‘What Matters Is What Works’: The State and the National Health Service in Scotland and Wales By Colin Leys

6 May 2011 — The Bullet Socialist Project • E-Bulletin No. 498

After forty years of ideological onslaught the very idea of ‘the state’ is close to joining others, such as ‘collective’ (not to mention ‘socialist,’ and even ‘left’), in the depository of Unclean Concepts. ‘State bad, private good’ may be a crude and simplistic slogan, but it is the very real starting-point of many politicians and most media commentators and BBC interviewers today, from John Humphrys down.

NHS Not For Sale

‘State’ is so often coupled with ‘nanny,’ ‘bureaucratic,’ ‘inefficient,’ ‘wasteful’ or some other negative adjective that this hardly raises an eyebrow. The state is never called ‘rational,’ ‘efficient,’ or even ‘democratic’ – even though commentators and interviewers like to stress the accountability of government (state) to parliament (also part of the state, and always called democratic) when criticizing extra-parliamentary forms of political action. A perfect illustration of this ideological schizophrenia was provided on television by Nick Robinson during the student demonstration outside Parliament last November. He contrasted what he saw as the illegitimate activity of the demonstrators outside with what he called ‘the democratic process’ going on inside – when what the students were objecting to was precisely the fact that the Lib Dems inside were doing something undemocratic – raising student fees after promising the electorate not to.

Wasteful Military?

Elements of the state that the corporate world likes and needs are usually treated as somehow not part of the state. The armed forces, the police, the judiciary, the monarchy and the Church of England are never described as part of the nanny state, or as being bureaucratic or inefficient. Even the notorious inefficiency of the Department of Defence’s procurement policies manages not to count, since the idea of privatizing it does not commend itself to the armed forces. The nanny, inefficient, wasteful, etc. state just means, in practice, those parts of the state (especially local authorities and quangos, but also central spending ministries such as the Department for Work and Pensions) which spend tax revenue on services for everyone – schools, social services, cultural services, and not least the National Health Service (NHS) – and which the right doesn’t like.

The effect is to narrow down our concept of the state to just these parts of it, and to make us at best indifferent toward them. We stop seeing them as the historic collective achievements they are, as expressions of what a mature society can accomplish through collective effort, as services of which we are all equally beneficiaries, and which we have a collective responsibility to protect and sustain. Instead we unconsciously absorb the message that they are by nature bureaucratic, inefficient, slow, monopolistic, etc. Every fault they exhibit tends to be accepted as evidence of an inherently defective institution. Above all we are conditioned to think that if they need improving, we ourselves can have no role to play in doing so – and that the only route to improvement is via privatization.

Yet the NHS itself provides a dramatic contradiction of this whole way of thinking. Unlike the English, the Scots and the Welsh have used their devolved powers to keep and develop the NHS as part of the state. We hardly ever hear about this. It is not something that the pro-market forces and commentariat in England like to acknowledge. It shows that people value the state as a bulwark of social protection and social solidarity, and see a state-provided health service as central to it. And where the political system has enough autonomy, and the voting system prevents unrepresentative minorities from determining election outcomes, they are able to get what they want.

The Scots and the Welsh have rejected the marketization of the NHS. The purchaser-provider split, which is at the root of the marketization project, has been revoked in both countries, and neither Foundation Trusts nor payment by results was introduced in either of them. Private finance initiative (PFI) was used in Scotland under the first Labour government in Holyrood, and one private treatment centre for NHS patients, but the use of PFI has since been scrapped by the Scottish National Party (SNP) and the treatment centre has been renationalized. Neither PFI nor private treatment centres have been used in Wales. The NHS in Scotland and Wales is once again planned and managed through a mix of central and local structures, as the NHS was in England before the 1990s.

Forward Looking NHS

But that doesn’t mean that the NHS in Scotland and Wales has reverted to the past. On the contrary, in both countries the NHS has been modernizing, but under the influence of very different mechanisms from those being adopted in England. Instead of fragmenting the NHS and opening it to commercial competition, Scotland and Wales have opted for democratic and accountable planning. There, the drivers of change are: a) the input of medical specialists and GPs on the Area and Local Health Boards where key policies are developed; b) the input of community health and social care/social work staff; and c) in Scotland, input from members of the local community, elected to the Boards since 2009 on a trial basis.

The restoration of full state responsibility for health services has led to further democratizing or redistributive measures, including the abolition of prescription charges, and the abolition of charges for personal care in Scotland, and their radical reduction in Wales. Equally significant, and contrary to the claims of marketizers in England, health services in Scotland and Wales have steadily improved, on various measures, including waiting times. Scotland’s have been among the lowest in the UK.

The contrast with England – where the NHS is being driven into decline and, increasingly, into chaos, in the service of privatization – is dramatic. If ‘what matters is what works,’ as Tony Blair liked to say (confident that the catch-phrase was enough to justify privatization), it is actually publicly-provided and democratically-managed health services that work, and the evidence for this is right here in the UK.

It will be very interesting and important to follow what further improvements are achieved in Scotland and Wales – and how what counts as an ‘improvement’ is defined when it is patients’ needs, rather than business values, that are the measure of it.

At the same time we should not expect improvements to run ahead of changes in other parts of the state in Scotland or Wales. The state was famously defined by the young Karl Marx as ‘the table of contents of civil society’: it registers the balance of social forces, and the level of democracy and solidarity and civic energy, that exist in the wider society. Thus far little creative thinking or experimentation has been done in any advanced capitalist country to expand the possibilities of democracy beyond the skin-deep variety consisting merely of periodic heavily-managed elections. Without more, the progress made with the NHS in Scotland and Wales is bound to run up against limits set by the wider context.

Yet the progress already made in the NHS in Scotland and Wales could itself encourage experimentation in other fields, from education to central government. And it offers a badly-needed antidote to ‘Anglo-Saxon’ ideology. At the very least, the ‘Celtic’ example shows that the state can be a democratic, rational, progressive state – if we want it to be. •

Colin Leys is an honorary professor of politics at Goldsmiths College London, and former Professor of Politics at Queen’s University in Kingston, Canada.


Further details on the NHS in Scotland and Wales are given The Plot Against the NHS by Colin Leys and Stewart Player, Merlin Press 2011, pages 150-54. But serious study of what is happening in both countries is urgently needed.

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