon Brown quoted was written by DrJames Stockinger.

21 Jack Chapman, chapter in G. Hassan (ed.), After Blair:Politics after the New Labour Decade, Lawrence andWishart, 2006.

22 Simon Caulking, ‘How Labour turned the UK into a SovietTractor’, Observer, 23 April 2006.

23 Simon Bowers, ‘NHS £6bn IT system poor value, sayexperts’, Guardian, 22 January 2007.

24 See www.kingsfund.org.uk/publications/kings_fund_publications/our_future.html.

25 Simon Caulkin, ‘Why Things Fell Apart for Joined-upThinking’, Observer 26 February 2006.

26 Simon Jenkins, ‘Blair is Blinded by a Belief that Big is AlwaysBeautiful’, Guardian, 13 December 2006.

27 Anne Perkins, ‘Targets are Damaging Services’, Guardian,10 January 2003.

28 John Carvel, ‘Public Sector Targets to be Scrapped’,Guardian, 18 July 2007.

29 Keep Our NHS Public (KONP) report ‘PatchworkPrivatisation’, UNISON, ‘In the Interests of Patients’,Pollock NHS plc.

30 Patricia Hewitt, ‘Investment and Reform: TransformingHealth and Health Care’, speech made at LSE on 13December 2005.

31 Ibid.32 Patricia Hewitt, ‘The Nation’s Health and Social Change’,

New Health Network, 2005, p22.33 BMA evidence to Health Select Committee on foundation

trusts, May 2003.34 Quoted in Public Finance, 14 March 2004.35 Patricia Hewitt, ‘Labour’s Values and the Modern NHS’,

Fabian speech, 20 July 2005.36 Ibid.37 Speech to launch Public Matters: The Renewal of the Public

Realm, Methuen Politcos, 2007, at RSA, 23 May 2007.38 Ibid.39 Robert Hill (ed.), The Matter of How: Change and Reform

in 21st Century Public Services, SOLACE Foundation,September 2006.

40 John Denham, ‘The Rigid Market Model Won’t Survive theReal World’, Guardian, 21 December 2005.

41 John Carvel, ‘Hospital Choice Irrelevant, Say Patients‘, Guardian,14 May 2007.

42 John Carvel, ‘Doctors Claim Study on Patient ChoiceSuppressed’, Guardian, 1 January 2007.

43 Johnston Birchall and Richard Simmons, ‘Choice, Voice andConsumer Involvement’ – paper at Treasury, 24 June 2005.

44 Theodore Dalrymple, ‘We Want a Doctor Who KnowsBest’, New Statesman, 12 January 2004.

45 David Walker, ‘The Negative Effect of the Tesco ModelSociety’, Guardian, 20 December 2006.

46 David Marquand, Decline of the public, Polity, Cambridge,2004, p3.



Endnotes

47 Ibid., p118.48 Patricia Hewitt, ‘Investment and Reform: Transforming

Health and Health Care, speech at LSE, 13 December2005.

49 Allyson Pollock et al., ‘The Market in Primary Care’, BMJ,Vol. 335, 8 September 2007.

50 Department of Health, Our NHS Our Future: NHS NextStage Review Interim Report, October 2007, pp25–26.

51 Patricia Hewitt speech to the ippr, 19 September 2006.52 Alan Finlayson, ‘Citizenship and the Democracy of Politics’,

Renewal, Vol. 12, No. 1, 2004.53 Polly Toynbee, ‘A Perfect Storm May Make the NHS a

Lightening Rod’, Guardian, 26 March 2006 54 John Kay, ‘The Failure of Market Failure’, Prospect, August

2007.55 Neal Lawson, ‘Freedom’, Centre Forum, 2006.56 Neal Lawson, Dare More Democracy, Compass, 2003.57 Jack Stilgoe and Faizal Farook, ‘Doctor, the Patient Will See

You Now’, in Simon Parker and Sophia Parker (eds)Unlocking Innovation: Why Citizens Hold the Key to PublicService Reform, Demos, 2007.

58 British Medical Association, ‘A Rational Way Forward forthe NHS in England – A Discussion Paper Outlining anAlternative Approach to Health Reform’, May 2007.

59 Johnston Birchall and Richard Simmons, ‘Choice, Voice andConsumer Involvement’ – paper at Treasury, 24 June 2005.

60 Seewww.pickereurope.org/Filestore/Publications/Trends_2007_final.pdf.

61 See www.which.co.uk/reports_and_campaigns/health_and_wellbeing/campaigns/Impatient_for_change/index.jsp.

62 Hilary Cottam and Charles Leadbeater, Health: Co-creatingServices, RED paper 01, Design Council, 2004.

63 Ibid., p17.64 Ibid., p35.65 Peter Taylor-Gooby, ‘Trust Versus Efficiency’, Prospect, April

2006.66 David Marquand, Decline of the Public, Polity, 2004, p33.67 ICM poll in the Guardian, 25 October 2006.68 TUC Report, ‘Bowler Hats and Bureaucrats – Myths

About the Public Sector Workforce’, available fromwww.tuc.org.uk/publicsector/tuc-9650-f0.pdf.

69 Simon Caulkin, Observer, 1 October 2006.70 Paul Bate and Glenn Robert, ‘Experience-based Design: From

Redesigning the System Around the Patient to Co-designingServices With the Patient’, Quality and Safety in Health Care, Vol.15, No. 5, 2006.

71 Madeleine Bunting and Simon Parker, ‘So Did Things ReallyGet Better?’, Public Finance, 22 September 2006.

72 Johnston Birchall and Richard Simmons, User Power: theParticipation of Users in Public Services, National ConsumerCouncil, 2004.

73 Richard Simmons, Johnston Birchall and Alan Prout, OurSay: User Voice and Public Service Culture, NationalConsumer Council, July 2007.

74 NHS National Centre for Involvement, Patient and PublicInvolvement (PPI) Health Democracy: The Future ofInvolvement in Health and Social Care, 2006. p95.

75 Karen Davis et al., Mirror, Mirror on the Wall: AnInternational Update on the Comparative Performance ofAmerican Health Care, Commonwealth Fund, May 2007.

76 Cliff Mills, NHS Reform: Consumerism or Citizenship?,Cobbetts and Mutuo, 2005.

77 See Richard Lewis and Jennifer Dixon, The Future ofPrimary Care: Meeting the Challenges of the New NHSMarket, King’s Fund, 2005, pp13–14, 19–21.

78 Patricia Hewitt, Social Enterprise in Primary and CommunityCare, Social Enterprise Coalition, 2006.

79 Richard Lewis, Peter Hunt and David Carson, Social Enterpriseand Community-Based Care: Is There a Future for MutuallyOwned Organisations in Community and Primary Care?, King’sFund, 2006.

80 Linda Marks and David Hunter, Social Enterprises and theNHS: Changing Patterns of Ownership and Accountability,UNISON, 2007.

81 Department of Health, Our NHS Our Future: NHS NextStage Review Interim Report, October 2007, p46.

82 Nicholas Timmins, ‘Care Trust Chiefs May Be Elected ByPatients’, Financial Times, 19 June 2003.

83 One Wales: A Progressive Agenda for the Government ofWales, agreement between the Labour and Plaid CymruGroups in the National Assembly, 27 June 2007.

84 British Medical Association, A Rational Way Forward for theNHS in England: A Discussion Paper Outlining an AlternativeApproach to Health Reform, May 2007.

85 Andy Burnham, ‘The Next Decade in the NHS: Quality, NotQuantity’, Fabian Society, 5 June 2007.

86 Nicholas Timmins, ‘Councils May Win Bigger Say overNHS’, Financial Times, 9 July 2007.

87 Keith Syrett, evidence to House of Commons HealthSelect Committee, March 2007.

88 Niall Dickson, ‘Too Much of a Good Thing’, Guardian, 1November 2006.



89 Compass and UNISON are preparing a forthcomingpublication on the case for co-production.

90 Charlie Leadbeater, Prospect, January 2007.91 Chartered Institute for Personnel Development, ‘Public

Sector Reform: Workers’ Responses’, December 2001,CIPD Perspectives, Public Services, Spring 2004.

92 Terry Leahy, ‘Like Tesco, the NHS Must Accept theConsumer is King’, Guardian, 5 February 2005.

93 Involvement and Participation Association, The HighPerformance Workplace, 6 February 2006.

94 IPA and Unions 21, Moving Partnership On – Final Report,December 2005.

95 Cabinet Office and TUC, Drive for Change,www.driveforchange.org.uk.

96 Jane Steele and Kerri Hampton, Unblocking Creativity inPublic Services, Office of Public Management, 2005.

97 Office of Public Services Reform, Trade Union andEmployee Involvement in Public Service Reform, case studyreport, prepared for the Public Services Forum,September 2004.

98 Andy Burnham, ‘Days Out in the NHS: Listening to NHSstaff ’, letter to Patricia Hewitt, 31 January 2007.

99 Brendan Martin and Conor Cradden, Partnership andProductivity in the Public Sector – A Review of the Literature,Partnership Resource Centre, New Zealand Departmentof Labour, November 2006.

100 Helen Bevan, ‘Social Movement Thinking: a Set of IdeasWhose Time Has Come?’, NHS Institute for Innovationand Improvement.

101 Don Berwick, ‘Improvement, Trust, and the HealthcareWorkforce’, Quality and Safety in Health Care, Vol. 12, 2003.

102 Paul Bate, Helen Bevan and Glenn Robert, Towards a Million

Change Agents: a Review of the Social Movements Literature: Implications For Large Scale Change in the NHS, NHSModernisation Agency.

103 See for example John Craig (ed.), Production Values:Futures for Professionalism, Demos, 2006.

104 David Marquand, Decline of the Public, Polity, Cambridge,2004, p55.

105 See Edward Andersson, Jonathan Tritter and RichardWilson (eds), Healthy Democracy: the Future of Involvementin Health and Social Care, NHS, National Centre forInvolvement, p100.

106 Compass is planning some research work on the futureof professionalism. Please get in touch if you areinterested.

107 Martin Newlands, ‘Is Cameron Really Equipped to DealWith Social Division?’ Guardian, 5 October 2006.

108 David Marquand, Decline of the Public, Polity, Cambridge,2004, p140.

109 Peter Kostenbaum, ‘Freedom and Accountability at Work’,Jossey Wiley, 2003.

110 Statement to the House of Commons by Rt Hon AlanJohnson MP, Secretary of State for Health, 4 July 2007.

111 Department of Health, Our NHS Our Future: NHS NextStage Review Interim Report, October 2007.

112 More information about how to take part can be foundby visiting the Review website, www.nhs.uk/ournhs, or bywriting to Lord Ara Darzi, Department of Health,Richmond House, 79 Whitehall, London SW1A 2NS.

113 Gordon Brown, statement to the House of Commons, 3July 2007.

114 Gordon Brown speech to the National Council forVoluntary Organisations, London, 3 September 2007.

Endnotes

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