Everyone agrees that Britain’s 75-year-old NHS needs rescue and overhaul. But what does this mean? Surgery, therapy, the oxygen of cash, a slap in the face or just a hip replacement? And how is this to be decided? At that point agreement ends. There is silence.
This week the former health secretary Sajid Javid said the service’s current structure was “unsustainable” and in need of a royal commission. His successor, Steve Barclay, disagreed. The NHS, he said, was so “treasured” that it needed evolution, not a “big bang moment”. Labour’s health spokesperson, Wes Streeting, said the NHS had no need of a commission, “it needs a Labour government”. If no one can agree on how to search for a solution, the chance of finding one must be nearly zero.
Cut to any sector of the public services and the prospect is the same. Everyone agrees that profit-stripping by water monopolies is outrageous. So why has it continued for so long? Silence. Why is Britain unable to regulate energy prices, unlike other European cultures? Our schools are being dragging down by Whitehall’s fixation on quantifiable exams. This is narrowing curriculums, demoralising staff and plunging pupils into mental distress. We can all see this is wrong. Nothing happens.
We read daily of immigration policy in chaos. The Home Office is outbidding local authorities for temporary accommodation, for asylum seekers it cannot process. It keeps setting impossible migration targets and writes laws that prove illegal. No one has a clue what to do.
Patients across Britain are crying out for cannabis-based and psychedelic medicines, freely available in other countries. Yet drug policy in Britain is frozen. As for regulating food additives, improving rented housing, dealing with prison overcrowding or legislating on assisted dying, you can throw up your hands and forget about it. Discussion of any such topics on the BBC follows a fixed format. The government says it is spending millions on what is at issue and the opposition says it will spend more. Of true reform, there is no sign.
This mess is rooted in the shallowness of bipartisan debate. The NHS was born in 1948 amid a fierce row between the minister, Nye Bevan, who wanted a national service run from the ministry of health and his colleague, Herbert Morrison, who wanted local councils to run it, albeit centrally financed. There followed a second row with senior doctors convinced that a healthier population would put them out of work. They were bribed with high pay, while “juniors” were left to slave in hospitals, a division that lies at the root of today’s strikes. In 1952, the UK had one of the longest life expectancies globally – by 2021, it had dropped to 29th.
Arguments were then arbitrated by an elite civil service and experienced postwar politicians who were able to see the wood for the trees. In most cases where a consensus was needed, politics turned to the institution of the royal commission, composed to cut through partisan interests and lobbies. These commissions had brought expertise to bear during the great reform era of the 1830s and 40s, pushing Britain into the European vanguard of early industrial and welfare reform.
Commissions again stepped forward in the 1950s and 60s, leading to radical reforms to capital punishment, divorce, policing, local government, universities and the legal system. Even where their recommendations did not all succeed, they marshalled cross-party debate and laid the ground for change.
Royal commissions fell out of use in the 1970s with the rise of thinktanks and interest lobbies. Parties felt they could fall back on their own supporters – and funders – for policy advice, advice that was likely to accord with their party line. The commissions had been accused of having taken too long. Having worked for one, by John Redcliffe-Maud on local government, I can attest to that, but its debates led to a radical shake-up of localism in the British constitution, since rendered shambolic – and undebated – by centralism and austerity.
Royal commissions were intended to look forward. They have been replaced by “judge-led” committees of inquiry looking backwards, usually at accidents, crimes and disasters. The current Covid inquiry is due to take years; the Grenfell fire inquiry closed – though we still await its final report – after four years. Inquiries into Bloody Sunday, the contaminated blood scandal and the Hillsborough disaster seemed to have lives of their own. I doubt if anyone can recall much about the seven-year child abuse inquiry. These show trials are mostly about political blame sharing. In practice, they delay rather than promote reform.
The last royal commission on the NHS was in the 1970s and fell foul of a general election. The last commission of any sort was Tony Blair’s attempt at Lords reform in 1999. Its sensible proposals got nowhere because no one could agree on how to implement them. The British constitution suffers from a critical dysfunction. There is no agreed way of changing it, with reform relying on one party outvoting the other in the Commons. Party antagonism will always triumph over consensus or compromise.
That is why Javid must be right – not because a royal commission is always the answer, but because Barclay and Streeting must be wrong. Politicians regard their role as simply defending or attacking the status quo. There is no leverage behind effecting reform. Is the present NHS, free at the point of service, worth it, given the rationing by delay? Might income-related fees do better? Is health insurance bound to lead to a two-tier service or might it perform better, as in France and Germany? Is there a model anywhere else in Europe from which we can learn?
We can apparently spend £100m debating what went wrong during Covid, yet all the while the NHS is crumbling in the here and now. It should not require a commission to answer these questions. The health sector is crammed with ineffectual thinktanks and foundations. Yet serious debate is dead in the water.
Simon Jenkins is a Guardian columnist
