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.

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  1. Tony Jewell says:

    Interesting thought piece – thanks. Certainly RAWP and the need to have resource allocation according to need leads to centre leadership on funding. Inequalities also need redistribution of wealth (SE England v the Rest) and this needs HMRC and industrial strategies from the centre. National standards too even if there can be devolved freedoms to do things differently. Finally NHS pay and T&C are an important basis for the NHS to ensure staff recruitment and retention is not skewed.

    1. Steve Iliffe says:

      Tony, central resource allocation is compatible with decentralised management – this is what we have, after all, with ever more conditions attached to resources. The model is education, originally a ‘national system, locally managed’. The irony is that the weak command and control management system of the NHS up to the 1976 economic crisis was strengthened by the wave of neo-liberal reforms after 1979, making decentralisation (under Major’s and Blair’s governments) easier to carry out. National standards are set centrally but enforced locally. Staff recruitment and retention is skewed already, making a case for local pay rates and terms and conditions, to swing resources away from the golden triangle, but that would require central oversight. If the NHS had gone down the same path as education, and local politics had influenced health service development, might the political debates about the NHS be more mature and knowledgeable, and less marginal, than those we now experience?

      1. Tony Jewell says:

        Thanks Steve. The H&SC Act started to weaken the national democratic accountability and the NHS has never allowed health authorities to survive long enough with co-terminosity of footprints with LA boundaries to develop their profile and local accountability. The Education system seems to be fragmenting with the undermining of LA controls/resources. Academies, free schools and no LEA capacity and less remit. Not a pretty picture either!

  2. rotzeichen says:

    Not to offer too simplistic a solution to defend the principle of a uniform health system, but fragmentation of any kind brings problems of greater magnitude due it’s inherent complexity.

    Bevan created the most efficient, comprehensive health care system in the world precisely because he understood how fragmented services fail.

    Simplicity is the core principle to efficiency, that was what made the NHS what it was before the private marketers got involved. Neo-Liberals are intent on fragmentation as a process, which allows room for manipulation, competition, and interference to suit a political end not consistent with delivery of care.

    Lets go back to what works and forget the bullshine that somehow the NHS was defective, The problems with the NHS was the deliberate policy of dismantling the finest institution that any country could conceived.

    In short Neoliberal politicians of all political colours set out to destroy the finest health service in the world for their own personal gain, corruption lies at the heart of the demise of all our public services, and that is what we need to stamp out, and the private sector needs the same level of scrutiny that our public services suffer. Not only would they be found wanting but exposed as the real problem we have in government of this country.

  3. healthaudit says:

    The model is higher education.
    And expecting local government to do anything when it is being dismantled seems optimistic at best .
    The acid test will be Manchester. Hyped as an exemplar of decentralisation but likely to be hung out to dry.
    Integration of health and social care was promoted to help preserve social care on the basis that funding would be protected by being under the healthcare banner. The reality is that local government are looking to dump social care onto the NHS and the NHS has to give priority to the sick not the destitute. It does not augur well for the future..

    1. Steve Iliffe says:

      State education followed the ‘national service, locally administered’ model with councils providing the local administration. Higher education is another matter, and Collini, whilst interesting, is irrelevant here. As the Revenue Support Grant nears zero (estimated 5% by 2021) some local governments may look at the local NHS – a huge local economy – and see a potential income stream as well as a political role. Labour’s new policy on STPs allows some room for political activity around joint working and possible service mergers, and makes a lot of sense. Tory councils may respond differently to decentralisation, of course, and there will be lots of scope for political conflict which Labour might well lose; but giving up in advance ensures failure.

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