AND IN THE NHS
The similar relaxed, 'paternalist' organisation of the NHS is described by Rudolf Klein, author of a general history of the NHS - The Politics of the National Health Service, 1983. followed in 2006 by an updated version, The New Politics of the National Health Service. Klein, formerly a 'distinguished faculty fellow' at Yale University School of Management, is more sympathetic than Leys to the market reforms. In his essay 'The Politics of ideology vs the reality of politics: the case of Britain's National Health Service in the 1980s' (The Milbank Memorial Fund Quarterly. Health and Society, Vol. 62, No. 1,Winter,1984) he describes the NHS as based on a principle of 'paternalistic expertise':
'It is precisely this emphasis on creating an instrument for the deployment of paternalistic expertise, rather than a system of health care responsive to consumer demands (whether articulated through the political or the economic market), which makes the NHS unique in the Western world. In comprehensive but pluralistic health care systems, like Germany's or France's, demands are mediated by a variety of sickness funds. Even in a near-monopoly system, like Sweden's, control is devolved to local government. But, consistent with its founding ideology, Britain's NHS is designed to insulate decisions from either individual or political demands so that they may be taken according to rational criteria based on scientific or professional knowledge. Consequently, it divorces political decisions about the NHS's total budget from professional decisions about the allocation of resources to individual patients. The budget is set annually by central government; the use of resources, however, is determined at the periphery by doctors who are subject to neither audit nor review procedures. While countries like the United States, which have open-ended financial commitments, insist on elaborate exercises in accountability, Britain's NHS offers almost total autonomy to doctors. '
He argues that this 'belief in paternalistic expertise' was intrinsic to British culture, bringing together 'Fabian reformers like the Webbs, Liberals like Beveridge, and Tories like Joseph and Neville Chamberlain' and characterised by 'its suspicion of competition, its reliance on a strong civil service, and its belief in elite consensus engineering'.
In a later article - 'Risks and benefits of comparative studies: notes from another shore', Milbank Quarterly, Vol 69, No 2, 1991) Klein reflects on the change of culture which has produced the Kenneth Clarke reforms and the extent to which this may be attributed to American influence:
'One of the triumphs of the NHS, it is conventionally held, is that it manages to provide a comprehensive service both reasonably equitably and extremely parsimoniously. What is much more rarely recognised is the extent to which this achievement depends on the public's acceptance of the medical profession's definition of needs: political decisions about resources are, in effect, disguised as clinical decisions. In return for conceding an extraordinary degree of clinical autonomy to the medical profession, the state in fact delegated to it the responsibility for rationing - and thus made it [the rationing - PB] socially acceptable. It is precisely this implicit contract or bargain that is now in question, given the recent changes in the NHS introduced by the Conservative government. In turn, the public's acceptance of rationing decisions by doctors may well reflect deep-rooted attitudes of deference to professional expertise. These, however, are gradually being dissipated: witness the semantic revolution in public debate that is transforming patients (those to whom things are done, essentially a passive concept) into consumers (those who go out to buy things for themselves, essentially an active concept).'