Taking the politics out of public services (again)
11:52am Friday, 15th June 2007
Cipfa's incoming president John Butler recently became the latest in a long line of mandarins and wonks to argue that politicians just get in the way of delivering good public services.
The answer to this problem is always the same - an NHS constitution of sorts, semi-independence for as many services as possible. It's easy to see why these demands are being made. Blair's ceaseless reform of the NHS in particular has shown a shocking lack of strategic thinking and created a vast amount of unnecessary upheaval.
But the problem with the Butler approach is that while it might create more stability, it ignores the fact that most of the problems public services face are fundamentally political in nature. There are lots of ways to reduce waiting lists, the challenge is for politicians to create consensus around a particular course of action.
This is even truer in areas like public health, where politicians have to make a case for greater public engagement in healthcare to reduce cost pressures over the next decade.
Seen in this light, Labour's great failure was its inability to build consensus around the PFI or payment by results - Blair often gave the impression that medical opposition to reform was actually a good thing, because it meant he was taking on vested interests.
It is hard to see how a semi-independent NHS makes any of this reform business easier. In fact it might make it harder by putting new, tougher barriers between politicians and professionals who already find it hard enough to talk constructively.
My point ultimately is that the problem isn't too much politics, but not enough. We need more debate about how we live together, how we change our society, what our right and responsibilities might be. Our aim has to be better politics that has the courage of its convictions, not less of it. Adaptation is good, but it needs leadership.
Butler's intervention seems like a slight reheating of congealed technocracy and rotten new public management. New Zealand took his kind of approach and it didn't stop the National governments of the 1990s instituting three different healthcare systems in less than a decade.
The answer to this problem is always the same - an NHS constitution of sorts, semi-independence for as many services as possible. It's easy to see why these demands are being made. Blair's ceaseless reform of the NHS in particular has shown a shocking lack of strategic thinking and created a vast amount of unnecessary upheaval.
But the problem with the Butler approach is that while it might create more stability, it ignores the fact that most of the problems public services face are fundamentally political in nature. There are lots of ways to reduce waiting lists, the challenge is for politicians to create consensus around a particular course of action.
This is even truer in areas like public health, where politicians have to make a case for greater public engagement in healthcare to reduce cost pressures over the next decade.
Seen in this light, Labour's great failure was its inability to build consensus around the PFI or payment by results - Blair often gave the impression that medical opposition to reform was actually a good thing, because it meant he was taking on vested interests.
It is hard to see how a semi-independent NHS makes any of this reform business easier. In fact it might make it harder by putting new, tougher barriers between politicians and professionals who already find it hard enough to talk constructively.
My point ultimately is that the problem isn't too much politics, but not enough. We need more debate about how we live together, how we change our society, what our right and responsibilities might be. Our aim has to be better politics that has the courage of its convictions, not less of it. Adaptation is good, but it needs leadership.
Butler's intervention seems like a slight reheating of congealed technocracy and rotten new public management. New Zealand took his kind of approach and it didn't stop the National governments of the 1990s instituting three different healthcare systems in less than a decade.
LOGIN to add comments
Comments
Aside from the usual annoyingly simplistic cries from the ‘old’ left about privatisation of public services, the rest of the political spectrum seems to have reached a consensus on the way forward for the NHS, with both the Conservatives and New Labour committing to both of the above.
Consensus is a good sign, and one that seems to be implicitly behind the idea of an independent NHS. There is nostalgia for the NHS in the days of the post war consensus. It is almost irresistible to see the NHS golden era coinciding with health not being a bloody political battleground and not conclude that it is political interference that is responsible for its’ current maladies. How true this is I can’t say but I instinctively feel there is a more than a grain of truth to it; much of the NHS crisis can be traced back to the Tories wrecking ball approach to the NHS.
Politicians are necessary for determining strategy but experience has shown us that they are pretty useless at directing implementation. An independent NHS governing board that is accountable to Parliament but has its’ strategic vision set by government doesn’t seem like a bad idea at all. The less operational decisions taken to satisfy political expediency the better. This will serve to lessen tensions between the front line and policy and help to ensure that the routes taken are the best fit for the health system.
An independent NHS won’t remove political interference, but merely limit it to where it can do the most good and most importantly, the least damage.
If the NHS became semi-independent, then presumably it would still be subject to independent inspection with priorities set politically, and presumably politicians would still be able to restructure it reasonably quickly. If they can't do that, then isn't independence fundamentally undemocratic? Are we really going to let managers set their own targets?
I think you also underestimate the extent of the unresolved tensions in the NHS that require political action. I've already spoken about Wanless and public health, but what about the hospital closures and restructurings that will emerge from PBR?
I still say we need better politics, not less of it.
And in any case, according to your argument, golden ages are characterised by consensus, and you say we have consensus now. So where's my golden age?
If anything an independent NHS would be more accountable than it is at present. Politicians would still be accountable for strategy as they are now, but there will be an
extra layer of accountability for operational failures that just doesn’t exist at present.
The independent NHS governing board would be responsible to ministers and parliament, and I don’t see any reason why the current system of inspection and measurement would need to change.
An independent NHS has nothing to do with frontline staff setting targets but it may mean that the targets that are set are those required to meet long term health objectives not short term political requirements.
I think you’ve underestimated the inability of politicians to take the tough actions required to make a market based system work. The decision of whether to close a failing hospital will be made by Monitor, not an independent NHS Board. Politicians will find it politically difficult to let hospitals close and so will no doubt inappropriately intervene. This will create a worst of both worlds, with an NHS operating in a market based system without the incentives/disincentives to drive more efficient behaviour.
I think my comment on consensus and the golden age was unclear. I meant that there is a nostalgic image of the NHS during the consensus years and that this perceived link between political non-interference and more positive views of the NHS may be part of the driver behind the idea of a non-political NHS. Consensus isn’t necessarily apolitical, but in the case of the NHS the post war consensus meant the fundamentals of NHS weren’t political footballs in the way they are at present.
There is political consensus as to how the NHS should be changed, let’s see if the NHS itself can work out how that can be most effectively done.