Claiming authority over the NHS SCOTT L . GReeR
There is a small subgenre of ministerial comments about the difficulty of getting anything done, from Nye Bevan’s story of how the ‘very powerful men’ were always one level up, to Gerald Kaufman’s comparison of ministerial office to occupying the signal box at Clapham Junction only to find that the levers aren’t connected to anything (Foot 1975; Kaufman 1997). Frustrated with their inability to pursue their agendas, or achieve their goals, or just make a mark, ministers have turned out to be great consumers of proposals that will harness all manner of technology and social organisation to the task of getting the system to produce what they want – even if there has often been less clarity about what they want. Here they fall into the kind of trap that Bevir associates with modernist social science (Bevir 2010). Governments of all parties in office in the UK have adopted a wide range of tools for NHS reform. Tools that are supposed to produce greater direct government control over the NHS produce more complexity. Tools that are supposed to relieve government of the burden of managing the NHS lead to it making still greater claims to manage it. Policies focus on managers and their incentives, and are often frustrated by professionals and patients in practice. The result is an endless series of ironies; policies that seem to have the reverse effect of that intended. Over time, the cumulative result is an ongoing increase in claims of authority by the state over the management of health care, claims taking the form of policies that try to organise some aspect of health care that was previously organised by somebody else – typically professionals or intermediate bodies such as local boards. The focus of this chapter is on establishing the extent to which we can read various policies as claims made by the centre over the NHS. They are modernist efforts to make a complex, vast, and diverse system legible and manageable, through techniques as different as establishing general management, collecting data, and creating specialist regulators. This interpretation runs contrary to analyses that focus on the introduction of markets. The next section sketches out the argument that we can read policies as claims of authority at the expense of intermediate bodies – notably professionals, with their clinical knowledge, and territorial units, with their broader political sense and tacit knowledge of local
conditions. Subsequent sections discuss NHS policies since 1983, identifying a growing trend towards claims of authority by the centre over the NHS, even as the policies themselves often produce unexpected results.