he political class in Britain remains committed
to the idea and the practice of a public health service,
but its commitment is now qualified. If the current phase
and reform do not deliver visible changes in the provision
of health care, the critics of the NHS may prevail. This
was expressed in the Wanless Report, and the message was
by Wanless himself in the recent New Statesman debate about
the Norwich Union’s ideas about ‘stakeholder health
The idea that an insurance-based system would be better
than a taxation-based health service has had several lives,
current incarnation starting with the Carlton Club conference
in 1983. Then a group of Conservative politicians and NHS
clinicians and managers met out of public sight to debate
for the health service, concluding that a slow transition
to an insurance-funded service was necessary, using an expanded
form of National Insurance as a transitional arrangement.
the debate is conducted in public, with Labour supporters
seeing the value of market mechanisms in health care whilst
doubt that insurance-based systems can or should aim to deliver
How should those on the Left respond to a political agenda
set by commercial interests and appreciated by the current
government? There are obvious topics, like the risks to equity
and the judicious use of public money by Foundation Hospitals
and Private Finance Initiatives, and there are old favourite
slogans about democratic control, but there are no signs
that political activity on these issues will do more than
the reform process.
There are three themes that need to be considered and explored
if the Left is to regain the initiative in policy for the
NHS. The first is ‘provider capture’, the second is ‘modernisation’ and
the last ‘responsiveness’.
New Labour struggles with the forces of conservatism, which
obstruct necessary reforms in defence of their own interests.
In the health service they are found both in trades unions
and in the professional organisations, which resist changes
in working practices that would benefit the public. This
identification of professional organisations as problematic
was a strong feature of the policies of the Conservative
governments of 1979-1997, particularly when Kenneth Clarke
was Secretary of State for Health, and has carried over to
New Labour. Whilst not wrong in itself, it is one sided,
because the professions in particular have two other important
attributes. They represent the health service, in a face-to-face
relationship with citizens, in ways that administrators and
policy makers are not; and they are to greater or lesser
extent locked into tripartite alliances with industry and
with the universities.
We can understand ‘provider capture’ not simply
as the influence that professions have over the delivery
of health care, but rather as the functioning of an industrial-medical-academic
complex which shapes medicine itself, and so influences the
priorities and performance of the health service. Consider
two increasingly common problems as examples of ‘provider
capture’; obesity and depression. Both are constructed
and experienced as individual problems, amenable to control
at individual level, if only the right technique could be
found to achieve control. Fat-busting pills, faddish diets,
dietary advisors and weight control groups offer solutions
to the problem of obesity, but have little beneficial impact.
Anti-depressants and assorted therapies are presented as
treatments for depression, but the prevalence and incidence
of depression rises, seemingly inexorably. Both problems
may well be expressions of social malaise, in particular
the commercial marketing of unhealthy food and the insecurities
of life in market societies, but both are also market opportunities
with numerous niches waiting to be exploited.
For each problem a public health approach that promotes
healthy consumption and social empowerment might be a better
than any quantity of medication (they could hardly be worse),
but such an approach must compete with commodified solutions
supported by government and mediated by academia and the
professions. This situation could change, of course, if
government regulates medicine marketing more closely, changes
in research funding and alters its priorities in supporting
the professions. And it might change even more if political
movements began to argue for different solutions to our
current problems, and openly question the motives and reasoning
current practice. This is a large task with plenty of potential
for error. For example, the only serious and current threat
to the medical model comes from those refusing to immunise
their children with the MMR vaccine, a group with an understandably
suspicious attitude to professional claims and an almost
total ignorance of science.
The NHS was designed before penicillin became available,
and it sometimes feels that way to those who use it or work
in it, despite the best efforts of committed staff. Modernisation
is necessary and in some places overdue, but has become almost
synonymous with ‘choice’, a term whose meanings
are easily overlooked. There are different kinds of choice,
which in health can be seen either as object-related and
discretionary (homeopathy for eczema, private rooms, operation
dates, getting pregnant by artificial means) or related to
direction and the resolution of uncertainty (should I have
a PSA test, will chemotherapy for cancer buy me useful time
or ruin the remains of my life?) The former types of choice
are easily marketable, the latter depend more on knowledge,
dialogue and trust.
Those most concerned with ‘choice’ are keen to
sell discretionary services, and are seeking to expand markets,
by undoing public provision if necessary. We should be concerned
with promoting knowledge, dialogue and trust. This does not
mean advocating a bland ‘partnership’ approach,
but understanding that dialogue and trust can be achieved
through mutual criticism, if conducted safely by people whose
existence is not threatened.
A pious call for collaboration not competition may be worthless,
when it is necessary to work through conflicting opinions.
Nor does the view that ‘every cook shall rule the State’ help
us, because on past experience it enforces an ultimately
fruitless and token involvement in decision making. We need
multiple opportunities for involvement in decision-making,
from the individual to the strategic level. Here we have
a huge amount of experience, from which we can learn much
if we can synthesise it.
Who can be in favour of unresponsiveness in public services?
The issue in the current debate, however, is responsive to
whom? Whether we induce responsiveness through a command-and-control
approach, or through market mechanisms, depends upon whose
interests are being met. A health service responsive to the
affluent and largely healthy top third of the population
would meet their needs for anxiety containment through counselling,
satisfy their perceptions of safe treatments through alternative
medicine, treat sports injuries well, value cosmetic surgery,
run on time to their timetable and prevent their elderly
parents becoming a drain on the family income.
A health service
responsive to the poorest third of the population might
focus on their higher rates of illness, on health promotion
health maintenance, and on compensating for disabilities.
Whilst we in the NHS have no choice but to try and respond
to a broad range of needs and wants, the most articulate
and affluent seem keen to re-engineer the public service
towards their own agenda, and if that fails to abandon
it altogether. This political problem is the central one,
the moment, but behind it lies another. Why do we assume
that widening disparities in income and education are inevitable?
Should we not think of the alternative, that the income
gap decreases, with a consequent narrowing of health inequalities
and less competition between social strata for resources
A European problem?
These issues seem to be common to all health care systems
in industrialised countries, whatever the source of funding
and the style of health service organisation. Perhaps it
is time to think about health care reform beyond national
boundaries, and seek a European solution to our problems.
This is a task that the International Association for Health
Policy in Europe tries to address in its Stockholm Manifesto,
reproduced here. The Stockholm Manifesto is slowly evolving
and changing, and anyone can contribute to this process
by responding to any theme or arguing for new ones.