Playing the system

A new report from Civitas describes how the National Health Service is failing the poor at the expense of middle class patients. This is not just because of variable quality of NHS services in different parts of the country (although this is a factor). The Guardian reports:

In spite of unprecedented sums spent on healthcare, the gap between the sort of NHS treatment that can be expected by those at the top and those at the bottom of society has actually grown under the Labour government, [Nick Seddon, of Civitas] said.

In the report, Quite Like Heaven?, Seddon quotes a series of studies which he said indicate the extent to which healthcare has become a lottery.

He points to a York University study which showed people living in deprived areas are more likely to need hip replacements but they are less likely to get them.

And he said patients in Wales can expect to wait only 47 days for an MRI scan, while those in the north-east of England can expect to wait 100 days. Individual hospitals offer scans in anything from 10 to over 170 days.

Older people and ethnic minorities also suffer "substantial inequities" in NHS treatment, the report said. It quotes watchdog the Healthcare Commission, which found the problem was even worse for elderly people who had a mental illness.

And while people on lower incomes are more likely to see their GP, they are less likely to be referred on for further care such as hospital treatment, the report said.

Seddon said this is partly because the middle-classes are more likely to have the assertiveness, articulation and confidence to communicate their demands to healthcare professionals. But personal contacts in the NHS also count.

"Higher socio-economic groups are more likely to have family or friends who work in the health services, and even if these contacts are not directly used to gain access to services they act as an important source of advice on how to work the system," he said.

Seddon said there are no panaceas but lessons can be learned from other nations. He pointed to the mixed financing of the Swiss healthcare system and a health insurance scheme based on regulated competition in the private sector in Holland. Both, he said, show that equitable care can be delivered through more responsive and high performing systems.

In other words, bureaucratised public services work in the best interests of those who are best able to navigate their way through bureaucracy: in general, the middle classes. The same applies also in the benefits system - those who are best able to play the system are best placed to get the most out of the system. Seddon is of course correct that the best way to overcome this problem is to replace the bureaucratic ethos of public service with a competitive one. Service providers - if they are obliged to compete for customers - will naturally seek to attract the largest possible client base, and are therefore less likely to be manipulated by the smaller numbers who make up the cleverest or most motivated sectors of society. A freer, more responsive, higher performing health care system will also be a more equitable one.

An ethical foreign policy

David Aaronovitch in the Times, after interviewing Tony Blair for the new BBC TV series The Blair Years, reveals what ought to be obvious to any informed observer - but which is constantly overlooked: Tony Blair supported the invasion of Iraq not because he had been somehow hypnotised by President Bush, but simply because he believed the decision was right.

It was 9/11 that created the political bond. “The moment I saw what was unfolding and realised the scale of it,” Blair told me, “I felt a really deep sense of mission.” It was clear to him immediately, he said, what it was he had to do. With Bush showing, in those early days, a restraint and a focus that hadn’t been expected of him, Blair toured the world helping to put together a coalition for action. By Christmas 2001 the Taleban were defeated and Bin Laden was on the run. Now, the question was, what came next? The American answer, by early 2002, was Saddam. Our man at the UN, Sir Jeremy Greenstock, was, he told me, very surprised because he couldn’t see the relevance of Iraq to 9/11. What had changed, Greenstock thought, was the calculus of opportunity — Bush could now get support for action against Iraq that would previously have been opposed by the American people.

In London, Tony Blair was thinking about Iraq in a slightly different way. To him, according to Sir David Manning, his foreign policy adviser, it was the calculus of risk that had altered with the attack on America.

The nightmare was the confluence of WMD with terrorism; nuclear programmes were believed to be up and running in Libya, Iran and North Korea, and Saddam’s continued defiance of UN resolutions seemed to confirm intelligence reports of continuing WMD capacity. Worse, the existing sanctions regime against Iraq was crumbling. “What you could get away with before 9/11,” explained David Manning, “was no longer acceptable.”

From early on, Tony Blair operated with an implied hierarchy of options over Iraq. The worst, in his view, was that Saddam should be permitted to continue in his defiance. The best was that the international community, acting through the UN, should threaten action sufficiently convincingly to get Saddam to back down completely. Then, as happened with Milosevic, Saddam might well be forced from power. In between these poles were other possibilities, ranging from an internationally agreed plan to force Saddam to comply, to the much less welcome possibility of unilateral military action undertaken by an isolated United States.

Indeed, Blair's views on liberal interventionism were well defined before the Iraq episode. As Aaronovitch points out, it was Blair who persuaded a reluctant Bill Clinton to threaten the use of NATO ground troops in Kosovo in 1999: in this case the threat alone was sufficient to ensure that Milosevic backed down. It is from this era that Blair's key foreign policy speech was delivered in Chicago.

While it is possible to dissent from Blair's views on foreign policy, it is impossible in view of the above to claim that he had no such views of his own. Although it may be that the full implications of his liberal interventionist approach had not dawned on him before entering Downing Street, the likelihood is that he had a clearer view of what an "ethical foreign policy" might involve than his first Foreign Secretary, the late Robin Cook.

In retrospect, the premiership of Tony Blair looks ever more visionary and expansive, and the regime of his successor ineffectual and trivial. However difficult the Iraq War has been, however grave the mistakes that were made, there is an inescapable sense that Bush and Blair took the decisions they did for the simple reason that they were right. Now that the political establishment is tiring of the strain of military intervention, it is unlikely that we shall see such courage from their successors - at least on this side of the Atlantic.