Mr Blair has no real agenda for public service reform

'Politics is the pleasure principle; government, the reality principle. With Blair the two are in contradiction'
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Where Tony Blair complained about "wreckers" yesterday, read "embarrassments". Over the past fortnight, Mr Blair has suffered embarrassment which he does not enjoy, especially when it comes from unexpected quarters.

It all started with the Tories. For the first time since the Winter of Discontent in 1978-79, the Tory party was able to use the issue of health to land blows on Labour. This caused apprehension in No 10, where they prefer to believe that health was a locked-up issue for them.

They would also like to believe that their trade union support is equally secure. No so, apparently. Some unions have been spending a lot of money on advertisements designed to wound the Government, which would prefer them to save the cash to pay for Labour ads designed to wound the Tories.

Much of the trouble is coming from John Edmonds, a truculent, self-important character whom a lot of ministers regard as a pain in the neck, when they are putting it politely. But there are uneasy fears that this time, Mr Edmonds is not only speaking for himself: that he may be articulating the discontents of many traditional Labour supporters, whose votes will be needed.

So Mr Blair has hit back, trying to conceal a warning to the unions behind an attack on the Tories. That is the sort of cunning ploy which Mr Blair is so good at, and which has often served him well. This time, however, he may have miscalculated. The advance briefing invited the press to concentrate on the defiant and aggressive language, which they did while noting the cynicism. But none of that is likely to impress thoughtful voters, who will also have observed the petulance, and who would prefer a more serious, thoughtful tone. If the PM were to make a major speech on public services, many of his own supporters would have wanted him to move beyond the name-calling of the past fortnight to focus attention on his own agenda.

This he failed to do, and not only because he is easily rattled by criticism. There is a more basic explanation: a fundamental problem when it comes to Tony Blair's agenda for the public services. He hasn't got one.

Politics is the pleasure principle. Government, the reality principle. The human psyche is so constructed as to bring the two into contradiction and conflict. The same applies to the Blair Government. Until the '97 election, it was all pleasure: getting stuck into the Tories. But this had a downside. Mr Blair's political victory was so complete that his plans for Government went unscrutinised. No opposition had ever been put under less pressure on policy questions.

Lack of pressure did not encourage hard thinking. It is true that some covert radicals were elected. In the early months of 1997, ambitious youngsters from the Labour think tanks would whisper "Nixon in China". The argument was that the Tories were incapable of reforming the public services, and especially health, because they would never enjoy public confidence. Labour would. President Nixon went to China, Tony Blair would reconstruct the NHS.

The youngsters were sincere, and not without reason. One of Mr Blair's strengths and weaknesses is his ability to persuade his interlocutors that he agrees with what they say (he may even persuade himself). In the pre-election months, secret seminars were probably held during which Mr Blair seemed to be buying his ticket for China.

In those days, he still thought that it would be easy. In those days the reality principle was still over the horizon. To be fair to Mr Blair, Nixon had the easier task. The problems of NHS reform are vastly more complex than a single trip to China. The NHS had begun as a cheap, ethos-based service enjoying both an effectual monopoly of health provision and the confidence of the public.

But that was bound to come under strain as society changed. The NHS came into being in the era of rationing when it was natural to queue for scarce resources. Equally – and though it may have been a socialist creation – it depended on a hierarchical structure within hospitals, with condescension towards poorer patients and deference from them. It also relied on cheap labour.

None of that lasted. within a couple of decades a new generation had forgotten all about rationing, could not see why it had to queue and was damned if it would be condescended to, let alone respond with deference. In hospitals, meanwhile, junior doctors wanted time off while nurses were no longer prepared to let Matron run their social lives, or to work for pin money. Nurses joined trade unions. So did cleaners.

That put pressure on costs, as did technology and drugs. In the endless trench warfare against death and disease, medicine was winning battles and pushing back the front line. This inevitably made medicine more expensive.

When he was minister for health, Enoch Powell identified a problem which would become progressively more acute under his successors. The worse the NHS did, the more it could demand additional resources. As the years went by, every health minister recognised the force of Powell's observation. The worst the NHS performed, the more impossible it seemed for politicians.

Even Margaret Thatcher felt obliged to say that "the health service was safe with us". This was true. It ought not to have been. Mrs Thatcher would never have dreamt of talking that way about the defence service or the education service, thus conflating a social good with a bureaucratic structure. Yet even she felt obliged to suppress her radical instincts and to pretend that a bureaucracy established by Clement Atlee in the late-40s should have have been sacrosanct in the late-80s.

The world has moved on. Why should the NHS be immune from change? If its existing structures are not adequate to meet legitimate public expectations they ought to be replaced.

It would not be easy to do this. How could we preserve the best of the old ethos-based public service while introducing management techniques to ensure that resources are applied efficiently, and also introducing new medical techniques without spending 100 per cent of GDP on healthcare.

Those are all legitimate intellectual difficulties, which the Government could pray in aid of its inability to come up with instant solutions. But there is no evidence that the Blair government is interested in intellectual difficulty. It just wants cheap politics.

That may be a miscalculation, for the electorate is noticing. I suspect that the "Wreckers" speech will receive as much respect as its intellectual content justifies. Mr Blair ought to beware. If he is perceived to be incapable of tackling the problems of health, this could well fuel the dangerous general sentiment that it is now time for a change.