The New Politics of the NHS, Seventh Edition

345 Pages·2013·19.69 MB·\345

by  Rudolf Klein (Author)

The New Politics
of the NHS
From creation to reinvention
Seventh Edition
Rudolf Klein
CRC Press
cJ*C
Taylor & Francis Croup
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© 2013 Rudolf Klein
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Contents
Preface vi
Acknowledgements ix
1 The politics of creation 1
The emerging consensus 2
The curtain goes up 5
Coalition compromises 7
Private negotiation into public controversy 12
Whose victory was it? 18
References 21
2 The politics of consolidation 23
Infinite demands, finite means 24
Whatever is best administered is best 30
Centre-periphery relations: the circle refuses to be squared 35
The pattern of inequalities 38
Professional influence and public power 40
Agenda for the future 42
References 43
3 The politics of technocratic change 46
Growing scarcity in an era of growth 49
Planning and rationing 54
National policy and medical decisions 61
In search of an organisational fix 66
References 72
4 The politics of disillusionment 76
The NHS in a new economic and intellectual environment 77
The exploding health care policy arena 80
The politics of ideological confrontation: a case study 85
The politics of organisational stasis 90
Back to the drawing board 96
References 101
5 The politics of value for money 105
The changing environment 106
Political v. financial constraints 112
The return to centralisation 114
The new managerialism 117
iv Contents
A drift to privatisation? 123
Controlling the gatekeepers 129
References 134
The politics of the big bang 140
A dialogue of the deaf 142
Reviewing the options 146
An explosion of opposition 152
General practitioners on the rampage 158
Implementation as learning 161
New themes in the health policy arena 166
A new hierarchy of command 169
The Conservative legacy 171
References 179
The politics of The Third Way 186
The Third Way 187
New Labour in office 189
Strategy for the NHS 191
Regulating the medical profession 197
Resources, rationing and crisis 199
Commanding but not controlling? 204
References 206
The politics of reinvention 210
Economic success, political victory 211
The great transformation 213
Present needs, future demands 217
Managing the performance of the NHS 219
The implementation gap 223
Enter the regulators 225
Changing the money flows 229
Balancing voice and choice 231
The private sector to the rescue 233
The State and the profession 235
Reorganising yet again 238
Beyond the Department of Health 242
References 244
The politics of transition 251
Interpreting the Brown oracle 252
A pandemic of visions 253
Towards the fiscal ice age? 256
A new management and a new agenda 258
The NHS and the people 262
Scarcity among plenty 264
Contents v
Dropped bedpans - yet again 266
Performance, perceptions and expectations 268
Conflict within consensus - yet again 272
References 273
10 The politics of confrontation 279
No more tinkering 280
The opposition mobilises 281
The sleepwalkers awake 283
Defanging the proposals 285
Resources v. aspirations 287
Autonomy v. accountability 289
Who gets the blame? 292
The quality industry 295
A half-time report 298
References 299
11 From church to garage 304
Policy-making in an international context 307
The future: unfinished business 311
The challenge to come 317
References 319
Index 323
Preface
The history of the National Health Service, now in its eighth decade, has been
marked by frequent organisational changes, periodic scandals and occasional
prophecies of impending collapse. System reform has been the norm, stability the
exception. Measures denounced yesterday as a threat to the NHS's very existence
have become today's policy solutions as the political parties have competed to steal
each other's clothes. So the monolithic, paternalistic 1948 model - which once
made the NHS unique among the health care systems of Western democracies - has
been transformed into a pluralistic model. The vocabulary of the market - choice
and competition - has become the language of policy debate. Deference to medi­
cal authority is no longer automatic as the patient, reborn as a consumer, shops on
the web. Insistent fiscal pressures are forcing policy-makers and professionals to
re-examine many of the assumptions which have guided them in the past: a new
agenda calls for nothing less than the transformation of the NHS.
The story of the NHS could therefore easily be told in terms of policy drama and
organisational turbulence. However, both the drama and the turbulence have been
contained in a cocoon of institutional and cultural continuity. The NHS remains a
tax-funded service that provides comprehensive, universal health care that is free
at the point of delivery. The values that inspired the founding fathers, and shaped
the NHS in the first place, still drive the service and command support across the
political spectrum. Launched amid acrimony, the NHS has become a much loved,
if also much criticised, national treasure.
To make sense of this combination of change and continuity, radicalism and
conservatism, means making sense of the NHS's political history: the aim of this
book. It is the history of the NHS which explains why the foundations of the NHS
are set in the concrete of popular support and political consensus. It is the history
of the NHS which also explains, however, why successive governments have over
the decades struggled to cope with the flaws in the 1948 model, itself the product
of political controversy and compromise. For only ideological piety can sustain the
notion that the NHS's survival for so many decades simply reflects the perfection
of the original design.
To interpret the policies adopted by successive governments requires therefore
an understanding of both the strengths and weaknesses of the 1948 model as
they emerged subsequently. From this perspective the reforms of the post-2000
era can be seen as one more step, albeit a particularly radical one, in the evolu­
tion of policy over the decades as governments sought to adapt the structure of
the NHS to changing medical technology, changing demography and a changing
society - developments which were not, and could not have been, anticipated by
the founding fathers.
This book concentrates on the policy-making process in the NHS and the accom­
panying political debates over the past 70-odd years. It examines the influence of
ideology and the role of interest groups in shaping policy. But it does so in the wider
context of the NHS's changing environment. Many of the problems confronting
Preface vii
the NHS are specific to it. So are many of the constraints facing policy-makers.
But the NHS is also a mirror of society. As society changes, so will perceptions of
the NHS and the assumptions of policy-makers. The 1948 model accurately mir­
rored a society strong on collectivism, reconciled to scarcity and with a firm faith
in the technocratic rationality of planning. The tide of collectivism receded; scarcity
yielded to rampant consumerism and faith in planning evaporated. In turn, policy­
makers began to operate with a new set of ideas and assumptions about how to
manage the public economy: intellectual fashions matter. The wider transforma­
tion of society and the changes in the dominant public philosophy are therefore
an essential element in any analysis of the evolution of health care policy.
In preparing this new edition I have not tried to re-write the past with the ben­
efit of hindsight or to take account of the literature that has been published since
I first wrote the text. I would not, in any case, wish to make any major modifica­
tions to my interpretation of events, and there seems little point in engaging in
scholarly niggles. So the first seven chapters taking the story up to 2000 remain
unchanged from previous editions. Three chapters deal with events since the turn
of the millennium: a period of hectic activity and policy drama. The first tells the
story of how the Blair administration abandoned its attempt to fit the last remain­
ing monument to Old Labour into New Labour's Third Way strategy and struck out
on a new course, in effect resurrecting Mrs Thatcher's internal market even while
repudiating the label. The second takes the story up to the 2010 General Election.
The third analyses the impact of the Coalition Government and the strategies for
coping with a new, much harsher economic environment. A final chapter reflects
on the evolution of the NHS over the decades, the tensions built into its design
and the challenges for the future.
Edition-by-edition, the perspective shaping the analysis has shifted somewhat
as new questions have come to the surface. However, the book remains structured
around themes and preoccupations that have organised the text from the begin­
ning and continue to do so. It is shaped, above all, by the assumption that the NHS
(and the wider health care policy arena) can be seen as a laboratory for a whole
range of social, institutional and organisational experiments with implications for
other areas of policy and perhaps other countries as well. To quote the preface to
the first edition:
The NHS illustrates with special sharpness, for example, one of the main
policy dilemmas faced by all modern societies: how best to integrate
experts into the policy machinery - how to reconcile policy-making
seen as the product of political processes and policy-making seen as a
search for an abstract rationality based on expertise. Again, the NHS's
experience underlines the tensions between policies designed to achieve
national standards in the pursuit of equity and other policy aims, such as
the encouragement of local participation: it can be seen as a case study
of conflicting values in the design of social policy. Lastly, the NHS pro­
vides an opportunity to study the classic question of political analysis:
who gets what? In short, a health care system can be seen as a political
world in its own right, where the balance of power will determine the
distribution of resources.
Other themes run through the text. One is the tension between central government
viii Preface
and delivery agencies, between the State and the professions, between the
requirements of public accountability and professional autonomy. How is politi­
cal overload to be avoided in a tax-funded service which inevitably pulls decision
making to the centre? Should rationing be explicit or implicit? What should be
the currency of performance evaluation? Finally, edition-by-edition, it has become
increasingly clear that if the NHS is a laboratory in which the micro-politics of a
specific policy arena can be studied, it is also an example of how macro-politics
can reshape an arena.
In exploring these themes, the book is written to appeal both to those with
a special interest in health care policy and those interested more broadly in the
policy-making process. Accordingly, it is assumed that the reader does not neces­
sarily come equipped with any knowledge of the NHS.
A final disclaimer. This book is not a history of the NHS but, as its title implies,
it is a history only of the politics of the NHS. Accordingly it is highly selective. It
concentrates on those policy issues which seem best to illuminate the analytic ques­
tions and to provide the most insight into political processes. Others have provided
more comprehensive accounts. And it is selective in another respect as well. The
organisation of health services in Scotland and Northern Ireland, and to a lesser
extent Wales, differs in important respects from that in England, and divergence
has become more marked since devolution. To make the task of analysis manage­
able, a Little Englander approach has therefore been adopted.
Rudolf Klein
London
July 2013
Acknowledgements
Over the years and editions, I have incurred many debts. My analysis through­
out is informed by interviews and conversations with policy-makers in central
government, in the NHS and in professional and trade-union organisations. All
interviews were conducted on a 'lobby' basis; that is, on the understanding that
the information given was for use but not attributable. The conversations were all
the more useful for being informal but, for that very reason, the insights yielded
are once again not attributable. Which is why no sources are given in the text for
quotations drawn from such interviews and conversations and why, furthermore,
I cannot name all those who have helped me. Those currently or recently involved
in policy-making - whether as civil servants or politicians - probably would not
thank me if I identified them.
The following list of those who have helped me, and to whom I would like
to express my gratitude, is therefore very incomplete. It includes only those no
longer active in the policy arena. My thanks (in many cases, alas, posthumously)
go to: Lord Aberdare, Michael Alison, Barbara Castle, Richard Crossman, Sir
George Godber, Sir Roy Griffiths, Sir Graham Hart, Douglas Houghton, Dr Gordon
Macpherson, Sir Alan Marre, Sir Richard Meyjes, Sir Patrick Nairne, Audrey
Prime, Kenneth Robinson, Dame Enid Russell-Smith, Simon Stevens and Dr Derek
Stevenson.
I am also grateful to the Keeper of the Public Record Office (as it was when
I trawled through the files; now the National Archives) for permission to quote
Cabinet and other papers. I have tried throughout to quote from original sources
wherever possible since policy-making is dialogue and it is important to catch the
tone of voice, the intellectual style and assumptions used by those involved. In
this respect, the analysis of policy-making is rather like the analysis of literature:
to paraphrase documents is to risk losing precisely what gives them their distinc­
tive character.
I owe another debt of gratitude to academic colleagues in this country and
abroad. Some of these are acknowledged in the footnotes. But more important
than the printed word has been the challenging question in a discussion over
lunch or at a seminar which has forced me to re-examine my own assumptions.
This is a form of creative subversion at which North Americans excel and I owe
much in this respect to friends like Ted Marmor, Carolyn Tuohy and Dan Fox, with
whom I have enjoyed a transatlantic dialogue over the decades. At home, I owe
much to Patricia Day, my collaborator on a series of research projects that gener­
ated many of the ideas that inform the analysis, and to conversations with Gwyn
Bevan, Nick Black, Anna Dixon, Nick Mays, Adam Oliver and Martin Powell that
have helped me to keep abreast of recent developments. Lastly, I must apologetic­
ally acknowledge the help and stimulus of those whose ideas I have unconsciously
appropriated: originality is, as the saying goes, a function of forgetfulness.
In the first edition I acknowledged the help of Sylvia Hodges and her efficiency
in organising me and in typing the manuscript. That was 1982. Since then the