IT HAS taken a while for Britain’s political classes to recover from their post-war torpor, but the row over giving a few hospitals a bit of autonomy in the way they manage their affairs has done the trick. The government’s modest plans for introducing so-called “foundation” hospitals to England’s highly centralised health-care system have had backbench and union critics up in arms, accusing it of destroying the founding principles of the National Health Service. So profound was the government’s unease about the scope for a damaging rebellion that before a vote that they easily won ministers seemed more intent on saying what foundation hospitals were not than what they are.
Yet the idea that Tony Blair and Alan Milburn, the health secretary, are conspiring to end the system whereby health care is free at the point of use and treatment is based on clinical need rather than the ability to pay is manifest poppycock. So what is really going on? At the heart of the arguments over public-service reform now raging within the Labour Party are two quite distinct and opposing ideas of citizenship, not to mention a good deal of intellectual confusion.
As Catherine Needham argues in a pamphlet published last month by Catalyst, a leftish think-tank, the real split is not over foundation hospitals as such, but over the nature of the relationship between the citizen and the providers of public services. On one side is a traditional, sentimental Labour view that good public services not only express the value the community places on collective provision, but define the nature of the community itself. Implicit in this is the belief that citizenship stems from the social solidarity that is fostered by shared interests and decent minimum standards.
On the other side are those New Labour types (including Mr Blair) who are edging towards neo-liberalism. They see citizens as consumers whose relationship with the state is largely bilateral and whose political preferences are revealed mostly by economic decisions. Although they recognise that there are difficulties, they want public services to be provided more like privately supplied goods. That way, they believe, people will gain more control over their lives.
It is an article of faith for Mr Blair and New Labour that the party helped to make itself unelectable because its response to Thatcherism was a knee-jerk defence of public-sector unions combined with unthinking hostility to the privatisation of the old state monopolies. Just as Labour had allowed itself to become associated with the drabness of rationing in the 1950s, in the 1980s it looked equally out of touch in identifying itself with producer interests instead of coming to terms with the rampant consumerism the Tories had unleashed.
In a speech to the Labour Party conference in October 2001, dripping with frustration over what he regards as the almost pre-historic attitudes of many in his party, Mr Blair said: “This is a consumer age. People don’t take what they’re given. They demand more.” Mr Milburn, defending his proposed NHS reforms, echoed: “We are in a consumer age whether people like it or not. What will destroy the public services is the idea that you can retain the ethos of the 1940s in the 21st century.” In particular, Mr Blair reckons that the prosperous middle classes, whose taxes pay for hospitals and schools, will desert the public sector unless service providers start to respond to their needs as the private sector does.
Mr Blair and Mr Milburn are right: the time when people were grateful for whatever they were given has gone. And the last few years of rapidly rising spending on health unmatched by better results should have silenced opponents of change. But even now, the prime minister appears uncomfortable about where the logic of his argument is taking him.
Mr Blair yearns for a “third way” that reconciles what Ms Needham disapprovingly describes as the “self-regarding”, atomised citizen-consumer with the good old Labour values that his critics claim he doesn’t understand and is doing his best to undermine. He continues to insist that the reason he believes so “passionately” in public services is “because they are what community is all about. They bind us together.”
Any colour as long as it’s black
Mr Blair might not go as far as the Catalyst paper, which advocates a form of “civic republicanism” that would judge public services on the basis of what they contribute to society rather than whether consumers were satisfied. But one aspect of the blueprint for the new foundation hospitals suggests that Mr Blair is in a muddle.
In a bow to the currently fashionable “new localism”, the foundation hospitals will supposedly be answerable to boards of governors of which a majority will be elected from the local community and patients. Not surprisingly, the detail of how this might work is distinctly lacking. However, given the complexity of modern hospitals and the tensions that are bound to arise between local worthies, who are likely to be natural conservatives, and managers to whom the government has given the freedom to expand and innovate, there is plenty of scope for trouble in the future.
What New Labour’s citizen-consumers lack is not democracy or community but market power. By constantly talking up choice and diversity, the government has raised expectations in a way that its cautiously incremental approach to reform can’t hope to satisfy. Until there is real competition between providers and some surplus capacity within the system, for most people wanting to educate a child or book an operation, choice will be as academic as it was for Henry Ford’s first customers. The one way in which citizens are likely increasingly to resemble real consumers is in their willingness to complain.