From rosy view to clear vision

We have grown up believing that one of the important distinctions between left and right is that between change and conservatism. While the left would be urging modernisation and renewal, the right would resist, appealing for a return to ‘the good old days’. That such familiar certainties not longer hold is well illustrated by the Socialist Health Association’s call for a return to traditional ‘NHS values’.

What are these values? Though not explicit, the SHA’s Campaign for a socialist health policy spells out three main policy demands which it believes embody traditional NHS values, all of which are to be strongly supported. But it whether these should be presented in terms to a ‘return’ to some past golden age of welfare justice is more questionable.

The first target is that services should be available to all on the basis of need, rather than ability to pay. This is a principle which Labour has always held dear, and is heard so often that it almost has the status of a religious incantation. But what does it mean? Usually, it has been interpreted in terms of removing the money from the relationships between individuals and their doctors, so that patients need not worry and doctors need not be swayed by avarice. Interestingly, in these days of rationing, we may have to reinterpret its meaning. Should services be available irrespective of the state’s ability to pay? Or, as for health promotion activity and cytology targets in general practice, because of the state’s willingness to pay?

Of course, the principle can — and should — also be applied on a population basis, distributing services geographically, by class, gender or ethnicity, according to need. Even now, known inequities in access to care persist. Yet such an interpretation was largely ignored for the first 30 years of the NHS, and it was not until 1976 that Labour’s RAWP formula explicitly addressed the redistribution of health service resources geographically. Paradoxically, equity in access to health care is today higher on the political agenda than ever before. There was no golden age.

The SHA’s second target is for an NHS which ‘promotes participation and is democratically accountable at all levels’, again a laudable objective. But again, this is not going back, but forwards, for there is no history of public participation nor local democracy to go back to. The story of Bevan’s rejection of the ‘local authority option’ is well known. The founders of the NHS installed no mechanisms for participation, nor any kind of influence at all on NHS planning, beyond national election. Community health councils were not created until 1974. For many years after that, the Soviet-style planning cycle of the NHS effectively bored even the most lively NHS activist into total rigidity.

Today, though, public participation in health service decisions is discussed as never before. We may not yet have it, but we know we want it. Issues such as the Child B case have focused attention on how to involve the public in difficult decisions. Experiments with citizen’s juries are springing up. The ‘local authority option’ is once more discussed seriously. In all of this, a return to ‘traditional values’ would be a return to professional and bureaucratic paternalism.

Finally, the SHA calls for the creation of a health-promoting society based on fairness, attacking poverty, poor housing and unemployment. Here we find a real contrast between the national commitment to renewal of the post-war years, and the official complacency of the nineties. But the mood of optimism and unity which supported national programmes on housing, health and social security after the war was achieved by looking forward, not back. The end of a millennium offers us the opportunity to look to a brighter future, not a rosy past.