Letter from Michael Jacobs, General Secretary,
Fabian Society (PSR 37)
1. In his evidence David Lipsey claims that
I was arguing for much higher public expenditure and corresponding
taxes at French levels, which would make a government unelectable.
My argument was only that if you want choice in the system this
requires spare capacity, and this is expensive. The French system
has choice because there is spare capacity, and it is expensive.
I was not arguing that we should go down their route, only that
we must recognise the implications of a simple slogan such as
"greater patient choice".
2. My remarks on the "postcode lottery"
were incomplete. There are two kinds of so-called "postcode
lottery". One is caused by performance standards. In some
areas NHS performance is much worse than others: the service provided
is less effective or efficient. This kind of postcode different
(on any significant scale) is unacceptable and should be addressed
by raising performance standards in lower-performing areas. The
second kind is caused by different choices being made about how
resources should be used. In principle I am in favour of greater
decentralisation of decisions about spending priorities, so long
as these are democratically accountable. I see no reason why health
providers in area X should not decide that, on the basis of local
needs, they will give a higher priority to particular treatments
than their counterparts do in area Y. This is what democratic
decentralisation is all about. It was unnecessary of me to refer
to the democratic boundary between the UK and France. It applies
between England, Scotland and Wales. As a result of devolution,
health spending priorities are now decided in each of the constituent
nations of the United Kingdomand rightly so. There is nothing
in principle to say that the relevant boundary for the NHS should
be regional rather than national. But it happens that I do believe
it should be regionalthough I am in favour of basic national
standards which act as a floor. (These could then be exceeded
regionally or locally), I want to see greater innovation and pluralism
in public services, and for this reason I am in favour of (democratic)
regional government. That is where in my view most public service
decisions should be made, including health ones.
3. On the substantive question we were asked
about, I would like to see the idea of the "public service
ethos" translated into a kind of "Hippocratic Oath"
taken by people who work in public services. This would probably
not be an actual oath, but a Code of Conduct or similar which
set out exactly what the community expects of public services,
and how public servants should behave. This would thereby enshrine
and make explicit the idea of the public service ethos.
4. The interesting question then would be
whether such a Code could be added to contracts the public sector
made with private (and voluntary) sector organisations. One of
the objections sometimes made to private contractors is that they
don't go "beyond the contract". Could such a set of
guidelines help ensure that private contractors could be held
not just to the letter of the contract but to its spirit?