What's the problem with the NHS?
This Sunday (29 September 2013), the TUC is scheduled to hold a rally at the Conservative Party Conference in Manchester. Describing growing concerns over the effects of ‘privatisation and the increasing fragmentation’ enacted by recent health service reforms, it is stated that the aim of the rally is to tell the Conservative Party Conference to ‘Save our NHS’. In contrast, defenders of the Coalition government’s NHS reforms in England argue that it is the extension and development of managed competition and choice that needs to be embraced if the NHS is to survive. The two parties appear poles apart, both with regard to identifying the problem with the NHS and in finding its remedy. Despite these stark differences, what is shared is the appeal to the rhetoric of decline in attempts to describe the state of the NHS and garner support for their claims.
Directly countering the logic of ‘if it isn‘t broke, why fix it?’ the rhetoric of decline is a recurrent theme in political speeches and media coverage of the NHS, if not, public services and society as a whole. The rhetoric of decline is particularly useful for politicians and lobbyists seeking to establish an agenda and appetite for change. The message and form is simple – run it down, undermine confidence and propose alternatives. The rhetoric of decline appeals to nostalgia and a long gone golden age, but unlike the equally suspect narrative of (unmitigated) progress, does not necessarily make any great claims that things will get much better. Rather, it merely recognises that things aren’t what they used to be and that something must be done, while castigating those who oppose any proposed actions as vested interests condoning failure and defending mediocrity.
Whether it is Tony Blair’s announcement on the eve of the 1997 general election, that voters had ‘24 hours to save the NHS’; the then Shadow Secretary of State for Health, Liam Fox’s remarks in 2002 detailing a ‘four-phase plan to persuade the public that the NHS is not working and couldn’t work’; or lobbyists advising the healthcare industry on how to exploit perceived failings in the NHS, the rhetoric of decline appears to be a valuable strategy for lobbyists and politicians to extend and intensify their efforts to persuade people that they have what it takes to make a difference.
To challenge the rhetoric of decline is not to suggest that there are no problems to be addressed. Rather, it is to ask the question of how those who make such claims package problems in order to meet their own interests. Presented with contested claims, a desire to cut through the politics and rhetoric is understandable, though arguably misplaced. It is more important to establish the position of the claims being made. Transparency is a start. Information on who has funded and lobbied the speaker can help the audience make sense of whose interests are being represented. However, once particular claims and the associated rhetoric enter into a wider circulation, it is not so easy to make the link between claims and interests. It is here that work needs to be done to go beyond transparency and establish the position of such claims. For example, what values and measures are reflected in claims that ‘managed competition and choice’ will halt the decline of the NHS? Who is set to benefit by such changes and at what cost?
There is a clear role for universities here that goes beyond attempts to collate data, analyse evidence and evaluate initiatives in the operation of policies. This includes not only examining what, how and why claims are made regarding problems, policy and practice but arguably, most importantly, furthering the capacity of organisations, communities and individuals to ask and answer the questions, ‘what is the problem?’ and ‘what are we going to do about it?’
Stuart Connor is a lecturer in Social Policy at the University of Birmingham, UK.