A discussion regarding foundation hospitals, in a pluralist versus centralist context, reveals some difficult choices.
The debate over foundation hospitals – a plan to give very limited autonomy to the best National Health Service units – seems a minor issue. But it provoked a major confrontation in the British Labour party. Those who detect a defining moment are right. The debate over the roles of state and market, which has raged in Britain and elsewhere for 20 years, is becoming – as it should always have been – one about centralism and pluralism.
It is easy to see how the confusion came about. The state is naturally centralist, the market naturally pluralist. But it is possible, and desirable, to run a decentralised state – as when good teachers are free to run their schools as they think best. And it is possible, and undesirable, to have a market in which power is centralised – as when Microsoft gains control over the evolution of the software business. The triumph of the market economies of the west over the state-controlled economies of the east was seen as a triumph of materialist motivations over political ideals. But in reality it was a triumph of pluralism over central direction, of decentralisation over dirigisme.
Britain’s postwar settlement was centralist. The term nationalisation is used today as if it were synonymous with public ownership. But what nationalisation meant in the 1940s was the process of bringing under central government control activities such as gas, electricity, hospitals and transport which were already publicly owned in many cases. Aneurin Bevan famously announced that the sound of a dropped bedpan in Tredegar would reverberate around the Palace of Westminster.
The story of why this philosophy worked so badly in Britain – worse than in other European countries – is long and dispiriting. No organisation could make Bevan’s vision work, and certainly not a government structure whose tradition – in contrast to that of France – was to emphasise process over outcome. If the health minister was responsible for the dropped bedpan, in reality it was the responsibility of no one at all. The government – and most of all the Treasury – held an authority it could not exercise but would not devolve. The result was destructive tension between those who controlled services and those who delivered them.
Privatisation was the Thatcher government’s solution but not, in the end, a very successful one. Few businesses the government floated thrived in the private sector, and some of the privatised structures created, such as Railtrack and the water supply businesses, were plainly misconceived. Privatisation generally did produce improvement in the services provided but mainly because the initial situation was so bad that almost any change would have been for the better.
In this debate, privatisation was portrayed – by its opponents and its supporters – as the only alternative to centralised state control. This is why progress in public sector reform has been so slow. If the choice in health, education and other services is between state and market, most Europeans would vote unhesitatingly for the state because they prefer a public service ethos to private motive.
The road ahead becomes clearer if privatisation is off the agenda. Many people who would prefer the state to the market would also prefer a pluralist solution to a centralised one. If the choice is between profit motive and public service, they prefer public service. If the choice is between central direction and local autonomy, they prefer autonomy.
The argument for uniform national provision is specious. Everyone wants the best: the real issue is whether it is possible for the centre to impose the best. So opposition comes from those in Whitehall who really do think they know best, and from those who entered politics to get power, not to give it away. They are the people who ask how local people (in reality politicians and bureaucrats) will have a say in how foundation hospitals are run.
Ordinary people do not want a say in how hospitals are run, any more than they want a say in how their supermarket is run. Their aspiration is that the hospital, like the supermarket, delivers the goods and services they want. Today, that aspiration is met by the pluralist supermarket but not by the centrally directed hospital.