As the Tories wept over the poor at their Harrogate conference last month, only the most inveterate of amnesiacs would have felt like weeping with them. The Conservative legacy to Glasgow, scene of Iain Duncan Smiths tragic tour around Easterhouse, included a vicious cap on local authority spending, prohibition of the use of council home sale proceeds to develop social housing, the regressive poll tax, and a cynical boundary reorganisation that cut off inner-city areas from their regional hinterland. But the sorrowing of Smith was more about political "mood music" than genuine attention to urban poverty. Profiting from the 11 September distraction, sundry government blunders and the fading of the Liberal Democrat challenge, IDS has grasped the opportunity to consolidate. The low Tory media profile has meant that nobody knows who IDS is which is useful, at this stage, because nobody knows or cares about Duncan Smiths hard rightwing past. Instead, IDS projects an image of the subdued, earnest, conversational paternalist: a higher-class version of John Major, without the strangled vowels.
Does any of this matter? Simply by not collapsing, the Tories have secured the pendulum. More importantly, they have entrenched the conservative political landscape in Britain. The situation can be illustrated by a key policy area: health.
Throughout the Thatcher-Major period (1979-97) the two main political parties were close on the essential principles of the National Health Service (free treatment at the point of use, paid for by general taxation) and far apart on issues of public health that were intimately connected to poverty. Public health, under Labour local government, was the object of a bitter Tory ideological struggle to purchase private affluence through social squalor. Everything from housing to sanitation, school meals to hygiene inspections, was mercilessly cut. After all, the middle classes are less reliant on local public spending than on hospitals: they already provide their own meals and houses. Tory zealots fantasised about doing away with the Bevanite inheritance, but Thatcher was too canny a politician to threaten a universal service that benefited the middle class. Her claim that the NHS was safe in our hands also reflected Nigel Lawsons uncharacteristically acute observation that the health service was the nearest thing to a British religion a psychological, as well as a material prop to the propertied. Thatcherite strategy was not, as the left claimed, to privatise the NHS, but to mould health delivery so that it increasingly advantaged the affluent. It was this that lay behind the introduction of the so-called "internal market", GP fundholding, the purchaser-provider split, and hospital trusts. The left always charged the Tories with cutting health expenditure, but this was not wholly true: not in comparison with previous governments, Labour and Tory; not in real terms, and not in fractional terms of GDP. The pay and conditions of health staff deteriorated, and the Tories failed to increase health spending in line with other European governments. But John Major spent a higher proportion of national income on the NHS in 1996-97 than New Labour did in the subsequent two years. Labour in opposition fought all of the Tory distortions of delivery, defending the status quo and promising more money. Its main rhetorical weapon was that the Tories were lying about privatisation, and could not be trusted to keep to the de facto consensus that existed between the party leaderships, even in the 1980s. This was that the NHS should be funded from taxation, and be free to patients.
Now that consensus no longer exists. Duncan Smith calculates that the tardiness of health improvements under Tony Blair offers an opportunity to stake out rightwing ground, under the cover of his ersatz indignation about Easterhouse. The NHS is facing the most sustained ideological challenge since its inception. Ignoring their previous condemnation of the "Eurosclerotic" social model, the Tories have declared their intention of replacing the NHS with an insurance-based system. By Europeanising the debate, in ironic contrast to their stance on the single currency, the Conservatives hope to replace the dark alter ego to NHS equality in the public mind: the American system of credit card surgery.
It must be admitted that the Tories have a case. The NHS delivers excellent outcomes on starvation rations male life expectancy, for example, is slightly higher in Britain than in France. But across most morbidity indicators, Britain fares worse than other European countries. The experience of the NHS is out of step with the consumerist world of expanding bourgeois society: rationing by the queue and the waiting list, lack of flexibility and individual choice of treatment, a paternalist "gatekeeper"system of general practitioners. Insurance is a good way of attracting extra funds on the basis of self-interest, without increasing taxation. It allows for the possibility of individuals subscribing to different policies, and thereby exercising some control over their own care. There is, of course, an ambiguity in insurance that the Tories are keen to exploit. Who insures whom? If the rich and healthy insure themselves and each other, then the less fortunate are thrown onto a skeleton service. This fits in with the general Conservative drive to turn universal provision into a subsidy for the affluent that can be used to secure established privilege (see that other hardy rightwing perennial, education vouchers).
In rejecting insurance, Gordon Brown is carrying forwards the basic postwar settlement. The whole debate has swung to the right. Merely by defending the principle of a tax-funded health service, New Labour is distinctly to the left of todays Conservatives. Meanwhile, the enlistment of private companies to own and manage delivery systems proceeds apace. The Blairites believe quite erroneously that such private management is more efficient. They also believe correctly that "public-private partnerships" are an easy way of attracting capital up-front (the taxpayer pays for this expensively over the long term). In the bigger picture of funding, however, Browns view is both traditional and static. Brandishing the Wanless report, Brown dismisses insurance as a burden on employment, an administrative black hole, and a fluctuating source of revenue.
Unforgivably slow in increasing health expenditure, New Labour has finally understood the urgency of new resources. At present, the government is committed to annual real increases of 6-8 percent. It is in the interests of the left for the governments programme to succeed, because the alternative is real Tory abandonment of the NHS. But the debate has been configured in such a way that a more radical, socialist reform of healthcare has been precluded. The idea that patients and healthworkers might own and manage their services more directly has been frozen out. The butchery of local health authorities has concentrated power in the unaccountable bureaucracy of private corporations. The self-denying ordinance on income tax has cut off the most progressive source of state finance. And the neglect of public health investment, the most pressing need of the deprived, is connived at by both major political parties.
All statistics in this piece are taken from the Special Report on Health, Prospect, April 2002, pp.46-52. In turn, this survey draws upon figures from the OECD and WHO.