IIt’s a problem familiar to millions of people: the hardships of trying to book a doctor’s appointment. Last week, suffering from a debilitating condition but not an emergency, I called the GP’s office to have him checked. There were no slots available for that day. I couldn’t make an appointment beyond that day either. Trying online, the best I was offered was a phone call in two weeks. Online slot machines are so valuable that by the time you choose one and enter your details, it has already been taken. I finally ended up in A&E, and luckily it all went well (good enough, at least, for me to write this column).
It’s a common story, and one that millions of people endure every day. There are many reasons, including the pressures imposed by Covid and lockdowns on the post-pandemic world and, perhaps most importantly, the shortage of medical personnel. Across the NHS, there are more than 132,000 vacancies, almost 10% of its planned workforce. Among general practitioners, with an expected and fully qualified workforce of nearly 30,000, there are more than 1,800 vacancies. And it’s the most disadvantaged areas that GPs miss the most.
Beyond these immediate causes, however, there is also a deeper reason, which not only shapes the difficulties in accessing health services, but also many contemporary problems, from rail chaos to the inability to mitigate the impact of soaring energy costs. All are, at least in part, the product of the changing nature of the state.
Political analysts have been talking for more than three decades about the passage from the “positive” or “ordering” state, which was used in the immediate post-war period, to the “regulatory state” which slowly emerged from of the 1980s.
Where the post-war state intervened directly to secure what were seen as desired social and economic outcomes – from the creation of the National Health Service to the nationalization of key industries, from railways to coal – the post-Margaret Thatcher regulatory state viewed desired outcomes as best shaped by market and saw the role of the state as less to provide services than to regulate the market and “steer” it towards desirable outcomes. A state that has made rules rather than material interventions. A state that has outsourced its ability to get things done to the market and to non-governmental organizations, whether private or public.
Over time, the regulatory process itself has been removed from the direct reach of government through the creation of independent quangos to provide ‘steering’, from Ofgem to the Low Pay Commission.
In his 1997 book The audit companyaccountant and economist Michael Power argued that Britain was becoming a nation more concerned with surveillance services than with actually improving them. “Rituals of regulatory verification,” he argued, have served as “empty assurances” to a public that has grown suspicious of professional judgment. It is a process that has deepened over the last quarter century.
The regulatory state has actually led to looser regulation and less ability to achieve socially desirable outcomes. We can see this most dramatically and tragically in the fire at Grenfell Tower in 2017. The investigation into the fire revealed how private companies not only flouted government regulations, but also how Regulators have often come to terms with violators or at least overlooked their activities.
The rise of the regulatory state has also made it more difficult for the government to put in place long-term planning, whether it concerns pandemics, energy security or resilience in the face of climate change. droughts.
At the same time, the outsourcing of government functions, and its reluctance to intervene directly, has undermined its ability to respond to crises, leading, for example, to the current paralysis in the face of soaring energy costs, a paralysis that goes far beyond the simple chasm in governance created by the Conservative leadership campaign.
The regulatory state has also created organizational incoherence and fragmentation. We see it in the railways, the water industry and the energy sector. Perhaps the most pernicious we can see in the NHS. The establishment of the “internal market”, the division between “commissionaires” and “suppliers” and the establishment of a multitude of semi-autonomous organizations have contributed to creating, in the words of a study“a highly complex bureaucratic structure, in which responsibility is so widely dispersed that accountability is virtually impossible” and in which even those entrusted with its administration find it difficult to identify “who exactly is responsible for health care planning”.
But, more than that, in the era of austerity, regulatory mechanisms have become less a means of ensuring good services than of restricting access to them for the poorest. This is why the process of making appointments with the doctor seems designed to be as difficult as possible in order to limit access to a dwindling resource.
Free market policies and the entrenchment of the regulatory state are often celebrated as enabling greater democracy, improving choice and empowering the ordinary citizen. In reality, they placed market efficiency and the conditions of profitability above social needs. They have also been used to attempt to insulate public institutions from democratic pressures. This is why the rise of the regulatory state has been accompanied by attacks on the unions and the further atomization of society.
As early as 1975, the Trilateral Commission, an elite non-governmental organization created two years earlier by David Rockefeller and Zbigniew Brzezinski, whose goal was to shape global governance, warned in a report titled The crisis of democracy, that a problem like inflation is “exacerbated by democratic politics”. This is because the idea that “government should be responsive to the people creates the expectation that government should respond to the needs and correct the ills affecting particular groups in society” and makes it impossible “to reduce spending, d ‘raise taxes and control prices and wages’. .
The “crisis of democracy”, in other words, is that there were too many. It was necessary to shield the state from democratic pressures and crush the expectation that the role of government was to “meet the needs and correct the ills” that afflict citizens.
This is exactly what the structures of the regulatory state have sought to do. And in doing so, they turned such a mundane task as making an appointment with your doctor into a torturous lawsuit while letting something as monstrous as rising energy prices hit us without any serious planning to mitigate. its impact.