Chapter 17: ‘Public Knowledge’ and Health Policy
Aeron Davis’s succinct overview of the contemporary determinants of the quality of public knowledge provides many of the elements needed for understanding what has happened to public knowledge about health policy since 1980. But knowledge about health care is not merely subject to the general impact of global market forces outlined by Davis in chapter 1, and the increased complexity of modern knowledge. Being almost entirely state-funded in Britain, and therefore a prime object of state policy, health care is also subject to a critical shift that has simultaneously taken place in the way all policy is made. The end of the hegemony of social democracy in the United Kingdom in the late 1970s saw the end of the liberal/social-democratic ‘policy regime’ that had been in place since the 1920s, if not earlier.1 The neoliberal policy regime that has replaced it effectively rejects—in intention and increasingly in practice—the concept of a ‘public sphere’ to which the concept of public knowledge is necessarily linked, and this is nowhere more evident than in relation to health policy.
The Institutional Foundations of the Public Sphere
The public sphere was above all a construct of the institutions through which social, economic and political knowledge was produced and assessed and policies were endorsed, independently of the influence of private interests. These institutions were the professions, insulated from both commercial pressures and from government; the universities, funded through arms-length arrangements to preserve their freedom to engage in disinterested teaching and research; the press, with freedom to allow for the exposure of official dissimulation or lies; public service broadcasting, to give the electorate valid information and a platform for public debate on how the information should be interpreted; judges, funded from the civil list to make them able to stand up to governments; and the senior civil service, dedicated to ensuring that policy was made in light of the public knowledge made possible by these arrangements.
The idea of a public sphere was thus closely linked to the idea of the public interest. At a minimum, the concept of the public interest is something distinct from, or which transcends, private interests, and involves a commitment to a norm of disinterestedness; but it could also connote substantive values, such as that human happiness should be maximised, for example, or that everyone should be as healthy as possible. As soon as this is acknowledged it is obvious that the idea that public knowledge as something universally shared is inherently problematic. At any given time, there is typically a body of conventional wisdom, the dominant ideas and norms of the day, that can be described as shared. But this set of ideas and norms is always contested. In the case of health, we are witnessing a drive to devalue and if possible eliminate a former body of ‘common sense’ and replace it with one according to which, instead of policy being produced in the public sphere to serve the public interest, it should be produced by whatever means will simply make markets efficient. Rupert Murdoch’s statement in relation to broadcasting that ‘the public interest is what interests the public’ was a fair representation of the neoliberal viewpoint; that is, the elite who have occupied the key roles in the public sphere are unrepresentative, and their claim to uphold an interest shared by everyone is undemocratic and invalid. On this view the only valid ground for any statement about interests is consumer preferences.
Dismantling the Public Sphere in Health Policy
From the early 1980s onwards the NHS became a priority target for neoliberals of this kind for several reasons. First, accounting as it did for about 15 percent of state expenditure, it was seen as a potentially major field for private capital accumulation. Second, being tax-funded and equally accessible to all, it was a bastion of social-democratic values and a constant reminder of the advantages and popularity of non-commodified services. Moreover, because there is a steep class gradient in ill-health, spending on health care necessarily also involves some income redistribution from rich to poor, not just from the well to the ill. For all these reasons, the NHS was one of the first branches of the state to feel the effects of the new neoliberal policy regime, beginning with a radical reorganisation of the Department of Health (DH).
The erosion of the department’s policy-making function has been the most complete of any government department. Since the creation of the NHS Executive in 1989, which shifted effective power over policy more and more into the hands of health service managers, the DH has been steadily run down, declining from 4,795 staff in 1996 (UK Government 2015) to 2,422 in 2013, of whom only 164 were in the senior civil service (a further cull of 650 DH posts was announced in February 2016; see BBC 2016), and almost all of these had been recruited from hospital management or, increasingly, from private sector sources, especially management consultancies. Of the thirty-two members of the ‘top’ team in 2006, eighteen were drawn from NHS management and six from the private sector; only one was a career civil servant (Greer and Jarman 2007, table 1). From 2003 to 2010, a 180-strong Commercial Directorate, consisting almost entirely of ‘interims’ seconded from the private sector, infused the DH with a market-oriented culture, while senior DH personnel moved in the opposite direction into senior jobs with private health companies, as did several former Labour ministers following the 2010 election.2
In this way, the defence of the public interest in health policy that was formerly provided by the senior civil service’s role in policy-making was effectively abolished; instead, from 2000 to 2010, the development of health policy was in practice largely outsourced to a mixture of management consultancies and two well-funded think tanks, the Kings Fund and the Nuffield Trust, the latter of which had strong ties with the private sector. McKinsey & Co. in particular played a major role in Labour’s health policy thinking in those years and is credited with shaping much of the detail of the coalition government’s 2012 Health and Social Care Act.
A further effect of the market-creation drive was to reduce the amount of information on the basis of which policy can be evaluated. For example, details of how the £60 billion plus a year now channelled through Clinical Commissioning Groups (CCGs) to pay the providers of secondary care is spent are no longer centrally collected. Moreover, most CCGs have outsourced the making and management of the contracts for these services to Commissioning Support Units (CSUs), embryonic management companies formed by the remaining staff of the now disbanded Primary Care Trusts, with the effect that many details of the expenditure of even a single CCG are not obtainable by public researchers (CHPI 2015). The combination of these factors means that the information needed for the critical evaluation of the outsourcing of acute hospital and community care scarcely exists.
These developments in health policy took place in the context of another general development in the erosion of the public sphere: the normalisation of spin (see Cave and Rowell 2014, chap. 4). The rapid development of new techniques for influencing public opinion coincided with the arrival in office in 1997 of a Labour leadership determined not to allow the right-wing press to repeat the savaging that had been meted out to the party between 1981 and 1992. In office, the party invested heavily in media management. Government publications became like corporate publications, designed to convey positive feelings and downplay bad news. Lord Darzi’s 2008 report on healthcare for England, to which McKinsey & Co. staff also made a large input, was a prime example of this style (Department of Health 2008). Another was McKinsey & Co.’s 2009 report on ‘Achieving World Class Productivity’ (McKinsey & Co. 2009). This report, in the form of PowerPoint slides, called for a programme of ‘efficiency savings’ based on manifestly unrealistic assumptions and financial projections for which no accessible sources were provided. Yet it became the basis of policy, whereby NHS managers were called on to maintain or even improve services while losing £20 billion in funding over five years. By 2010, no one seriously concerned with health policy any longer placed great confidence in the value of statements or claims emanating from the DH.3
As for the production of public knowledge by the fourth estate, the negative pressures itemised by Aeron Davis apply in spades to health policy. Health policy is complex and undramatic—and unattractive to editors at a time when newspapers are desperate to stem the loss of readers while simultaneously cutting editorial staff and making those who remain work longer and across more media. The temptation to rely on government press releases is nowhere stronger than in health policy.
On top of these general pressures there is the threat to public service broadcasting represented by the demand from private broadcasters for a slice of the television licence fee. Following the brutalisation of the BBC by Alastair Campbell for exposing the Blair government’s duplicity over the ‘dodgy dossier’ on Iraq, successive Directors General and BBC trustees seem to have concluded that the corporation’s future depends on recognising that the midpoint of the party political spectrum had moved decisively to the right. How far the BBC’s startlingly uncritical treatment of the 2011 Health and Social Care Bill was conscious policy, as opposed to the more or less unconscious internalisation of the new ideological reality by senior BBC staff, it is impossible to say. As Oliver Huitson notes in his review (Huitson 2013) of the failure of the media to provide a critical understanding of the Bill, the real aim of the legislation was too obvious to be overlooked, and a very large gap opened up between the mainstream discourse on health policy and that of the social media. This raises interesting questions: In the era of globalised capitalism, how far does the operation of representative government need shared public knowledge? Do voters increasingly expect to be told nothing they can really trust? How far does voters’ resulting indifference pose a significant threat to the legitimacy of the government and the representative state?
Two other notional pillars of the public sphere have proved fatally weak in relation to health policy: (1) the medical profession and (2) academic experts. Margaret Thatcher’s view that the professions were market-constraining monopolies that needed to be brought to heel led to a new culture of criticism of doctors and to considerable inroads into their independence and prestige. In 1945–1946, the BMA had come close to refusing to operate the new health service; in 1987 the presidents of the three biggest Royal Colleges of medicine took the opposite stand, this time in defence of the NHS, writing a joint open letter to the Prime Minister to protest the financial strangulation to which the NHS was being subjected. By 2010–2012, such confident behaviour was no longer thinkable. The BMA and the Academy of Royal Colleges were in a position to make it politically impossible for the Coalition to push through the HSC Bill, and over the months from July 2010 (when the white paper outlining the Bill was published) to the Bill’s passage into law in 2012, a majority of doctors became more and more opposed to it. But their leaders refused to adopt a position of categorical opposition or to actively communicate their members’ views to the public. Among many possible explanations, the most likely, as well as the most charitable, is that the leaders were ultimately more committed to the interests of the profession than to those of the public and judged that they could not afford to lose government patronage (see Davis and Wrigley 2013).
As for health policy academics, there too there is now an alignment of interest towards government policy rather than to the public interest. The conversion of universities into institutions primarily concerned with producing trained manpower for corporations and research useful for making money has been underpinned by their reconfiguration as businesses (McGettigan 2013). Research funding from the Economic and Social Research Council is explicitly oriented to the promotion of economic competitiveness, and much academic work on health policy is directly financed by the DH.4 There is strong pressure from university administrators to secure research grants, and there are few charitable funding sources that are not themselves aligned with government policy. In this context, few academics working on health policy, even among senior tenured staff, have been willing to become outspoken critics of the market-based model, even though both theory and empirical research show that market-based provision leads to higher costs and lower quality in health care. The pages of health policy journals contain much critical analysis of particular health policies, but it is mainly ‘immanent’ criticism relative to the expressed aims of policy, rather than critique based on any alternative conception of how the public interest might be served.
In conclusion, rather than seeing the issue in terms of the existence or non-existence of shared public knowledge, I am inclined to see it more in terms of competing visions of the public interest and competing knowledge paradigms derived from these visions, and to question how much the ‘sufficient legitimacy’ of election-based governments now depends on the paradigm favoured by the government of the day being widely shared. What is clear, though, is that in health policy the conditions for the maintenance of a concept of the public interest independent of politically dominant private interests have been largely destroyed, and with them the possibility of any coherent public discussion of health policy.
To take just one of many possible examples, consider the issue of cost, which is currently at the top of the political agenda. The question asked is whether the NHS is ‘affordable’—but affordable by whom, and with reference to what standard of reasonableness?5 In relation to the government’s austerity spending plans? Or to the proportion of GDP spent on health, which remains substantially lower than in comparable countries?6 How valid are the assumptions underpinning the claim that the NHS faces a £30 billion financial shortfall by 2021? What portion of this predicted shortfall is accounted for by the administrative and legal costs of operating the service as a market, compared with those of non-market provisions? What evidence is there that the costs of opening the NHS up to competition from private providers have been offset by increased efficiency? Is the problem primarily one of the scale of the resources needed, as opposed to a problem of resistance by corporations and wealthier taxpayers to raising the needed resources from taxation? Given the stakes, these are not unreasonable questions, but even if there was a shared willingness to seek objective answers to them—which there clearly is not—neither the data required nor adequate resources to study them any longer exist.
Barker, K. 2014. “A New Settlement for Health and Social Care.” Commission on the Future of Health and Social Car in England. http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Commission%20Final%20%20interactive.pdf.
BBC. 2016. “Department of Health to Cut 650 Jobs to Reduce Costs.” BBC, February 5. http://www.bbc.co.uk/news/health-35499277.
Cave, T., and A. Rowell. 2014. A Quiet Word: Lobbying, Crony Capitalism and Broken Politics in Britain. London: Bodley Head.
Centre for Health and the Public Interest (CHPI). 2015. “The Contracting NHS: Can the NHS Handle the Outsourcing of Clinical Services?” Centre for Health and the Public Interest, March. http://chpi.org.uk/wp-content/uploads/2015/04/CHPI-ContractingNHS-Mar-final.pdf.
Davis, J., and D. Wrigley. 2013. “The Silence of the Lambs.” In NHS SOS: How the NHS Was Betrayed—and How We Can Save It, edited by J. Davis and R. Tallis, 62–87. London: Oneworld.
Department of Health. 2008. “High Quality Care for All: NHS Next Stage Review Final Report.”
Department of Health. 2012–2013. “Annual Report and Accounts 2012–13.”
Greer, S., and H. Jarman. 2007. The Department of Health and the Civil Service: From Whitehall to Department of Delivery to Where? London: Nuffield Trust.
Huitson, O. 2013. “Hidden in Plain Sight.” In NHS SOS: How the NHS Was Betrayed—and How We Can Save It, edited by J. Davis and R. Tallis, 150–173. London: Oneworld.
Leys, C. 2006. “The Cynical State.” In Telling the Truth: Socialist Register, edited by L. Panitch and C. Leys, 1–27. London: Merlin Press.
Leys, C. 2012. “The Dissolution of the Mandarins: The Sell-Off of the British State.” openDemocracy UK, June 15. https://www.opendemocracy.net/ourkingdom/colin-leys/dissolution-of-mandarins-sell-off-of-british-state.
Leys, C., and S. Player. 2011. The Plot against the NHS. London: Merlin Press.
McGettigan, A. 2013. The Great University Gamble. London: Pluto Press.
McKinsey & Co. 2009. “Achieving World Class Productivity in the NHS 2009/10–2013/14: Detailing the Size of the Opportunity.” Department of Health, March. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_116521.pdf.
UK Government. 2015. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/390893/DH_WMI_Nov-14.csv/preview.