Machines, markets and morals: the new politics of a democratic NHS

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Neal Lawson (London, Compass): Too often those who want to see a new democratic settlement talk in abstracts, and making it easy for our opponents to write us off as merely ‘the chattering classes'. While we zip up our anoraks, they get on with the ‘real business' of running the country.

So it's helpful when we stumble into practical issues and debates about everyday political issues that support the cause of democracy. This is what I did when I started to research a pamphlet for Compass on the future of the NHS. Naively, I started out with a plan to write a blueprint by the tried and tested method of talking to all the biggest brains in the sector, and then put it together as a winning hand on how the left should run health services.

But I soon stumbled into real problems. First it became apparent just how horribly complex the NHS is, with layers of vested interests and organisational structures at local, regional and national level. Second, I found a central paradox at the heart of the NHS: the combination of our desire for equality and our need for diversity. Public services have to perform the function of equalising life chances, and when it come to matters of life and death that role is even more important. But the ability of the bureaucratic state to deliver more responsive and innovative services is limited, and the world has moved on from this model. Innovation is only possible by decentralising and diversifying to the point of local production; but this leads to difference. Like all paradoxes, there is no solution to the trade offs between universalism and diversity - just better ways of managing the balance.

In essence, the bureaucratic state has been continued by New Labour both to extend the push for machine like targets but also to oversee the commercialisation of the public sector, something that can only be willed from the centre. But to overcome the complexity and paradox of the NHS requires more than central bureaucracy - and the answer can only be the democratisation of the service. Only democracy can deal with complexity without inequality, and at every level it is the users and producers of the service who should negotiate the trade off between the levels of equity and diversity, through processes of co-production and co-decision making.

Democracy is the means not only to make the NHS more efficient, by building in organic and systemic methods of innovation and design, but also contributes to the remoralisation of this most public and essential of services.  What is true for the NHS is largely true for other public services such as education, social care and local government. Democracy could and should become not just a means to an end - but an end in itself.

So here is an opportunity to make the case for democracy on eminently practical grounds: building a better NHS in a way that shares the problems of service delivery with people by sidestepping the logic of the market and going beyond the old centralised state. The argument won't be won quickly or easily, but win it we must.

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