Dangers of diversity

There had to come a time when the government gave up trying to
manage the NHS directly. Its founder Nye Bevan may have wanted the
sound of every falling bedpan to reverberate through Whitehall, but
today they crash down so often and with such force that the noise
is deafening and the effect counter-productive.

So this month the health secretary Alan Milburn gave a speech that
may mark a turning point in Labour’s thinking about the NHS. Having
contrived to build a national framework of targets and indicators,
he now wants to devolve power to hospitals and primary care trusts,
with more patient choice and more “diversity”.

Foundation hospitals, said Milburn, would “usher in a new era of
public ownership”. Modelled on co-ops and such like, they would be
owned by local members including staff, patients and other
“stakeholders” who would elect the governors. Before long, he
signalled, they would be able to raise their own funds, perhaps by
issuing bonds. Greater local control would inevitably mean greater
diversity, but wouldn’t that be a route to more rather than less
inequality? Here, Milburn resorted to Richard Tawney’s 1931 book
Equality: “The more anxiously a society endeavours to secure
equality of consideration for all its members, the greater will be
the differentiation of treatment…”

These are murky waters. If you want to reduce inequalities you must
understand the ways in which needs vary and address them in
different ways. Treating everyone the same would certainly make
matters worse. In that sense, “diversity” is essential. But a
foundation hospital in a leafy suburb could become a lot richer
than its counterpart in a deprived inner city, attracting higher
quality staff and providing higher standards of service. In this
sense, “diversity” will have the opposite effect to that imagined
by Tawney.

I don’t want to disparage Milburn’s devolutionary ambitions. I
share his conviction that Whitehall must step back and give more
power to patients, managers and clinicians. But there is far too
little clarity as yet about how to reconcile local empowerment with
the goal of reducing health inequalities. Suggesting that diversity
is simply a route to greater equality is disingenuous to say the
least.

In fact, there is far too little clarity in the whole endeavour.
The new effort to devolve power in the NHS is deliberately set in
the context of the “new localism” – a radical campaign to gear
local government towards “embracing community leadership”,
enriching local democracy and drawing on the “creativity and
imagination of local people” to address local needs and
problems.

Proponents of new localism want elected councils to develop ways of
involving local residents in decisions and actions to achieve
“community objectives”. Here, too, is the prospect of a range of
public, non-profit and private groups delivering a wider variety of
services to different communities across the country.

So health and local government are apparently both in the throes of
devolution, with power shifting from the centre to the locality,
from monopoly to pluralism, from state to citizen, from service
provider to community. Does this mean the two sectors are
converging? Unlikely. They represent two very different, often
opposing, cultures. The NHS jealously guards its distance from the
messiness of representative democracy. Local government deeply
resents the lofty corporatism of the NHS. Both sectors are already
labouring under huge pressures. Each fears that closer contact with
the other would compound its own difficulties.

But if they are not converging, how are they going to interact?
What role will local government play in the newly devolved health
system? Milburn did not say. If each sector is committed to finding
new ways of engaging with communities, are they going to set up
separate, perhaps competing, mechanisms? If so, won’t they quickly
exhaust the tolerance of local people? And, above all, what will
happen to the public health agenda? Who will take responsibility
for narrowing the “health gap” between rich and poor? Where will
leadership be located and where will the driving force come
from?

Foundation hospitals and semi-autonomous primary care trusts will
be preoccupied with learning how to cope with their new powers and
with providing health services. Perhaps now is the time to create a
new kind of leadership for health (as opposed to health care)
within a reinvigorated and empowered local government.

Anna Coote is director of public health, the King’s
Fund.