TINA?  Institutional Parameters for a New Deal for the NHS.

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The difficulty lies not so much in developing new ideas as in escaping from old ones.  

JM Keynes.

Many Labour MPs are still enamoured with TINA

Members of the Leeds ‘Keep Our NHS Public’ (KONP)  are active in local campaigns to raise public awareness and build resistance to the dismantling of the NHS.  We work through street demonstrations and marches,  supporting  local campaigns.  Many in the group considered it a waste of time to contact local Labour MPs who are considered incorrigible New Labour aficionados.

In August last year we found that only 4 out of 36 Labour MPs in Yorkshire & Humberside actively voted for the draft NHS Reinstatement Bill that sets out to fully repeal the 2012 Lansley Act – part of the neo-liberal agenda which has caused so much harm to our national health service. The NHS is one of the bedrocks  of the Labour Party achievements and is supported by most people. We asked why don’t Labour MPs see the consequences of the 2012 Act and what it will do to the principles of universal health care provision for all? Why neglect a real vote winner?

So we prepared a letter to our MPs asking them to meet and engage in a friendly and non-confrontational dialogue.  This included an information pack setting out the evidences, the arguments, and the policies needed to reverse the NHS privatisations and marketisations since their introduction in the early 1990s.

But we had zero response from any Labour MP except John Trickett who is close to Jeremy Corbyn. Not even an acknowledgement of the posted information pack from the others.

A direct request by a member to meet his Constituency MP did lead to a meeting.  This MP’s reasons for not supporting the draft Bill included the costs involved in repealing the 2012 Act, the need to have some competition and ‘comparators’ with which to assess NHS performance, and a reluctance to ‘go back’ to the NHS of the 1970s.

We explained to him that the best economic comparison is at the macro-level where the UK spends 8% of GNP on health, whereas France and Germany spend 10% and 12% respectively.  And the public service ethos in the NHS is priceless, and that the present market-ideology will destroy this.  Going back to an NHS based on public service values rather than market values is in fact going back to the future.  That is, a rejection of the political world view established by Margaret Thatcher and her ‘there is no alternative’ convictions.

The story of TINA and the Individual as Queen

The intellectual arguments for TINA and ‘no going back’ are summed up in Julian Le Grand’s book ‘Motivation, Agency, and Public Policy’ that questioned the altruism of public service professionals to deliver good quality health and education services,  and if patients, parents and pupils behave as grateful recipients or active consumers.

Le Grand was a senior policy adviser to Blair’s government for two years on the quasi-market reforms in health, education and social services and was intimately involved in formulating the analyses that underlay these reforms.  Le Grand was inspired by David Hulme’s assumption that all men (and women) must be supposed to be knaves and have no other end than private interest, and that this is the starting point for designing governance for the public good.  That is, the question of Socrates – ‘How should we live together’,  may be addressed by summarising the arguments in the conceptual framework provided by the two axes of Fig A below which emphasises that the individual is the centre of public policy.

Le Grand argued that the market-oriented paradigm of the 1980’s allows the individuals ‘queen’ like choices rather than being passive pawns as under previous political thinking.  And that public servants’ behaviour is better understood by assuming they behave like knaves rather than knights.  In this representation the social democratic tradition is seen to be backward, and the Third Way or Market Socialism is a compromise with neo-liberalism.

Quite how Le Grand aligns Third Way with Market Socialism is not clear, and why the two axes are supposed to represent political reality is also not clear. A critique included in the book by Mathias Risse (Harvard University) questions why user empowerment should be included at  such a late stage in conceptualising the secondary role of the state in its organisation of public services, whereas any useful theory of the liberal democratic state  would give citizens the primary role from step one.

Also the chess terms are somewhat loaded.  Queens are aspirationals and free to move in any direction (New Labour hopefuls), only a few can be queens.  Pawns (Old Labour hopeless) are expendable and able to move only one step at a time and sacrificed when necessary.   And public service ethos knights shuffle three steps forward and one to the side like the Man of La Mancha. But David Hulme’s knaves!  This is what turns the Blairites on!  If it comes from the Scottish Enlightenment then there is no need for any more questions.

Emphasis on Citizens in a Social Democracy

Figure A represents New Labour policies and describes how many Labour MPs see NHS Reinstatement as going back to the ‘failed’ social democratic political paradigm of the past.  However, if the social democratic paradigm is presented with its emphasis on citizens within the state then a different representation of the political world become apparent.  Instead of aspirational queens we have an emphasis on open democratic life and engaged citizens.  And instead of La Mancha knights we have public servants who are intrinsic members of civil society.

This world view is set out in Fig B below.  It was prepared on a local administration reform job in Syria (before the civil war) where the Minister wanted to know how to move from the central planning paradigm and Constitution imported lock stock and barrel from East Germany, and transform their society into a Scandinavian  model.

In this presentation neo-liberalism is seen as an instrument of corporate capitalist politics with weak citizens rather than the world to be aimed for by TINA beliefs.

Therefore if we want to choose how we should live together, and reject  the ideology of TINA, we can usefully draw on approaches elsewhere by re-examining a social democratic vision of the political world.  This will be the starting point for formulating a New Deal for the NHS.

What is required is imagination in designing public services where citizens do have an active role, and where public servants are respected for their public service ethos.  Getting there for the NHS means identifying and designing parts of the systems that promote citizen participation in an open democratic political life.  There are many ways to do this but all of them require a change in mind-set by the politicians in the Labour Party.

Neo-liberalism diagram

The Constituency Labour MP above was given two books. One by David Hunter (The Health Debate) gives the reasons why public service ethos Knights are fundamental to the NHS.  The other by John Seddon (Systems Thinking in the Public Sector) sets out how individuals and not markets must come first in any planning.  This MP is now fully supportive of the campaign against the outsourcing and privatisations of the NHS – partly because he is convinced, and partly because he has a small majority and local NHS campaigners can put 15 people on the streets during elections.