Published: 14/03/2002, Volume II2, No. 5796 Page 20
There is something wearisome about the cyclical nature of health policy because we seem to learn so little from the past and make little advance on it. The criticism applies both to those making policy and those analysing it.
Policy analysts ought at least to have a sense of history and be able to make connections with past experience. Regrettably, the King's Fund's tract from its futures group under Lord Haskins' chairmanship fails this test with its proposal for an NHS corporation working at arm'slength from government.
1Of course, we would all agree that the level of debate about the health system we have is the poorer for being subject to the whims of party politics. But to conclude that the remedy is to take the NHS out of politics is simply naive. It will not work.
The issue is not new. Some 20 years ago Sir Roy Griffiths produced his infamous 21-page letter to the health secretary which ushered in general management.
Sir Roy was exercised by the absence of effective management at the centre and by the tendency for politicians to interfere in the detail.Does it all sound horribly familiar?
Sir Roy fell into the same trap of believing that it was possible to insulate the NHS from political intrusion. The dilemma he confronted was one where consistent management from the centre is always likely to be incompatible with the demands, however seemingly arbitrary, of a political system which insists on the right to influence events.
There are important lessons to learn from Sir Roy's experience and the subsequent operation of the NHS Executive under Sir Alan Langlands. Sir Alan, as NHS chief executive, was unequivocal in his view that the NHS, and therefore the Executive, could not be removed from politics.Nor should it be, he insisted, if the NHS wanted a seat at the top table, which he had, to advise ministers and influence policy.
As a society we have the politics we deserve, and if they are shallow, superficial and obsessed with form rather than substance, then we are all guilty of tolerating - or possibly even colluding with - such a system. Rather than being beguiled by the prospect of getting the NHS out of politics, perhaps we should be investing in the much tougher task of bringing about a new politics.Of course, this will be dismissed as naive, too, but if we were at all successful we might achieve more, and have a marginally healthier political system to boot.
Advocates of the structural solution of removing the NHS from politics might have a case to answer if their prescription stood a chance of success. But the fate of the Griffiths report demonstrates that separating the NHS from politics is fundamentally flawed because governments will interfere whenever they wish and/or whenever the public mood dictates. Examples litter the public sector, from the old public corporations and nationalised industry boards to the more recent debacle over the direction of the prison service.
Health is intrinsically a political matter, especially when priorities have to be set and judgements made. The NHS is not delivering a typical consumer product with a clear bottom line.
Therefore the technocratic appeal of unfettered management is not a serious alternative.
Where things may have gone badly wrong in Britain is that we have a group of ministers who, not content with being politicians, fancy themselves as managers. It is they who have strayed beyond the broadly accepted boundary between politics and management not by being politicians but by acting as quasi-managers.
Paradoxically, the politicisation ofmanagement by politicians is taking place at the same time as the depoliticisation of politics.
We have the bizarre spectacle of politicians speaking the language ofmanagers, and managers acquiring the skills of politicians in order to be able to second-guess them.
So what is to be done? For a start, there is no single, simple solution.One way of escaping the hothouse atmosphere of the Whitehall 'village'might be to bring the politics closer to the front line.Regional government in England beckons.Those in Scotland, Wales and Northern Ireland will groan at this, believing that devolution is proving more troublesome than anything coming out of London.
But it is early days, and if we are serious about crafting a new politics and creating the conditions for sensible debate about health policy, we need that discussion at a level in the system where it makes most sense to have it. It makes no sense at all to have a centralised system of political control predicated on a discredited signal-box model of change, with ministers pulling levers and then wondering why so little happens.This is neither good management nor effective politics.
1King's Fund. The Future of the NHS: A framework for debate.
Discussion Paper. King's Fund, 2002.
David Hunter is professor of health policy and management at Durham University.