Should health services be commissioned by technocrat or democrat?

Much has been made of splits in the Coalition, both on health and other aspects of the Government’s agenda.  Many of these differences are to do with political positioning, as the respective parties seek to convince their sceptical bases that they are delivering on core values and not ‘selling out’ (whatever that means in the context of a coalition).  The need for clear blue/yellow water became greater as the Conservatives and Liberal Democrats both faced difficult electoral tests.

As this recent post on Lib Dem Voice indicates, there is an undoubted pride in being seen to tick off manifesto pledges.  In the world of Coalition point scoring, the number of pledges delivered seems to matter almost as much their substance. Yet there are also some big philosophical differences between the parties: those on crime, civil liberties, Europe and – yes – voting systems have all received extensive scrutiny.  In health, the differences were laid bare by the Liberal Democrat Spring Conference’s vote to demand substantial revisions to the reforms

Yet much of the controversy on health is not as simple as a Conservative-Liberal Democrat divide.  A significant section of the Liberal Democrats are avowedly pro-market and have, in the past, advocated much more radical market-based solutions than those included in the current reforms.  Even when you strip away the election hyperbole from this article published last year, it is clear that Nick Clegg himself has been prepared to think the unthinkable on the NHS in the past, floating ideas which could be considered to be to the right of Lansley’s position. So to describe Paul Burstow as an outlier within his own party – as some commentators and even Liberal Democrats have – is wrong.  Burstow served as Chief Whip directly before the election and so is hardly a semi-detached, Liberal Democrat version of Frank Field.  Although he may not be a close ideological bedfellow of those leading the opposition to the reforms from within the Liberal Democrats, he nonetheless represents a significant strand of Liberal Democrat thought – one which is closer to the Conservatives than much of the current coverage might suggest.

Paul Burstow and Andrew Lansley are not, however two peas in an ideological pod.  There is a substantive – and underexplored – ideological difference in their approach to NHS reform.  Burstow is a passionate believer in democratic commissioning and would happily have transferred all commissioning to local authorities.  In his ideal world, putting local councillors on consortia boards would represent a tentative first step.

For his part, Lansley is intensely sceptical, fearing that democratically elected officials will be unable to take a long term perspective on the commissioning of NHS services and instead that experts are best placed to this, informed by the market force of patient choice.  This fear of the malign influence of politicians underpins the decision to create an NHS Commissioning Board.  After all, the stated intent of the policy is to insulate (or liberate) the NHS from the vagaries of political interference.  Locking out (or at least limiting) national politicians doesn’t sit well with giving local politicians a direct role in NHS commissioning.

It is hard to reconcile this difference.  You either believe that commissioning decisions should be subject to democratic will (either at a local level or nationally, as Paul Corrigan recently argued), or you believe that decisions are best made by experts.  Where they should be able to unite is on the importance of local democratic scrutiny of (as opposed to involvement in) commissioning decisions.  Yet, as MHP Health Mandate’s reports on commissioning prioritisation and quality accounts show, current scrutiny is patchy and shifting this is going to require as much cultural as policy change.  There is a way to go before scrutiny can become a genuine bridge between democrat and technocrat.

Martha Burgess has recently written on this blog about the potential for changes in the local political landscape, ushered in by the local elections, to have an impact on the direction of travel of health reform.   It remains to be seen whether this pragmatic political consideration impacts upon the philosophical tension which has done much to shape the White Paper and subsequent Bill.