Having just completed Nick Timmins analysis of the sorry saga of the Health and Social Care Bill 2010-12 Never Again, it’s worth reflecting for a few minutes on our ability to ignore lessons from the non-too-distant past.
According to Timmins’ account, Lansley refused to consider carrying through his proposals without using legislation (widely considered to be a viable, lower impact option) because he wanted to ‘lock in’ the changes in such a way that only further legislation could rescind them.
On one hand, this seems entirely reasonable, given the history of NHS reform and the constant chopping and changing of policy with each new secretary of state and government, not to mention the tendency to recidivism across the service when faced with any change.
Timmins confirms my view that the Act is intended to work like a formal constitution for the NHS. Whereas the actual NHS Constitution is a sort of Bill of Rights for the public, the Act details the machinery of government including the separation of powers (i.e. Lansley’s desire to distance ministers from the day-to-day management of the service). It can only be changed by amendments and supplementary legislation or by repeal. All of which will take parliamentary time and debate.
Again, there is some logic in approaching the governance of the NHS in this way, given the damaging effects of constant changes in management and direction. After all this kind of mechanism works adequately for many national governments and the scale and complexity of the NHS, not to mention its budget, is comparable with any number of states.
The problem I have is that in order to follow this path, Lansley and co have had to re-imagine the system from the bottom up in quite extravagant detail, and in a way that is constrained by existing structures. So the ‘new NHS’ that Lansley has played Dr Frankenstein to is an elaborate, finely balanced contrivance, but one cobbled together from new and existing components and shot through with a dose of parliamentary electricity to kick it into life. These are not auspicious beginnings.
What impresses is the shear arrogance and hubris of someone who really believes that they can re-engineer a complex mechanism like the NHS to this degree and in a way that will result in a functioning system largely free of inefficiencies and perverse incentives.
It beggars belief, particularly when set against the abject failure of similar attempts to re-engineer complex systems such as the privatisation of the railways. It’s no small coincidence that that ill-starred venture was rushed through at the fag-end of the last Conservative administration for entirely ideological reasons.
Rather hilarious then that David Bennett, the new chair of Monitor should claim that our experience of privatisation and regulation over the past thirty years means that we’re ideally placed to construct such an edifice. He’s obviously not been paying much attention. There is little evidence to suggest that this attempt to build a clockwork universe will be any less prone to error that those created for utilities or railways.
But given the railways for context – the sacrificing of safety for profit, the expansion of overhead costs to run a contrived ‘market’, the loss of accountability in a morass of contracts and penalty clauses, the fragmentation of a once coherent system, the opportunity cost of potential investment siphoned off for personal fortunes and shareholder dividends, etc, etc – Lansley represents the ideological hard core who believe that the only way to run public services is via some kind of market mechanism however artificial. Or in the case of the NHS a ludicrously contrived parody of a market, beset by unfathomably complex inputs and outputs, where nobody will be able to judge success or failure for years if not decades.
Setting aside the fact that it’s naive to the point of imbecility to believe anyone working largely alone could design such a system successfully, Lansley’s ‘clockwork universe’, the supposed self-perpetuating, self-improving, perfectly incentivised mechanism, is a neoliberal myth. But it’s a myth every bit as ugly and disturbing as the one Mary Shelley created, and ultimately, it’s just as relevant a comment on the arrogance and hubris of some of those who rise to high public office.
