Assuming Austerity: The Politics of the NHS Systems

The English National Health System (NHS) is one of the world's most famous health systems. In international health and social policy conversations, it is an influential ideal type whose experiences inform policy and analysis. In some political conversations, especially in the United States, it is a nonsensical bogeyman of rationing and poor care that politicians of the right use to scare their constituents (Ehlke 2011). In others, it is a model of an innovative and egalitarian health care system. In Britain, it is seen as an expression of identity, “our NHS,” the “closest thing to a national religion” according to Nigel Lawson (Hardman, 4), and, as endless surveys and actions show, one of the UK's most popular and beloved institutions (Stewart 2023). It is an important case in comparative social policy, a highly egalitarian and redistributive health care system in a country that is generally not egalitarian at all, and an ideal type of “Beveridgean” social policy. It is hard to be interested in health politics anywhere without hearing references to the NHS, and it is hard to be interested in anything about the UK without seeing a connection to the country's largest employer and, arguably, most admirable national icon.One element of the NHS's personalization as well as popularity is that it has widely recognized birthdays. Two of the books explicitly discuss how it came to be that what amounts to a government agency has publicly celebrated birthdays (and enjoyed a lengthy, emotional, and very entertaining celebratory section at the opening ceremony of the London Olympic games in 2008). Americans might love their national parks, but how many of them bake birthday cakes for the National Park Service or would expect dancing park rangers to appear in Olympic opening ceremonies?These three books critically celebrate the NHS's 75th anniversary from different disciplinary and political perspectives. They are often giving different interpretations of the same broad headlines. Hardman and Paton both cite the exact same obscene quote from Gordon Brown, and Hardman and Seaton both cite the exact same uplifting quote from 1940s Labour MP Edith Summerskill. The top tier of politicians, such as prime ministers, apparently did not want to inform any of these books, so such politicians appear mostly through well-known public statements or leaks. Even on a less important level, the shared informational constraints show. Blair government minister John Reid, for example, did not give interviews about health after he left the post (I can confirm). While he had a big impact on health policy, most notably by signing staff contracts that created a needless financial crisis in 2005–2006, he is less central in Hardman's and Paton's accounts than the talkative former academic Paul Corrigan, an advisor to Reid and later to the prime minister, who becomes a remarkably visible policy explainer. A lot of people who made the last 20 years of policy are alive and fully engaged in reputation management. By making themselves available, they can skew the availability of data and ideas. They do not just assign credit and blame in ways that suit them; they also tend to give retrospective coherence to chaotic policy.What differentiates the three books is their priorities, their interpretations, and the sort of background information that they think matters. For Hardman, that means party and personal politics; for Paton it is the intricacies of NHS management and policy; and for Seaton it is social movements and social history. A result is that the books sometimes emphasize different issues. Hardman and Seaton, for example, give attention to reproductive health politics, with Hardman alone giving serious space to reproductive freedoms. Paton, like most political scientists writing about the NHS, focuses on the detail of organizational reforms and the reasons for them, while Seaton chose to not discuss them and instead frames his treatment of 40 years of exciting reorganization politics around issues such as the workforce and the ideas of neoliberal privatizers who never had much real political traction. Paton, more or less alone of the three, puts austerity at the center of the analysis.Hardman is a political journalist, assistant editor at the influential Spectator magazine and a BBC radio presenter, married to a life peer, and writing for a domestic audience. That might not be a good sign in general, but she has written a very good book. It is a political history of the NHS, covering the same ground as major older works but with up-to-date coverage and less detail and scholarly apparatus (Ham 2009; Klein 2013a; Rivett 1998; Webster 2002). The political journalist's touch is visible across the book: interviews with protagonists and good quotes, a focus on Westminster personalities and politics leavened with well-placed stories from around the country, and a noticeable tendency to become more fun as we get closer to the present and the sources she knows best. The most interesting parts are interviews with protagonists of health policy over the last two decades, as reported by somebody who is very familiar with Westminster. Her interpretation of motives rings true of people in the “Westminster village” and suggests, beyond citations, immersion in that world. That world is extremely class-ridden and partisan (the Spectator's former political editor was Rishi Sunak's political adviser, and it was once edited by well-known truth-teller Alexander Boris de Pfeffel Johnson). Against such a background, her evenhandedness and sympathy to people and causes across the political spectrum is really striking. For readers who enjoy British politics and are not too interested in the mechanics of the working NHS, this is the best NHS birthday book. Just be aware that Hardman only discusses issues when they are politically salient or matter to one of her chosen themes.Paton discusses the mechanics of the working NHS, extensively. He is not just a policy-focused political scientist; he is also a representative of the British political scientists who developed a distinctive approach to the analysis of health politics that puts a lot of emphasis on almost sociological studies of how the system worked. They are among the rare breed of political scientist who do not reflexively assign most of the agency in policy making to people in formal politics (e.g., Ham 2009; Klein 2013a; Exworthy, Mannion, and Powell 2016, 2023). Paton's writing, though, is frustrating. His explanations of the intricacies of financial flows that matter greatly to his arguments are not always easy to follow, and his bibliographies are inadequate. (For just one example, the top of p. 36 claims “Later, evaluations suggested . . .” but there is no citation on that page to multiple evaluations; in fact, there is no citation at all on that page.) The book also contains a lot of score settling with other participants in rather obscure policy, political, and political science debates. It will be a rare English reader, and a very rare foreigner, who would have read enough about Labour and health policy to fully understand chapter 7 (on the left's approach to Conservative health policy) or enough political journalism to follow most of his COVID-19 coverage. As with the other books’ COVID-19 discussions, the ongoing official inquiry and unofficial investigations (McKee, Hanson, and Abbasi 2022) are likely to provide better information, even if the stories might remain broadly the same. Meanwhile, a new edited collection delves into NHS politics and policy much more systematically (Exworthy, Mannion, and Powell 2023).Paton nevertheless presents by far the most important thesis of all these books, of clear relevance to anybody interested in health systems. The argument is in the subtitle (“Revolution, Counter-Revolution and COVID-19”), which also conveniently is the three-part organization of the book. He details a market-oriented revolution starting with Margaret Thatcher's purchaser-provider split. It culminated in the astonishing reforms of Cameron's health minister Andrew Lansley, about whom the only debate, as Rudolf Klein wrote, was between the “indignant” who saw right-wing vandalism and the “incredulous” who could not believe a minimally competent government would bring forth such legislation (Klein 2013b).Paton then details a “counter-revolution” that is much less well known in England and scarcely known outside. The political chaos of the Johnson and other Conservative governments allowed top NHS managers, under politically skilled NHS England chief executive Simon Stevens, to essentially undo almost the entire structure of purchaser-provider splits, competition, and private sector engagement (although the level of outsourcing is still far higher than it was in 1979). As he argues, the result was that by 2020, England had more or less managed to get itself back to something like the management structure of 1985, although at an unbelievable cost in money, wasted opportunities, human capital, inefficient outsourcing, and probably lives. Chapter 5, costing out all the reorganizations and attacking the distortions in positive economic evaluations of them, is an important read for anybody interested in health policy anywhere.The story of a market-based revolution and pragmatic counterrevolution that does not map onto partisan politics is an important one. It easily turns into hypotheses about policy learning, the welfare state, and the structure of social policy that could be productively tested in other countries and policy areas.Seaton is a social historian with by far the strongest research contribution and use of literature. His particular approach to differentiating himself is to argue that popular affection for the NHS needs understanding: “The lack of doctors’ bills alone did not make the service the prominent component of national life that it is today. Previous history books about the NHS have largely overlooked this point because they tend to focus on elite politicians, civil servants, and prominent doctors, mapping the sequence of the services’ internal reorganizations without considering its relationship to the outside world” (3). In my view, the book does not show why his analysis is necessary to explain a preference for a lack of doctor's bills, and it is not even clear that it is set up to do so. His approach does, though, produce two interesting disjunctions with existing literature.For the first, he takes aim at a broad school of “consensus” writers who argue that some kind of national health service was politically inevitable at the end of World War II. Hardman is sympathetic to consensus arguments, and they have been taken to extremes by authors who apparently want us to believe there was little difference between the politics of Winston Churchill and Clement Attlee (e.g., Pierson 1996). The consensus thesis matters quite a lot, since it is the UK's contribution to ongoing global debates about when redistributive and tax-funded social policies can be adopted: are welfare states broadly consensual and pragmatic creations, or are they the conflict-born children of left parties?Seaton disagrees with the consensus argument on two grounds: that he found vigorous intellectual movements and even some social movements that were against a redistributive NHS, and that the evidence for consensus is weak in the single-issue public opinion studies he cites (along with reports from the large-scale social research project “Mass Observation” and popular literature). He does not show much skepticism about surveys, not even older ones conducted when polling techniques were much less refined. As a result, his evidence against consensus arguments often relies on finding a relatively even split in survey responses to particular questions and prominent angry doctors in antiegalitarian social movements. Innovative methods, such as Fennell's use of wartime censors’ reports (what they were seeing in soldiers’ mail) to show the extent to which Labour's promise of a health service was a reason for its victory in 1945, might cast some of this conflict in a new light (Fennell 2019). We can see why this approach gives his book a different feel vis-à-vis the more politics-focused accounts. Their goal of explaining the NHS's creation, survival, and evolution means they focus on the policy options seriously discussed by governments. It is not clear how Seaton's work challenges them.Consensus can seem like a straw man, but some distinguished historians and NHS observers debated it (Hennessy 1992; Klein 2013a; Morgan 1984; Timmins 1995; Toye 2023). Part of the problem, for the British literature and for comparative welfare state debates in general, is that consensus is a tricky concept. How much conflict over payment systems or the role of local government can there be before we do not call it a consensus? Charles Webster, official historian of the NHS, agrees with most of the consensus authors that there was huge pressure for the removal of barriers to health care, but he highlights partisan and interest group conflict about just what policies would achieve that goal (Webster 1988, 2002). Seaton codes Webster's work as a challenge to the consensus thesis (Seaton 23), but by comparative standards we might say that the disputes Webster catalogues fit within a reasonable definition of “consensus” (Jacobs 1993). Disagreement is theoretical about specifying the line between conflict and consensus.The second disjunction with most of the existing literature is Seaton's explicit decision to downgrade the “sequence of the services’ internal reorganizations without considering its relationship to the outside world.” The problem is that that sequence is much of the stuff of NHS politics. One of the most salient differences between health politics in NHS systems and health politics elsewhere is that so much of NHS politics and policy is really management. To observers accustomed to, for example, the US fascination with payment systems reforms, the characteristic oddity of the NHS systems is that a whole country's government can be convulsed by rules about whether government ministers can give particular kinds of orders to particular kinds of hospital managers. The result is that by any indicator of political salience, issues such as the internal market, Foundation Trusts, doctors’ contracts, and private finance for construction of buildings are enormously important. Managing the NHS is a lot of what a health minister does, sometimes in a very direct way (Klein 2010). Seaton gives these topics scarcely any space.The recompense, though, comes from the elegantly written discussions of other issues. Perhaps the best, a tale that others have hinted at, is a conceptual transition of the NHS. Initially, UK governments and charities such as the Rockefeller Foundation (Seaton 2020) expected the NHS to be an international beacon, and a form of British leadership in an otherwise increasingly bipolar Cold War world. After it became clear that other countries, and in particular the United States, did not see it as something to be emulated, British politicians begin to recast it as a symbol of British national identity, leading up to aggressive NHS branding and celebration starting under the Blair governments (chapter 4).Seaton, focused on the United States and the American Medical Association's rabidly anti-NHS claims, underplays the success of the NHS as a model in general. There are dozens of NHS-model systems around the world, and in some (e.g., Iberia) a reflective appreciation of the virtues of the actually existing NHS was clearly a reason why their governments chose to adopt that model. If anything, the more lasting and powerful, if theoretically confused, legacy of these transatlantic conversations is British political rhetoric about the evils of “American” health policy that Seaton discusses (Powell, Béland, and alone among all these also highlights the of the NHS on the between appreciation of the NHS and its It is hard to finding two important books at an NHS anniversary that center and to as much as Hardman's and has The UK has managed to its social policy on the by from the and then from the and 2020) and since from countries 2023). UK governments to rather than produce their health care and that has the NHS. that it is almost to in without many who work in the NHS, the NHS workforce as well as outside its care is also a serious problem of national in all three it is not clear that NHS has a Hardman and Seaton about the English NHS, which is by UK governments whose are and then about popular affection for the NHS. and not only have their health to their governments since they also have had in who are to the UK's over their and NHS systems as a reason to Against sometimes as a British the that there no NHS. As a result, it is rather important to any of NHS politics that we understand who the NHS as an of which in that are and politically does the country well between Britain, and the Hardman and Seaton about national affection for the NHS, almost on of the politics of the English NHS, the result underplays the of national the of might obscure an for the interest in the national of the health and have their in UK politics. In just the last three decades, they in a and They might also explain NHS and for whom the NHS became attention to the politics of might also the of whether means the same thing to Conservative and Labour or and or and or in which has never had an NHS. It is “our NHS,” as apparently but who are all of these books are about the in and do not to it to other that means they to a in British that the UK less and have than The NHS systems provide care that is broadly to systems in other They do it with doctors, and much than countries, and they more of the of between than health care systems in more egalitarian was a of comparative discussions of the NHS. In the and when it could the by international Their governments did not think they but like most politicians they were not in of international Perhaps the were and the but the NHS was health care for less and and its politics within of a years in the under after Blair to an of on it still the NHS systems do their very well when and just at data from the on Health and the or the In the years under Labour when they did so with its as a of they became probably some of the world's best health systems. The British elite that the NHS is a one not shared by British with health systems of and, it is that all three like many British writing in the last of Conservative the NHS as The privatizers Seaton discusses have generally been to NHS politics. The real is that austerity and such as we see will over to and of in the UK have to for private care when the NHS is too a American health policy The of a politically for the NHS model does not that the in a by more than a of austerity and policy books, written for British what out most in comparative conversations, which is They a of the shared affection for NHS and about its to but they all health politics in the UK has almost always been a story of success For all the in these books, something about British politics, British and the NHS systems have health systems far better than their would on some level, that why people love the NHS so after all, love a

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