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Grassroots government

Mark Easton | 18:15 UK time, Monday, 21 February 2011

When Professor Julian Le Grand walked through the door of Number 10 as Tony Blair's policy advisor on public service reform in 2003, the chatter was about how the London School of Economics academic wanted government to "give more power to the people".

hospital sign


Instead of state-run bureaucracies deciding what was best, he argued that in schools and hospitals, parents and patients should be in the driving seat.

Wind the clock forward to the present day and David Cameron is writing in the Daily Telegraph about "giving people more control" and signalling "the decisive end of the old-fashioned, top-down, take-what-you're-given model of public services".

There is a difference though. While Tony Blair now regrets that his plans for reform of public services did not go further and faster, Mr Cameron is pressing ahead with radical change to the way we are governed at break-neck speed.

Perhaps people haven't woken up to the implications yet, but his ideas might, for one thing, herald the end of the NHS as we know it - currently said to be the world's third largest employer after the Chinese Red Army and the Indian State Railway. The plan is for great chunks of the health service to be provided by non-state providers: private firms, social enterprises, charities, mutuals and co-operatives. It has already begun.
In Surrey, for example, many nursing and therapy services are no longer provided by NHS employees, but by the 770 co-owners of a not-for-profit social enterprise - Central Surrey Health.

District nurses, health visitors, physiotherapists, dieticians, podiatrists, school nurses and many other health personnel have moved out of the state-run service and are now responsible for delivering care and shaping their company's future.

They run community hospitals in Cobham, Dorking, Leatherhead and other Surrey towns - many of their patients probably have no idea that they are guinea-pigs in David Cameron's Big Society.

David Cameron


For Dorking read Anytown. The ideas being pioneered in Surrey are expected to be the norm for the NHS and public services more generally. With the exception of areas like justice and national security, everything is up for grabs. David Cameron writes today that there should a "new presumption that services should be delivered at the lowest possible level" and "should be open to a range or providers competing to offer a better service".

As one of the architects of the so-called "post-bureaucratic age", Oliver Letwin argued to the Public Administration Select Committee recently: "I think the whole history of the world, which is quite a large, rich evidence base, suggests that very highly structured command economies and very highly micromanaged societies have fared very badly, have not done well for their citizens and not lasted terribly wrong."

It is a good joke, but the ambition poses some serious questions. Moving from a top-down to bottom-up system of delivery and accountability will not be simple and there must be concerns that some vulnerable service users will suffer as the revolution takes place. (I discussed some of these ideas in a previous post.)

For the public sector unions, the fragmenting of service delivery undermines their strength. Unite recently complained that the reforms were "a recipe for dismantling the welfare state" and risked "opening up an Aladdin's cave for profiteering private companies to take over public services".

For lobby groups, the grass-roots model undermines their influence and traditional routes to power in Westminster and Whitehall. The British Medical Association recently argued that it was not aware of any evidence that significant numbers of NHS staff wanted to work in social enterprises.

For public sector workers, the turmoil and uncertainty of the changes undermines confidence. Many fear that the terms and conditions of their employment will erode over time and that the ethos of public service will be damaged.

Mr Cameron, though, is determined to "dismantle Big Government" and says it "is not about destabilising the public services people rely on". His greatest fear is not of reforming too fast but of reforming too slowly.


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