Column

Will New Labour restore old democracy?

What will Labour do about the very obvious ‘democratic deficit’ in the NHS? Perhaps they should take a look at the historical record of local authorities in managing health services, says Charles Webster

In its hectic rush to disassociate itself from its antecedents, New Labour would do well to consider what is entailed by its pledges concerning the restoration of democratic accountability in healthcare. Those whose memories stretch back to the 1970s will remember that Old Labour also attacked the reorganised health service engineered by Sir Keith Joseph for its betrayal of democratic accountability through adoption of a form of organisation which gave precedence to management considerations. The 1974 reorganisation accelerated the slide away from a meaningful degree of control over publicly-funded health services by their local communities. Under Barbara Castle some feeble attempts were made to restore the democratic balance, but the political and economic crisis of that time prevented more radical alteration of the Joseph system.

Since the origins of the labour movement, it had been accepted that social services should be administered as close to the local community as possible, and provided by officers accountable to the electorate through the normal channels of local democracy. Most of these services, such as education, housing, welfare and, of course, health, were also financed largely by local taxation. The health services of the early welfare state were built up by local authorities, often on the basis of Labour initiative. The health services were therefore controlled by committees comprised of elected representatives, with the chief officer, the medical officer of health, being their principal adviser.

The achievement of the local authorities in healthcare was considerable. The system of publicly-provided health services in 1939 accounted for about 3 per cent of GDP, not dissimilar in scale from the NHS in the 1950s. At its best, the local authority service showed itself to be resourceful and innovative; by 1939 exciting developments were taking place across the board, in everything from dentistry and infant welfare to acute hospital services. In the course of the 1930s, such progressive and reasonably prosperous authorities as Tottenham, Finsbury, Middlesex, Surrey, or the London County Council were renowned for their record of innovation.

It is of course important not to be uncritical of the record of the pre-NHS health service administration; authors such as myself, Jane Lewis, Linda Bryder, and others have poured scorn on the shortcomings of many local councils and their medical officers of health. But there was no reason to believe that reorganised local government, entailing larger units of operation, guided by more enlightened values, and more adequately resourced, was intrinsically incapable of administering health services.

This path was not followed in 1948, and it was not adopted by Richard Crossman when drawing up Labour’s definitive plans for health service reorganisation in 1970, primarily because of a veto exercised by the medical profession. Both Aneurin Bevan and Crossman, when out of office, regretted that health services were not under local government administration because of its superiority with respect to accountability.

Since 1979, a massive deficit of local accountability has built up. There must be a temptation for New Labour to write off this problem, as if local accountability was an unrealistic expectation, as in the case of the former public utilities, which in their origin were another branch of ‘municipal socialism’.

More likely, New Labour will continue to utter empty rhetoric about democracy, consider some unrealistic and impracticable reforms, but in government rest content with cosmetic changes. This would repeat the pattern of the Castle exercise in democracy, but without Castle’s excuses. It remains to be seen whether New Labour will commit itself to restoring anything like the level of local democratic accountability in healthcare taken for granted by old Labour before 1948.