From <I>Free Life</I>, No. 15, November 1991: "Reform and Reaction in Healthcare", by Professor David Marsland. This is a defence of the market reforms made since 1989 to the British National Health Service. Its author is a leading sociologist and the first winner of the Thatcher Prize. Length

At least the founding fathers of the National Health Service were serious in their belief that it was essential and that it would be effective.

Indeed, so fervent were they in their commitment to the new principles, policies and forms of organisation established in 1948 that they claimed, apparently with straight faces, that after initial investment costs health care would become rapidly and progressively cheaper. They were convinced that the level of public spending required to fund the NHS would diminish as the population grew healthier.

As we now know, they were gravely mistaken. Costs have continuously risen to the point where they seem to be out of control. The effectiveness of the NHS in reducing sickness and optimising health is patchy. It has not proved to be the bargain basement panacea which its initiators imagined they had created. But at least they were serious in their misconceptions.

This is more than can be said for today's champions of an unreconstructed NHS preserved in the aspic of antique collectivist principles. For Mr Cook, the public debate about health care is no more than an opportunity to demonstrate his socialist credentials. For Mr Kinnock, it provides merely a promising arena for extravagant display of his habitual emotional rhetoric. Vote Labour, he proclaimed with laboured effort at political rhyming verse in his Brighton speech, and "build up the NHS": vote otherwise and "break up the NHS". "After nationalisation" he might more honestly have urged, "ossification. After change, the status quo for ever".

The Trade Union sector of the resistance movement against health care reform - from NUPE and COHSE to the BMA and beyond - is even more disingenuously cavalier with the facts and with people's needs. In their jaundiced eyes, reform of the NHS is just the latest "class challenge" to be answered with all the intelligence and finesse of King Ludd. For the social researchers and social policy academics whose tax-financed role is to celebrate the ideology of the welfare status quo, health care reform is a threatening omen of imminent capitalist restoration. While for the media, including not least the BBC and the so-called quality press, the whole thing is a Thatcherite leftover and a calculated insult to the suffering poor.

Yet none of them - not the Opposition, nor the unions, nor the self- proclaimed experts, nor the journalists - are really serious in their resistance to reform, or genuine in their apologias for the status quo. They all know that the unreformed NHS is hog-tied with bureaucracy; that is squanders public money and precious skills, that its service to patients is crippled by labour practices as selfishly destructive as any in the docks or the print industry; that continually expanding investment is almost entirely swallowed by a limitlessly expanding wage bill; that attention to individual patients' needs is routinely obstructed by paternalist omniscience; that it has become in the end a pathetic travesty of its founding fathers' romantic dreams.

Radical reform of health care in Britain is transparently and unarguably essential. After careful consideration and widespread discussion, rather late in the day, and more than somewhat cautiously, the Government has set the requisite reform in train. It has been met by partisan reaction. It is this reactionary resistance to reform that I propose here to examine.

A proper understanding of the character and meaning of resistance to reform of the NHS requires first an examination of the Government's purposes and plans, and honest consideration of the main thrust of the reforms now being implemented.

the NHS is a monopoly, a State monopoly, a huge State monopoly, and a huge bureaucratic State monopoly. the reforms directly address the problems, the inefficiencies, the inequities which periodically and inevitably flow form these basic characteristics. Increased resources without reform - which is the Opposition's only policy for health care - will make these problems even worse, reduce efficiency still further, and aggravate existing inequities.

Waiting lists will lengthen. More wards will close. Buildings will decay. New technologies and drugs will become luxurious fantasies. basic research will wither. GPs will have even less time for their patients. And facilities for the elderly, the mentally ill, the handicapped, and for community care and preventative medicine will slip inexorably further down the list of health care priorities. Without radical reform such as the Government now intends, for the first time since 1948, the NHS will gradually collapse into the squalid conditions of the health care systems of Eastern Europe - where the art of comprehensive State monopoly health care has been perfected.

The reforms privatise not a single unit of the NHS. the offer not the slightest challenge to free and comprehensive delivery of health care. They leave the essential elements of the wartime reconstructionist settlement of health care absolutely intact. They are, nonetheless, radical addressing as they do the problems caused by monopoly, bureaucracy and inertia.

The crux of the reforms - acknowledged by the Opposition's categorical commitment to cancel them immediately on coming to power - consists in the organisational separation of purchasers and providers of health care, by the establishment of Hospital Trusts and of GP budget holding, and by fundamental changes in the structure, operations and funding systems of the Health Authorities.

Together, these reforms will challenge monopoly and bureaucracy by introducing, after four decades of artificial and ennervating insulation, a little healthy competition into the NHS. They will inaugurate at long last a modicum of attention to costs: extravagant and careless waste in the NHS remains enormous. They will demand from Health Service personnel some attention to patients as individuals and as consumers. They will permit the front line managers of the NHS to get on with their work untrammelled by bureaucratic interference from Whitehall, from Region, and from District. They will allow the health needs of each community to be looked into, and genuine priority needs to be dealt with at the expense of established habits and fashionable hobbies.

All this can - and is being - achieved by the current reforms, without a hint of the privatisation which the reactionary opponents of reform pretend to detect. Accompanied as they are and will be by continuing expansion of the resources devoted from public spending to health care, they represent our last and only chance to modernise British health care, and to raise it to the standards that our children will demand in the prosperous decades ahead.

We should be in no doubt of the Labour Party's determination to play the Health Service card for all it is worth and more in the long election campaign which has already begun. The speeches of both Party Leader and Health Spokesman at the Brighton conference provided ample evidence of their intention to scare the voters silly about the Government's alleged ambition to privatise the NHS.

Mr Cook stated categorically that "On day one of the Labour Government we will halt opting out. We will bring back the hospitals which have already opted out back into the NHS." He also promised - despite his Party's consistent historical record of sudden savage cuts in NHS funding - to restore what he called, with a disingenuous lack of specificity about actual sums of money, "proper funding for the NHS". Competitive tendering is apparently to go down the same hole of voter deception as Hospital Trusts, GP budget holding, the "commercial spirit", and the internal funding.

Pressed by consultants and television interviewers convinced of the transparently positive value of the separation of purchaser and provider functions - which is the essence of the internal market, and the primary mechanism initiated by the reforms for putting a stop to bureaucratic misallocation of funds and ensuring that resources follow patients to wherever the real needs are - he could do no better than mumble incoherently about the supposed threat to "public service" from any sort of market.

The shrill tone and shallow character of the Brighton debate demonstrated that the leadership of Her Majesty's Opposition are only too well aware that the NHS needs urgent, radical reform, and that the Government's plans are for the most part as sensible as they are overdue. Their hysterical resistance to reform is a product not of genuine conviction, nor even of nervousness about left wing or trade union pressures, which they could ignore as easily as they have in the spheres of defence and the market economy. It is a merely political tactic, designed to capitalise on the public's understandable anxieties about the spurious threat of privatisation.

While political expediency provides at present the most influential of the several grounds for resistance to health care reform, ideology is also playing a significant part. It is the main source of ideas and arguments for the Labour Party's scare-story campaign. It provides a convenient framework of assumptions for the media's one-sided treatment of health care. It subtly and surreptitiously fuels and distorts the worries of the man and woman in the street about what is happening to the NHS.

The Brighton conference provided plentiful evidence of the continuing popularity among socialist activists of the pure wine of NHS ideology. "In 1948" thundered Caroline Crolley of the TGWU, "the pride of the Working Class was born". "Every vote for a Tory" she continued, hoisting the Red Flag, as it were, on the ship of health care, "is one more nail in the coffin of the NHS. Every vote for Labour is a kiss of life for the NHS." A Mr McNulty condemned "the chronic underfunding and lack of planning in health care" as an "obscenity", and claimed that providing proper help for the elderly, the handicapped and the mentally ill was "socialism at its most pure". One might almost have imagined that neither liberals nor conservatives had ever done anything but deliberately harm them, and that only socialism could offer them any real help at all. Provided, that is, that socialism in health care consists of infinite funding casually dispensed and totalistic central planning.

The Tories, it was urged to loud applause, "were ripping the guts out of the NHS" and a doctor was cheered to the rafters for the bold assertion - wholly unsupported by argument or rational justification - that "We do not intend to become budget-holders".

Underlying all this tosh - and much more of the same - was the influence of a specifically socialist ideology which has no necessary relevance whatsoever to maintaining a genuine National Health Service in Britain such as its founders envisaged. This same sectarian and partisan ideology is peddled from beyond and outside the Labour Party by academic and media opponents of health care reform. Its essence, which the reforms explicitly challenge, can be summarised as follows:

None of these dogmatic assumptions was shared by Lord Beveridge or by any but an exceptional few among the founding fathers of the NHS. Each assumption has been wholly invalidated by experience and by the practical history of the NHS over the past four decades.

Public spending on health care has to take its competitive place with other urgent national priorities, such as defence, education, and social security. Availability of resources for health care is conditional on economic prosperity and progress. Centralised planning and detailed operational control of health care has proved, as in every other sphere, impossible in practice, and, to the extent that it has been insisted on, counter-productive. It prevents innovation, inhibits creative individuals, and entirely precludes attention to the unpredictable diversity of health care needs. Exclusion of competition between doctors, between hospitals, and at other levels has robbed the NHS of the best and most normal social mechanism for encouraging innovation, for improving standards, and for disseminating high quality service.

Studied neglect of costs has driven standards down rather than up by excluding a crucial criterion of efficiency and a fundamental stimulus to quality enhancement. Even more damaging has been the consistent unwillingness in the NHS to give a positive welcome to new technologies and improved patterns of service unless they can be replicated all round and "inequalities" avoided. This institutionalisation of socialist envy frustrates innovation and denies the NHS the benefit of competitive emulation - the most dynamic equaliser and improver of standards known to man. Instead of dogmatic resistance to an imaginary two-tier system, we should welcome with acclaim a multi-tier service with the tiers regularly catching up with and overtaking each other, and overall standards improving all round.

Atavistic opposition to independent health care is similarly socialist rather than civic in spirit, and counter-productive. Cooperation between the NHS and the modest independent sector can do nothing but good. Finally, the ideologically socialist commitment, imported entirely speciously and illegitimately into the NHS, to a level of "workers' control" unimaginable even in the motor car industry of the 1960s and 1970s, has been wholly destructive.

Thus each of the core assumptions in socialist health care ideology is mistaken and damaging. Each of them is decisively challenged by the current reforms. And - since none of them is a plausible, let alone an essential, principle of genuine high quality public health care - doctors, nurses, and above all patients and consumers will be much better off without them. Sensible voters will be as contemptuous of dogmatically ideological as of blatantly political resistance to reform of the NHS.

Health care workers, particularly nurses, have a proud tradition dating back to long before 1948 of disciplined commitment to serving their patients selflessly. The high public reputation and positive image resulting from this tradition have been grossly abused by employees of the NHS in recent decades.

Yet the public seem already to have forgotten the cruel absurdity - the obscenity, one might in this case justifiably call it - of members of COHSE taking it upon their under-qualified selves in 1979 to decide which patients were and were not emergencies, and therefore to be condescendingly allowed or denied access to proper treatment. So much for "comprehensive health care". Again, in recent years, the media, especially television, have consistently taken the BMA's dubious word for the altruistic motives speciously claimed by its leaders for this or that piece of obstructive recalcitrance.

And again, enormous waste in the NHS is occasioned by ancillary workers' arrogant opposition to sensible management. Given a choice between hospitals opting into Trust status and remaining under District management with wholehearted application of competitive tendering, NUPE leaders would soon be out campaigning for Hospital Trusts all round!

A substantial part of the current noisy resistance to reform of the NHS is a precise analogue of the print unions' opposition to (fairly) new technology, or even to the NUM's insistence on reserving jobs for their children in mines already empty of coal.

Morale in the Health Service matters, of course. Dialogue and cooperation are essential. But elections are lost not by resisting illegitimate industrial pressure (Mrs Thatcher in 1984), but by craven surrender in the face of intolerable union tactics (Mr Callaghan in 1978-9; Mr Heath in 1972-4). Much of the resistance to reform in health care is based on nothing nobler or more rational than last ditch defence of antiquated vested interests. The Government ought to demonstrate this carefully to the public, to press for acknowledgement of the real facts in the media, and keep on steadily and unapologetically with the reform process.

Resistance to reform of the NHS is being orchestrated by the Opposition and the media for purely expedient and narrowly political purposes. It is stiffened by ideologues for whom an unmodernised Health Service is an essential vanguard arena for their socialist campaign to strengthen the grip of alien collectivist principles on British social life. The resistance movement is manned by foot soldiers from professional associations and trade unions in the NHS, and their primary objective is to defend at all costs outmoded working practices and vested interests.

There is one further source of reactionary resistance to those essential reforms: our sometimes useful, often dangerous British tendency to prefer things to be kept more or less as they are, and to settle for a quiet life.

From the very start of the reform process, politicians, academics, and journalists opposed to it have sought to capitalise at least as much on their emotional attachment to the positive value of the NHS. They have been saddeningly successful in their shameless appeal to reflex conservatism and misplaces anxiety.

This can only be countered effectively if the case for reform is put clearly, fully, dispassionately, and unambiguously. This argument cannot and should not be avoided, or fudged by finding extra resources, over and above planned expansion, and imagining that this will serve instead of persuasion.

We need to see more of our best GPs who now manage their own budgets explaining on television precisely how they have been enabled to look after their patients better. We should expect news and feature programmes to allow the public to see the radical improvements already apparent in the quality of service offered by hospital Trusts. We should be hearing regularly from health economists who understand the lethal dangers for standards of health care from Labour's "policy" of reversing the whole programme of reforms while continuing to pour taxpayers' money into bottomless black holes in the bureaucratic machinery of the NHS.

Aversion to change may be natural and understandable, but is also a certain precursor of decay in the NHS and of collapse in the modest standards of health care we have, with so much effort and at so much cost, so far achieved.

Egregious even among the suffocating welter of sentimental nonsense which largely comprised the Brighton debate on health was the ringing banality of the claim that the NHS is "the envy of the world".

It really is marvellous how people who have spent a lifetime running down almost everything British can nonetheless heap unconsidered praise on those few British institutions which suit their own partisan book: "play-way" schooling, the trade unions, "public service" broadcasting, and above all the NHS in pristine bureaucratic condition.

Considered objectively, health care in Britain is better than in some few other advanced societies, but a lot less effective by any criterion than most. There is much to be proud of, but huge room for improvement. Radical reform is essential if the whole system is not to collapse in the face of new and escalating challenges.

Despite the noisy campaign of reactionary opposition which I have examined, the reforms are being, and will continue to be, implemented. The orchestrated programme designed to block the installation of Trust Hospitals and to prevent the expansion of GP budget holding has failed at each attempt so far. Competitive tendering is gradually being extended as hysterical bursts of local resistance fronted by militants collapse one after the other. New systems of management and the whole structure of the internal market are steadily taking root as staff begin to understand and appreciate them.

Until the coming general election - and, assuming the Conservatives win it, for some time after - resistance will continue. The implementation of reform will even so continue, and will begin to deliver the substantial improvements in quality of service which it promises.

Alternatively, the Opposition's scare-stories might, with media collusion, turn Health Service reform into a winning trick for the Labour Party. I find this outcome rather less likely than many commentators and social scientists seem to believe. Labour will have to win more seats than looks possible. Their Shadow Ministers may be popular with the media, but nearly all look to me likely to prove hopeless when it comes to electoral in-fighting, and implausible as Ministers. Moreover, economic issues are more important in general elections than welfare problems, health and education included - and the economy is plainly coming round.

Even in relation to health specifically, the Opposition's supposed winning card, the argument is only just beginning. As I trust I have shown, opposition to the reforms is wholly negative, and the case is amazingly poorly argued. As a recent analysis in The Economist[1] unambiguously demonstrates, the Labour Party currently has no policies whatsoever to offer the electorate as an alternative to reform - beyond simply saying "no" to reform.

"Intellectual laziness and political opportunism" to quote The Economist analysis, have left the Party of the NHS without any escape from domination of the Health Service by producer interests, without any coherent strategic plan for modernising health care as a whole, and with no option, supposing they were to be elected, except their usual oscillation between splurges of misdirected new spending and spasms of savage and arbitrary cuts.

Given a further decade of Conservative rule, health care reform will have been completed. At the same time, resources will have been expanded at no less than the same remarkable rate as during the past decade - that is, by 50 per cent in real terms. The quality of health care will have been improved immensely, as the scope for doctors, nurses, and managers (including not least managers who are also doctors and nurses) to apply their skills and commitment to the real health care needs of the whole population is opened up fully for the first time.

There will remain problems, of course, and countless issues which will require careful study and vigorous debate. I conclude by touching on a few of these:

In the meantime, the proper focus of serious analysis of health care is an honest comparison of the Government's health reforms with the Opposition's opaque and reactionary alternative. So far, the former have been investigated minutely, while the latter has been conveniently ignored. It consists mainly of the wild and logically incoherent accusation either that the reforms themselves comprise or that they prefigure privatisation. Since one excludes the other, it is impossible for both propositions to be true, and the Government has issued a categorical denial and comprehensive refutation of both charges. Duncan Nichol, Chief Executive of the NHS, has put it plainly:

It simply is not true. There is no foundation for it at all. How many different words can I find to say that the Health Service is not going to be privatised? It is not on the agenda at all.

There is no truth in it whatsoever. The idea is so unbelievable I don't even give it house room.

It is Opposition leaders rather than Ministers who are busy "cooking" policies which contradict their public commitments. The reported inclination of Labour thinking towards a specifically hypothecated Health Tax, in a context of references to the public's apparent willingness to pay higher taxes provided they are not lost in generalised public spending, quite plainly suggests that a so far entirely unacknowledged increase in taxation - its scale unspecified - is intended. Resistance to reform of the NHS may prove very expensive for the British people.

This paper was first delivered as a talk to the FOREST fringe meeting at the 1991 Conservative Party Conference in Blackpool

2. Peter Saunders and Colin Harris, in their Popular Attitudes to State Welfare Services: A Growing Demand for Alternatives?, The Social Affairs Unit, London, 1990, suggest that this may be an understatement.