One curiosity about the Bevan reforms was that they reduced local accountability. The National Health Service was deliberately statist. It is forgotten now, but Bevan thought a service dominated by local voices would be a second-rate affair.
Now the service has at important points been quango-ised, and arguably, this has returned as much real power to the grass-roots as is consistent with maintaining a nationally-even provision of service.
Talking over the workings of the post-Thatcher NHS with Douglas Caldwell (the chief executive of the Herefordshire Health Authority, one of the main "purchasers") and Jeremy Millar (chief executive of the Herefordshire Hospitals Trust, one of the main "providers"), I find reinforces my tentative enthusiasm for this new archipelago state, especially as one tries to see its real workings on the ground.
Both men, and all their works, remain accountable to parliament through the Health Secretary. They also remain accountable to parliament less formally: the county's two MPs are famously active on behalf of complainants. There are Community Health Councils specifically to challenge the executives. Local councillors hammer on the executives' door at will. League tables and annual reports make it far easier for the press and public to get a handle on the executives' "outputs". The HAs have to conduct several public meetings every year, and the trusts at least one. Mr Millar, who resists any "gagging" clauses in employee contracts, points out that he has also been held to account by feisty consultants.
Much of this goes beyond anything which happened before, and has about it an openness which surely exceeds smooth PR. Yet quangos remain disliked by most right-thinking people. Perhaps it's because they are run on commercial lines by commercially-minded people. But it seems strange to complain that knowing the price of a service is a bad thing. How else can we debate the ethics of screwing tax-payers to pay for quangos? It seems strange to complain about people who understand money having a say in spending immense quantities of it, and to mock a process in which public-spirited people invest time in helping others.
Critics often talk dismissively of the new army of quangocrats as the new "magistracy". This, too, is strange, granted that the modern magistrate is a very good example of how a cheap, commonsense tradition of voluntaryism can evolve well. Magistrates, like quangocrats, work within tight quality- control: we can be delighted about the work they do for us when they succeed, and easily discipline the cases of failure.
Quangos have been seen as conferring unacceptable patronage into ministers' hands. True, but Nolan has offered decent checks on that possible abuse. Besides, abuse is probably not widespread. As Mr Caldwell said: "I can't tell you the political allegiance of any of my authority members." Mind you, he also pointed out that he has worked for the "old" NHS under every stamp of local authority, and couldn't see the party-politicking there, either. Why shouldn't we accept and be grateful that people of every political colour and none have always worked for good service provision, under whatever model? And why shouldn't we see the traditional which underlies the modern, and take comfort from it?Reuse content