The NHS has no memory but the labour movement does, although it is sometimes patchy. A conference convened by the Institute of Public Policy Research and the London School of Hygiene and Tropical Medicine on May 9th illustrated how long-standing the issues now being debated around regional devolution of the NHS really are. Discomfort with devolution of powers is hard-wired into the NHS. Commitment to funding the NHS from general taxation inevitably leads to Parliamentary accountability, without the word ‘centralisation’ being used. Likewise, concern at inequities encourages central control to iron out variations in care.
Whilst politicians of all parties talk about local control of the NHS being a good idea, this is a rhetorical device, for the trend is towards ever greater centralisation of health services – described at the conference by Rudolph Klein as “the original sin of the founding father”. Bevan was a centraliser who (in collaboration with the TUC and the BMA) saw off the lobby wanting local government control of the NHS, and slowly his vision of a command and control structure for the NHS has been realised. Unlike the other nationalised industries the NHS inherited the pluralism of the inter-war patchwork of health services. In the beginning the periphery of the NHS – the hospitals- was strong and the centre – the Ministry – was weak and lacking in skilled personnel , but this changed with the arrival of New Public Management in the 1980s, with its performance indicators, outcome measures, economists and statisticians, and its endless data collection. Before this there were some attempts at directing medical labour, allocating resources according to need, and promoting service integration through the simple mechanism of co-location, but all struggled to have an impact.
With the neoliberal drive to modernise the NHS command and control became more effective and oppressive. Klein dismissed Blair advisor Paul Corrigan’s argument that there was command but not control in the NHS as untrue of the present time; what could be more controlling than special measures, he asked.
A presentation about campaigns against hospital closure reminded us that Margaret Thatcher proudly claimed to have ‘saved’ the Elizabeth Garrett Anderson hospital from closure; Labour has no monopoly on NHS salvation. Current campaigners have been through a bad patch when they were ignored by MPs and NHS practitioners, and looked like a middle class, white, retired Baby Boomer ginger group, but that had changed with the growth of ‘Health Campaigns Together’. The problems that campaigns in defence of the NHS have long experienced continue, however. The lack of democratic accountability in the NHS, and the opacity of its internal politics, mean that campaigners are prone to conspiracy theories and tend to conflate any change with privatisation, potentially paralysing service development. Hospitals remain the iconic sites in the NHS, which hampers any policy shift towards a primary-care led (or even based) health service. And there is a tension between local motivations – save our A&E! – and national opposition to neo-liberal ‘reform’, ‘modernisation’ and ‘reconfiguration’.
The IPPR/LSHTM conference made me think that we may be drifting back towards regional management of the NHS, with very different mixed economies in different regions, and plenty of scope for local jockeying for position to contract out services. Bevan’s centralised service may be approaching the end of its useful life, but it has to enforce decentralisation before it is done. Campaigners will not run out of things to do.