As it enters 2016, the NHS is not a happy organisation. It hasn’t been for some time but the problems and pressures that have gathered pace through 2015 are coming to a head.
A threatened strike by junior doctors is already a firm possibility but other issues are mounting by the day, ranging from cash‐strapped hospitals, allegedly underperforming GPs, shortages of clinical and nursing staff, poorly integrated health and social care, non‐existent or threadbare mental health services, the persistence of a bullying culture, to unforeseen cuts in public health funding that threaten to put further pressure on an already over‐stretched NHS. The list goes on.
The quick fix
It is tempting to pick these issues off one by one, reaching for the quick fix while also finding someone to blame for allowing things to reach such a parlous state. That would be a mistake and would fail to understand the forces that have brought the NHS to where it is today.
Taking the long view is a necessary prerequisite to finding appropriate solutions.
Key to this is understanding the politics of health. Conceptualising health as political and as the product of political action is integral to comprehending complex health systems and how they might be changed for the better. The problems of the NHS are not at the end of the day technical or managerial although they have their place.
All governments wrestle with a number of policy cleavages when it comes to health. These include the funding and organisation of health systems; the attempt to shift the emphasis from health care to health; priority‐setting and rationing health care; and the appeal of markets and choice and competition.
Public vs private tension
Running through each of these cleavages is a tension between the public realm and private realm that gets played out in discourses on the role and limits of government on the one hand, and on the role of individuals in taking responsibility for their health and in exercising choice on the other.
A persistent theme running through health policy in the UK since at least the early 1990s has been the ascendancy of the market in public services like the NHS. Governments of all persuasions have been seduced by the alleged virtues of markets and competition without appreciating their limits in areas of public policy such as health.
The seeds of the current UK government’s misconceived and unpopular NHS reforms introduced in 2013 by the then Conservative dominated Coalition government were sown by the last Labour government. This continuity in health policy has been a marked feature of the political landscape in England while the devolved administrations in Wales and Scotland have chosen to pursue a different path that seeks to retain the NHS’s public service ethos.
An underlying cause of much discontent within the NHS, including the junior doctors’ dispute, lies with the successive waves of reforms foisted on the NHS by all governments. The 2013 changes have attracted most criticism and resulted in an erosion of trust between NHS staff and politicians.
Anger
The deep seated anger felt by junior doctors is a manifestation of its growing frustration with the government’s stewardship of the NHS.
There is a widely held perception that the government’s real agenda is to dismantle the NHS as part of a wider redesign of the public realm. The feeling is that it is happening in other areas of public policy so why should health remain an exception.
For a government intent on pursuing a neoliberal agenda, institutions like the NHS and the BBC stand out as curiosities in the vision of a smaller state in which public services are largely privatised or outsourced.
Is there another way? Yes, there is always another way because that is the essence of politics. There are always choices. This does not mean a retreat into a mythical golden age for the NHS that never existed. But it does mean acknowledging that some activities end up in the public realm for sound reasons, not because they have somehow escaped the virtues of markets, choice and competition.
Politics is at the heart of all that happens in health policy. Making sense of the NHS’s current predicament, however puzzling, requires understanding the beliefs underlying policy makers’ choices and the interests they represent. It is these, and not some spurious scientism or notion of evidence, that is shaping and driving their choices.
If we are to engage with these issues and chart a different course for the NHS, we need a new kind of politics from that which we currently have. We know that neoliberalism kills. To counter such an ideology we need a new political economy of health. A public debate about health that puts politics centre stage is both necessary and overdue.
This was originally published on The Policy Press Blog