Saturday 6 February 2021

Boris Johnson and Thatcherism

For quite some time now, former John McDonnell economics man James Meadway has run a campaign of sorts on Twitter. His misson is to reorientate the left and encourage it to grasp the Tories and Tory strategy as it is, as opposed to what too many comrades think it is. In practical terms, the left should swerve away from a dogmatic insistence on the Tories plotting to unleash another wave of austerity to "pay" for the pandemic. There's plenty of evidence to suggest this is not the case. For what it's worth (very little), Boris Johnson himself has rhetorically taken to the field against austerity 2.0. Then there's last year's stimulus budget before the realities of Covid hit. Even the more intellectually-minded wing of the party, noted for clinging to Thatcherite nostrums, have counselled against cutting. As something of a Tory watcher, I agree. Johnson's Tories aren't Toryism-as-usual, and the left should pay attention.

Consider the latest policy shift as splashed by The Times. Johnson and co mean to reverse key aspects of the 2012 Health and Social Care Act. For folks not au fait with the labyrinthine organisation of the NHS, this innocuous sounding legislation was the culmination of the Thatcherite project in health care. After inflicting a strategic defeat on the labour movement by humbling the miners, Thatcher's government implemented marketised schemes right across the public sector in a bid to drive costs down and improve efficiency. With no more evidence than her narrow-minded and thoroughly petit bourgeois view of the world, Thatcher supposed the introduction of competition between organisations delivering services would give value for money for the "taxpayer". That limited marketisation would offer new opportunities for business keen to sell products and services into the NHS, and act to undermine solidarity across the medical professions by situating them in competitive units was, of course, entirely coincidental. For their part, John Major consolidated this while New Labour renovated it by putting in more money, setting targets, and sticking NHS organisations in the straitjacket of debt thanks to the PFIs hospital trusts and others were forced to take out.

Contesting the 2010 general election, Dave and Osborne promised there would be no top-down reorganisation on their watch. A couple of years later, then health secretary Andrew Lansley announced the biggest NHS restructure since its foundation. Starting from Thatcher's point of view that competition is the most efficient form of service provision, the 2012 Act effectively abolished the NHS and replaced it with a network of organisations whose relations were mediated by thoroughly commercial relationships. The lynchpin was the 200 or so Clinical Commissioning Groups who became the budget holders for their district. They were tasked with buying in healthcare services from what the Act defined as "any willing provider" and CCGs were supposed to make decisions on value-for-money criteria. Reinforcing this, there was an expectation they would strive to earn a surplus. To all intents and purposes, the NHS ceased to exist. Instead we had a market underpinned by state money. But on the plus side (for the Tories), ministerial responsibility was taken out. The aim all along was to depoliticise its operation and present the government as aloof observers prevented from acting by the rules they devised.

Why was this bad? For one, it reiterated market criteria as the NHS market's organising principle. It was a disciplinary regime that ensured clinical priorities came second. And there are the problems with markets. Contrary to the efficiency promises of Tory dogma, they multiply bureaucracy. CCGs and other NHS organisations requires a cadre of administrators to track market signals, while service providers, including public bodies, likewise had to get into marketing and brand management to compete with other institutions for contracts. A completely absurd situation. Yet, contrary to the intentions of Lansley and the private health lobbyists who've pushed for more marketisation for decades, NHS actors have worked around the market. The conscious effort at depoliticising the NHS meant it had a certain freedom from Lansley, Jeremy Hunt, and now Matt Hancock. The responsibility for the secretary of state amounted to securing funding rounds from the Treasury. Health policy as such was outside their remit, and so strategic guidance was increasingly provided by NHS England, and where devolution had taken place in Scotland, Wales, Northern Ireland, and the city regions. Market relations and competition have grown fictive and mere formalities as CCGs and key institutions have begun collaborating with clinical need as the bottom line. The subversion of the 2012 Act was formalised in NHS England's 2019 strategy document. Funding was determined by strategic health priorities, not who was offering the cheapest tender.

The leak scooped by The Times and covered everywhere else suggests the government are taking back direct control of the NHS not to bed down marketisation, but as an acknowledgment of the present state of play. The market isn't working so why persist with the appearance of competition when it gets in the way? So there are good technocratic reasons for the trailed moves. But this isn't being done solely for management convenience. It's not like the government have seen the disaster of Serco Test and Trace versus the smooth roll out of the vaccination programme and are learning lessons. There are the politics.

What politics? It is well known Matt Hancock has found the independence of NHS England irksome, and particularly the growing authority of its chief executive, Simon Stevens. The new structure for the NHS abolishes it and merges it with the spending watchdog, scraps tendering as the de facto relationship between organisations within the NHS and, crucially, imposes the authority of the health secretary at all levels. In other words, this is practice entirely consistent with Tory governments past. Their own experiment with market reforms allowed for a semi-independent authority within the state system to emerge, and just as the professions, education, the civil service, and local government were and continue to be brought to book by an overweening executive, the Tories are moving to perserve their authority. A power grab? Certainly. But one that formalises the work arounds of the previous period and preserves the gains of more efficient services? True too.

This NHS move typifies the Tory approach to strategy. If markets are a challenge to the state, then Johnson's government will shove them out of the way. Pearls are sure to get clutched on the Tory backbenches, but this is the new way of the world. Johnsonism has moved on from its vapid phase of getting Brexit done to something more substantial and, well, it's looking a lot like Theresa May's plan for government. The Keynesian vibes, Johnson's levelling up agenda, the state picking winners, it was all there in her pronouncements on "tackling injustices" and industrial strategy. Johnson nicked plenty of her Brexit deal, and he's done the same with her programme.

But we shouldn't get carried away. I've seen this variously described as social democracy with Conservative characteristics as well as the end of neoliberalism. Neither are the case. It's rather a recalibration of the mode of governance, and one in which the characteristics of the latter are still in evidence. There are three key emergent features to the new statecraft in formation.

1. Big spending, capital projects and, eventually, more funding for public services. You don't have to take my word for it. This is what they're doing and said they're doing.

2. Keeping neoliberal governance. The Tories might be restructuring the relationship between the executive and its institutions and scaling back on market relationships, but the sovereign individual defined and disciplined as rational choice utility maximisers is staying. Unpicking this requires significant investment of time and resources and, besides, it's not in the Tory party's interests. Its cultural domination has underpinned the coherence of their electoral coalition, while its atomising impulse helps frustrate collective action and opposition against the Tories. It has proven particularly corrosive of the labour movement's appeal across decades, for instance. It makes appeals to individual judgement and responsibility politically effective. We only have to see how riffing off these logics have helped the Tories depoliticise the Covid crisis. The inculcation of neoliberal subjectivity and how most state institutions address its charges aren't about to change, at least where diktats from above are concerned. Therefore, in this crucial sense, Boris Johnson and his governments remain Thatcherite.

3. The authoritarian state is staying and Johnson and co will follow their predecessors in strengthening it. This also opens the door to more arbitrary decision making and a greater use of ostensibly technocratic criteria to alibi attacks on parts of the state system the government don't like. Given the devilry higher education enacts on the Tory imaginary, is it any surprise we see persistent rumours about assaults on humanities and the social sciences (though, strangely, never Business Studies - a soft subject if there ever was one), and "tweaks" to the HE market to preserve the class hierarchies between institutions?

None of this means cuts won't happen, but when they do they're going to be more targeted and likely to serve matters of perceived political expediency as opposed to a thought-through scheme of marketisation. In other words, we're dealing with a Tory beast at once familiar but at another arbitrary and random in its attacks on us. It could and most likely will be more consistent and stable in matters of economics and governance. This is what their record suggests, so the left needs to adjust accordingly.

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Blissex said...

«After inflicting a strategic defeat on the labour movement by humbling the miners»

Scargill had been begging for it, following the delusion that "one last heave" and capitalism would be smashed and the question "who governs Britain" would thereafter be "Supreme Commissar of the People Scargill" :-). The adventurists grossly underestimate the resilience and strength of the establishment.

«Thatcher's government implemented marketised schemes right across the public sector in a bid to drive costs down and improve efficiency. With no more evidence than her narrow-minded and thoroughly petit bourgeois view of the world, Thatcher supposed the introduction of competition between organisations delivering services would give value for money for the "taxpayer".»

The story told by K Clarke is a bit different:

"Kenneth Clarke: I had a lot of views, but they didn't coincide with No 10's", 2014-07-19, "The Observer"
«His first challenge at health was heading off Thatcher, who "wanted to go to the American system", he reveals. "I had ferocious rows with her about it. She wanted compulsory insurance, with the state paying the premiums for the less well-off. I thought that was a disaster. The American system is hopeless … dreadful."
He prevailed on her to take a different route by introducing more competition into the NHS. It became known – in a phrase he didn't like – as "the internal market". Ever since then, successive governments have pushed in broadly the same direction.

david walsh said...

The worst outcome of any rushed restructuring of the NHS would be one where new structures - and the associated bureacracy - is established BEFORE the determination of the place and setting of social care in the overall plan.

David said...

Great post, at your best I learn more from you than ploughing through the entirety of the Graun.

Alex said...

She wanted compulsory insurance, with the state paying the premiums for the less well-off

This wasn't, of course, the American system until Obamacare was implemented...

Blissex said...

«“She wanted compulsory insurance, with the state paying the premiums for the less well-off”»
«This wasn't, of course, the American system until Obamacare was implemented...»

I think she intended the "American system" as private insurers selling healthcare insurance plans, mostly to employers for their workers, giving access to "networks" of private health care providers; as a wholesale replacement for the NHS. The central "reform" ideas of reaganism/thatcherisms have always been "vouchers" and "gold/silver/bronze plans".

The "mandatory" was indeed not part of the "American system" until Romney. She probably had in mind Medicare and Medicaid as "the state paying the premiums for the less well-off”.

Or perhaps in 1988-1990 she was thinking of the "success" of the Pinochet variant of the "American system":