Bevan and beyond

Accountability Devolution

From its very beginnings, there has always been an ambiguity about the precise relationship between centre and periphery in the National Health Service. Even Aneurin Bevan, its founder, spoke with a forked tongue.  On the one hand, there was the Bevan who insisted that his aim of “universalising the best” required planning on “a broad national scale”. The logic of both equity and parliamentary accountability for public money led to the much quoted bedpan doctrine: “When a bedpan is dropped in a hospital, I want the noise to reverberate through the corridors of Westminster”. Yet there was another Bevan, the lesser-known localist who was in favour of “maximum decentralisation to local bodies”, with substantial executive powers delegated to Regional Health Boards and hospital management boards.

The language of localism never died out, even as the NHS evolved over the decades to become the most centralised health care system in the Western world. For while central control was indeed the logic of the NHS’s original design, it was not achieved in Bevan’s day and for some time thereafter. For the first half or so of the NHS’s existence, the centre simply lacked the administrative capacity to exercise tight control over what was in many respects a loose federation of local boards. As Richard Crossman, reflecting on his experience as secretary of state in the early 1970s, put it: “You have a number of powerful, semi-autonomous boards whose relation to me was much more like the relations of a Persian satrap to a weak Persian Emperor. If the Emperor tried to enforce his authority too far he lost his throne…”

Subsequently, however, the screws of central control were tightened decade by decade, and the various intermediary bodies axed  – even while successive secretaries of state, Labour and Conservative, proclaimed faith in devolving power. So here’s the puzzle. Why has the recurrent rhetoric of localism never been translated into effective policy? Why, over time, has change been in the opposite direction?

The short answer is that technology allowed the logic of Bevan’s bedpan doctrine to be put into effect. IT transformed the capacity of the Department of Health to know what was going on in the NHS in real time. Whereas previously information about the local activities of the NHS had been both inadequate and out of date, the challenge increasingly became how to interpret the cacophony of information alongside changing governments and their policy objectives. The long answer would, of course, be that this was all part of a sea change in the managerial style of public services with the emphasis on targets, performance indicators and regulatory bodies.

We now have a centre (whether the Department of Health or NHS England) which has the capacity to hold the periphery to account for achieving an ever-expanding list of policy targets; from waiting times to infection rates, from reducing inequality to keeping people out of A+E departments. And we are back to the twin foundations of Bevan’s bedpan doctrine. On the one hand, there is the centre’s accountability to parliament for the way NHS funds are spent, with an increasingly assertive Health Committee demanding answers about policy implementation. On the other, there are the claims of equity: even if the ‘“best’” cannot be universalised, surely equity demands that the Department of Health must strive to ensure that the same services and the same standards apply across the NHS?

So this is the key question that faces any move towards greater localism. How much local autonomy is compatible with being answerable for the way the money is spent? How much deviation from national standards in the name of local priorities is acceptable? How does the setting of local priorities in order to cater for local needs and preferences (something to be encouraged) differ from postcode rationing (something to be condemned)? And would any secretary of state resist media and public pressure to intervene in local affairs  – which has been the pattern until now, despite the introduction of NHS England, which is supposed to insulate the service from political pressure – whenever there is any hint of scandal?

Like successive secretaries of state, both public and expert opinion probably favours localism in the abstract and sees the centre as smothering innovation. However, the activities of intense, organised lobbies point in a different direction from the diffuse consensus in favour of localism. Public opinion mobilises not in favour of localism, but in defence of the status quo whenever a hospital or service is threatened with closure, often appealing to the secretary of state to intervene.

So it is best to be cautious about the depth of active political support for localism in the NHS. The decision to devolve the NHS budget to Manchester offers hope. But local decision makers there will have to work within the same framework of national standards, targets, inspectorial regimes and regulatory rules and under the same statistical microscope as the rest of the NHS.

Most likely, local decision making will mean greater freedom to determine how national policies are implemented  – and the balance between health and social care services  – rather than discretion about the policies themselves. It will be a constrained form of localism. Manchester bedpans will still reverberate in the corridors of Westminster, but at least the Manchester experiment marks a significant first step towards translating rhetoric into polic

This was first published by the Fabian Society