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A valid rack for several poolbillardtypes like...

As in pool, health policy is full of uncertainty -- get used to it.

I disagree with Chris Ham (CEO of the King’s Fund) that the ‘arm wrestling’ within the coalition is bad for the NHS (see here) Chris seems to believe it is better to have public agreement, and private disagreement, than the debate being played out in public for all to see.

The Coalition is made up of parties with different ideologies, though both should be broadly libertarian and their default political posture should favour citizen empowerment.  What Chris, and others apparently are missing is the comfortable fit of public policy and top-down policy-making, something neither Conservatives nor Liberals should favour, if, and I emphasise IF, they are true to their ideologies. But NHS thinking has generally been authoritarian, top-down and favouring a default logic of state mandated reform, rather than bottom-up reform. That this comfort zone is being sought causes me great discomfort. Perhaps, too, they miss being paid attention to, as Coalition politics does derive more sustenance from the public sphere, than majoritarian politics.

If, as Chris asserts, it is causing health professionals to be anxious or that it is stopping people from doing their jobs, then the problem lies with the NHS not the political debate. Having spent time in hospital management, while we may have had our anxieties with public policy, it never stopped us from getting on with the business of running a hospital.  If this is in fact true, though, then the public should be far more concerned with the ability of the NHS to deliver a service than it might already be, and far more concerned with that than a lack of political consensus within a Coalition government — where differences of opinion should be expected, not supressed.

The real public policy challenge of the current debate is less about the elements of reform than the mode of its presentation — regretfully, the Coalition appears to be buying off the vested interest groups and forgotten about the long-suffering patient and health consumer for whom the system exists in the first place.

These reforms are minor compared to the really urgent priority of ensuring that financial discipline exists within the system, that it is responsive and innovative, and can in fact reform itself from within — what is called emergent reform, quite natural in complex adaptive systems, but not familiar to people who when push comes to shove prefer the comfort of authoritarian policy.

Unsurprisingly, as you move closer to government, one finds increasing policy authoritarianism. I should blog a bit about how policy options are suppresed within government, how policy consultation processes selectively filter options out that are probably the best solutions, and how the upward accountability of civil servants to ministers often fails to pass the test of ‘speaking truth to power’.  And this is not to ignore the behaviour of ministers to ignore the advice of civil servants, and to prefer to take their options from the public space, something that can upset overly academic policy groups and think tanks, who live and die by the press they get.

I doubt there will ever be a time when there will be a consensus on health policy. Differences actually matter in policy and are evidence of opportunities for reform itself.

The pluralism that the NHS so badly needs, to replace the one-size-fits-all mentality, should be the direction of travel.

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