Feature

Right a bit more

Steve Harrison assesses Labour’s proclaimed ‘third way’ in health policy and finds that the strategy consists of little more than old – and right wing – policies dressed up in new clothing

The general election will be over by the time you read this and New Labour will be ensconced for a further term with a solid majority. So how can we characterise what it has been doing with the NHS during its first term of office?

My day job pays me – among other things – to take an overview of health policy. Here I will try to give a brief analysis of the big picture, which of course cannot avoid mentioning, let alone do justice to, the experiences and opinions of colleagues in the NHS.

As a reference point, I have used some of the claims made under New Labour’s own precept/rubric/formula of the ‘third way’, which has been used both to describe a general approach to politics and government, and to label specific NHS policies. I will draw out two ‘big’ themes, each of which relates to one of these conceptions of the third way which – to avoid phrases like ‘the second third way’ – I shall term TW1 and TW2.

TW1: a new politics beyond left and right?

A typical definition of TW1 is one proclaimed by Tony Blair: ‘It is a third way because it moves decisively beyond an old left preoccupied by state control, high taxation and producer interests; and a new right treating public investment, and often the very notions of ‘society’ and collective endeavour, as evils to be undone.’¹

The language is curiously ambiguous. Despite a literal claim (amusingly, in terms that might be the language of Marxist dialectical materialism) to be moving to something new (‘moves...beyond’), the structure of the passage contrasts left and right in a way that might allow it to be read simply as a middle way, a compromise between extremes and thus an attempt to occupy the centre ground of politics. So which is it?

Three trends are discernible within this theme. First, the move towards increasing privatisation of provision, most obviously through government support for the private finance initiative (PFI), which accounts for the majority of large-scale capital development under way in the NHS, in the shape of new hospitals for example. Such schemes, which have been thoroughly analysed in the work of Allyson Pollock,² employ private sector finance to relieve immediate public capital expenditure, substituting public revenue repayments over perhaps 30 years.

PFI schemes are extremely complex – the set-up costs divert large amounts of public money to accountants, management consultants and legal advisors – and may include the private provision of hotel services once the construction work is complete.

It is necessary to make optimistic assumptions about, among other things, the relative efficiency of private and public sector construction and service provision in order to conclude that it would not have been preferable to use public capital in the first place. Furthermore, the government no longer objects to the private provision of NHS clinical services within PFI schemes, and it is also possible for the new primary care trusts to be run by private companies.

Second, after an early reversal, there is now a renewed trend towards commodification of health care. By this I mean a tendency to reinterpret health as health care, and health care in turn as a series of discrete encounters between provider and patient.

The recognition that ill health is largely a product of environmental and economic conditions has ostensibly underpinned the concept of health action zones and health improvement programmes. But in practice, these have turned out to be largely about services for individuals, and there are no plans to extend them. Developments such as NHS Direct and primary care walk-in centres have further reinforced the concept of health care as a matter of solitary encounters.

Unlike privatisation, I feel there are some positive aspects to commodification. Anyone who has had to wait three days for an inconvenient GP appointment or agonised over whether to call out the deputising doctor will welcome these changes. But there are also dangers in commodification, which brings me to the third trend.

Many commentators argue that the NHS has become overpoliticised, with politicians falling over themselves to deliver better health care than their opponents. However, I would see the third trend as the increasing depoliticisation of health in a more fundamental sense.

I cannot express this more succinctly than Colin Crouch does in his Fabian Society pamphlet, where he states that government is increasingly presenting itself as ‘something more resembling shopkeepers than rulers, anxiously seeking to discover what their ‘customers’ want in order to stay in business’.³

Of course, there are positive elements to this. We all want good-quality services. But to concentrate purely on this aspect of health is to divert attention from the more fundamental questions about how we should be governed and how we should distribute resources in society. This trend of consumerism is consonant with the way in which – as Norman Fairclough has pointed out – much of New Labour’s language has the effect of naturalising a consumerist view of the world, in which the activities of global capital are viewed uncritically.⁴ Economic globalisation is indisputably a real phenomenon, but that does not mean we have to like it.

My conclusion about TW1 is that it cannot be seen, in any sense, as transcendent of the ‘old’ politics, but is rather a compromise between left and right, a sort of middle way. As I have suggested above, this does not mean that there are no elements I welcome, but does imply a shift to the political right.

TW2: a new NHS management beyond command and competition?

New Labour’s definition of the third way as applied specifically to the NHS is given both in terms of what it is and what it is not. According to the white paper, The New NHS, it is neither ‘the old centralised command and control systems of the 1970s’, nor ‘the divisive internal market system of the 1990s’; rather, it is a system ‘based on partnership and driven by performance’.⁵

Leaving aside the literal nonsense of the last phrase – surely, performance is driven by certain factors, not vice versa – the third way here is a mythical construction whose existence depends on the creation of other myths about a first and second way.

First, the label ‘command and control’ simply does not correspond to the findings of empirical studies of NHS management under previous Labour governments. Such studies (on several of which I have spent a large part of my working life) show that managers were ‘diplomats’, whose main role was to facilitate matters for the local medical profession, and that it was the Conservative governments of the 1980s that turned them into agents of government.

Second, as the research of Rob Flynn and others has shown,⁶ the label ‘divisive internal market’ is a gross exaggeration. Despite having produced some competitive and non-cooperative behaviour, especially as a result of GP fundholding, the NHS quasi-market was characterised by a general lack of competition and a high level of cooperative behaviour.

So what has actually been happening in New Labour’s NHS? Three trends are particularly obvious.

First, the existing trends of managerialisation have continued and, in particular, have been extended to primary care: primary care trusts (PCTs) will increasingly look like hierarchical organisations rather than federations of small businesses. Primary care has been notoriously variable, so there is much to be welcomed if this development can be handled in a way that does not alienate GPs with excessive bureaucracy.

However, the existing trend towards regarding appointed board members as substitutes for elected members has continued and indeed proliferated with the creation of primary care groups and PCTs, a situation which would not have been improved by the intended abolition of community health councils. Although some of New Labour’s rather complex proposals for replacing CHCs, particularly the involvement in the NHS of local authority scrutiny committees, were promising, they could hardly be said to have amounted to a major injection of democracy.

Second, there is a very strong trend of regulation. This is most obvious not only in the work of the National Institute for Clinical Excellence (NICE), the Committee for Health Improvement (CHI) and in the notions of clinical governance and performance indicators, but also in the myriad new agencies and ‘teams’ created in the NHS over the past three years.

It is part of my job to keep track of NHS organisational changes, but I have been temporarily defeated by this sheer bureaucratic promiscuity. By comparison, the health secretary Alan Milburn’s recent decision to reduce the number of health authorities and (not quite) abolish Department of Health regional offices seems insignificant. Ministers, and indeed top managers, are traditionally rather fond of reorganising: it shuffles the spoils around and is something they can be confident of achieving.

While organisation is important, a strong theme running through many of these changes is that of low levels of trust. People cannot be trusted to get on with their jobs adequately, so they and their organisations need to be controlled by rules and constantly inspected.

Some people are indeed not to be trusted, as evidenced by the recent succession of NHS scandals, but more regulation and control only results in a reluctance to blow the whistle and a damaging professional culture of ‘live and let live’. A huge NHS internal regulation industry will divert time and resources from provision of care, lead to ‘gaming’ in which organisations learn how to look good rather than be good, and risk staff alienation. It is ironic that New Labour would never dream of imposing such levels of regulation on private enterprise.

Third, and closely related to regulation, is what one might call technocracy, the idea that in any given circumstances there is a single correct way to do things. The most obvious manifestation of this is evidence-based medicine and professional practice, the official version of which takes a much narrower view of what counts as evidence than, as Sandra Tanenbaum has shown, many clinical professionals.⁷

Such an approach to evidence, especially when linked to the new regulatory mechanisms and buttressed by strong exhortations to adhere to ‘clinical guidelines’, is further confirmation of New Labour’s aspiration to control. This is especially evident in its propensity for ‘evidence-based policy’. This will not catch on, though: as one minister put it, the next logical step would be evidence-based politics, which would never do.

And, of course, this is my point: I’m all in favour of research and evidence but, as Brian Fay showed many years ago, scientific research is not value-free.⁸ Thus for both democrats and professionals there is a crucial difference between viewing research as authoritative – which is what many of the regulatory bodies mentioned above are designed to do – and using it as a starting point for dialogue about what should be done.

Interestingly, there seems to be something of a tension between a ministerial predisposition for CHI to operate as a high-profile ‘hit squad’ that will sort out future scandals and CHI’s own preference for a more developmental role in encouraging NHS trusts to examine their own performance.

My conclusion on TW2 is that the NHS is, in fact, moving towards an unprecedented degree of command and control. As with TW1, there are elements I welcome, but in general the government is using regulatory mechanisms that have everything to do with a certain sort of performance, but very little to do with partnership.

Going back in time

Overall, we have less of a third way than a shift to the right, perhaps to a position on the political spectrum that was once occupied by the pre-Thatcher Conservative mainstream.

None of the trends that have brought us to this point are purely party political. In part, they are political responses to larger economic and social trends such as globalisation, consumerism, increasing distrust of experts and professionals, and growing consciousness of – and aversion to – uncertainty and risk. These trends will not change quickly, so under the new government we are likely to see more of the same. I am not in the habit of making specific predictions but I will conclude by making three points.

First, there is the potential for strong conflict between consumerism and technocracy: the NICE experiences with the drug beta-interferon suggest that institute is not necessarily authoritative, especially when global capital has a hand.

Second, it is preferable for societies and the organisations within them to operate on the basis of trust. While a series of medical scandals has given us good grounds for not trusting naïvely, excessive regulation may well be self-defeating.

Finally, privatisation may well be a one-way street and, for that reason, governments ought to be wary of effectively cutting off their options.