Feature

Hands up for democracy!

The structure of the health service reflects a history of political compromise and personal rivalry, says Colin Thunhurst — and now the arguments for local authority control of the NHS are stronger than ever

It is unusual to begin an article by admitting that you’ve very little new to say. But that’s the way I feel about democratising the NHS. The reasons why the NHS needs democratising have been stated often and well - so I have no doubt that many people will be weary at the prospect of churning over some of the same old arguments. Why not just let the issue rest peacefully ?

The answer is very simple. Despite the regularity with which the arguments have been put, the prospects for change remain as remote as ever. Indeed, with the Labour Party in a permanent state of electoral preparation, and with its consequent retreat from voluntarily raising difficult issues, we can, yet again, expect the issue to move back down the political agenda.

The reasons why the democratisation argument can not be ducked were expressed forcefully by Mark Ponnampalam in the second issue of healthmatters. He argued that in attempting to ‘save the NHS’ we were defending the indefensible - that it is ‘riddled with secrecy, professional cliques, racism, sexism, ageism, and yes, corruption’. Having served as a health authority member for three years I recognise the force of Ponnampalam’s arguments; but I also recognise that the vast majority of people in the UK would not. They value the NHS as providing them with the basics of a service which still does, just about, stand ‘in place of fear’. They may be a little misguided, but I do not think they are totally wrong. Ponnampalam is, I fear, throwing out the baby with the bath water.

The NHS is as Ponnampalam characterises it because there has never been any legitimacy with which to counter the ‘professional’ legitimacy of the medical, and other controlling, power groups. When I served as a health authority member, I could at least claim that I was there because the trade unionists of Sheffield wanted me to be. The only other people who could make similar claims were the elected members of local authorities. Nobody else had any basis on which to challenge the positions advanced by the variety of professional interest groups that form the well-defined pecking order of the NHS.

Ironically it was that very fact of having been through an electoral process - that we felt accountable that rendered the ‘labour group’s’ arguments so frequently inadmissible in the eyes of the would be Jimmy Savilles. We were accused of behaving politically. I plead guilty and ask for many other cases to be taken into consideration. I find it absurd to suggest that HA members could be anything other than political. Given the choices that we were supposed to be making over the allocation and distribution of resources, how could we be anything else? As somebody once said of the education system: it is not we who wish to politicise the NHS; the NHS is political. So we should not be looking to ditch the NHS, we should be looking to subject it to meaningful local political control.

What has been depressing about much of the response to the government’s reforms is the way the opposition has been prepared to stand in the reflected arguments of the medical profession. Notwithstanding the ease with which the BMA’s opposition can be (and has been) bought off, should we really be relying so heavily on an interest group whose history of involvement has been geared to the preservation of its own privileged position?

We must be able to offer something more positive for the future, and that must include a democratised NHS, in which the medical profession take their rightful position as one group of workers amongst the many who provide a valuable service.

The most recent attempt to keep the issue alive was made by Bob Quick in a lead article in Socialism and Health last year. Quick, a COHSE regional secretary, rightly stated that ‘it is not an issue that will go away. Labour must be able to present clear and viable options’. He went on to argue for a ‘system which allows local authorities to ‘manage’ local health services on behalf of the secretary of state for health, and to include a commitment to industrial democracy within local government’. This hybrid formulation is well worth further development; but it is probably also worth remembering the essence and the history of the cases for and against local authority control.

Bevan stood out against administering the NHS through local authorities for a variety of reasons. That the NHS was born of compromise, and that Bevan himself allowed the inclusion of a number of anomalies which he anticipated would be tackled as the service developed, is something that all but the most uncharitable of commentators would accept. One of these anomalies was clearly the privileged position of the medical profession. Their biggest objection was to becoming salaried employees, and particularly salaried employees of local government.

Add to this the personal rivalries of Bevan and Morrison, the minister responsible for local government, to whom Bevan was anxious not to surrender control of ‘his’ NHS, and you have a powerful explanation for the curious structures that emerged in 1948 The failure to tackle the original anomalies of the NHS is now history, a lesser known part of which is that Bevan himself was arguing, by 1954, that ‘Local authority control of hospitals is right’.

Local authorities themselves have hardly been models of democracy. This is a strong plank in the arguments of those who oppose the local authority option. But why accept undemocratic local authorities? Indeed, the enhanced interest and involvement that including health in the remit of the authorities would bring, would itself be a very powerful force for the democratisation of the delivery of other local authority services. But this is an opportunistic response, it is not an argument for local authority control. Those arguments lie in the broader awareness of the social, economic and political causes of ill health that has developed over recent years, and the need to respond to this in a way that is locally sensitive.

If the 1980s can be celebrated for anything it must be as the decade in which health in the UK broke out of its highly medicalised model and in which a meaningful notion of ‘public health’ re-emerged. We may be critical of the individualised perspective that underpins a large number of the Health for All programmes; and we may suspect that discussion of ‘equal opportunities’ within the NHS is just blind rhetoric; but at least authorities now feel the need to issue the rhetoric. Inequalities have been inescapably ‘rediscovered’ and it is essential that the logic of that rediscovery is pushed through to beyond the rhetoric.

Housing, the environment, transport, employment, even poverty and other areas of social policy are now firmly back on the health agenda. The challenge is to get health back on to the agenda when these other areas of social policy are being framed. So many of the arguments for the public provision of services are public health arguments. Separation of the health dimension has considerably weakened the case for, say, public housing, public transport, or even public nutrition policy.

So the essence of the argument is twofold. Local authority control of the NHS is needed to provide a basis for countering the power of the forces which currently dominate, and local authority control is needed to ensure that the emergent ‘new public health’ does not itself become distorted and medicalised but becomes the framework for the reconstruction of social policy.

But what will happen to the ‘national’ health service? Avoiding the obvious retort that there is currently very little of a national service, a national character can be established by the creation of minimum national standards. I do recognise the vulnerability of isolated working class communities in Tory areas. What is ironical is that this argument has turned 180 degrees in the last fifty years. The concern as the NHS was being created was that affluent Tory areas would be the providers of the superior services, and that the Labour areas would get left behind. Try telling that one in Wandsworth.

So local authority control, with statutorily prescribed involvement of workers and users, and with nationally determined minimum standards, provides the only coherent framework. But that is just a framework. By the next general election, it is vital that the detail is properly filled in and fully and widely understood.