The tides they are a changing

To many outsiders governments and politicians are all-powerful entities aloof from the 'real world'. In reality politicians are constrained by external factors such as economic performance and the wider 'history of ideas'. In a very real sense, politicians are corks that bob on the tide of history. And history is ultimately governed by the moon of ideas.

A dominant assumption of our age in health is that a stateenforced egalitarianism is more beneficial than any alternative.

Government regulation, public ownership and funding from taxation are often assumed to be more kindly and sophisticated ways of organising health and care than any other.

Yet 140 years ago, whether one was of a classical liberal or a cooperator socialist disposition, you were mindful of the advances being made in modern medicine for the benefit and improvement of every social class, and generally hostile to government intervention, however argued.

You were certainly opposed to state-enforced egalitarianism.

In the latter half of the 19th century, British and European radicals were steeped in the traditions of the classical liberal, co-operative and anarchosocialist movements. They viewed government and notions of the 'public good' as the propagandistic playthings of the rich and powerful.

Public ownership was not equated with state ownership.

Instead, it meant individuals trading with or in part owning a rich tapestry of health and welfare organisations including commercial enterprises, friendly societies, charities and mutuals.

Reputation was seen as a better guarantor of quality and service than complex, often counterproductive and arbitrarily imposed government regulation.

Taxation was mistrusted because it would be directed towards the vote-winning agendas of a factionalised political class and not the desires of ordinary people, particularly society's poorest.

As the 20th century progressed, these ideas were largely forgotten, and health and welfare came to be dominated by state ownership, government regulation and taxation. It is with some irony that having gone down the road of big government in recent decades, politicians are today busy rediscovering themes that echo earlier 19th-century radicalism.

Across today's health and welfare debate you can hear the past at every turn. 'Public-private partnerships' echo the 19th century's celebration of diversity and support for a wide range of health and welfare provision.

'Best practice' is the modern term given to innovation and the desire to find and spread success.

Away from the uniformity of rules that underpin all systems directed towards statist egalitarianism, innovation echoes the search and spread of nothing less than good reputation.

The private finance initiative and even the recent concordat with the independent sector point to a future with radical and worthy roots in the past. Who today believes the public sector has a monopoly on expertise when it comes to reputation, provision and responsiveness?

At the beginning of the 21st century, no one sector can 'do it all' in health and social care.

Rising expectations, new technology, an ageing population, pressures on services: finding answers to these matters requires teamwork between all of Britain's health and social care services - NHS, local authority and independent.

Today, the independent sector delivers 85 per cent of residential community care and a million surgical procedures a year; and provides more than half of all medium-secure mental healthcare. Much of this work is done in partnership with the NHS and local authorities.

In 2001, thanks to the recent concordat between the government and the Independent Healthcare Association, it is accepted that NHS patients should receive the surgery they need in independent acute hospitals. It is accepted that NHS patients have access to independent sector intensivecare and high-dependency beds when people are often at their most vulnerable; and that NHS patients should not remain in hospital when they would be better off in high-quality, best value, independent sector intermediate care facilities.

Today's politicians really are corks bobbing on the tide of history. And the moon of ideas that guides them is more concerned with the timeless qualities of reputation, choice and consumer responsiveness than the increasingly outdated politics of top-down uniformity.

Slowly, but surely, we are all going back to the future.