It’s a common story, and one that millions endure every day. There are many reasons, including the pressures imposed by Covid and lockdowns in the post-pandemic world and, perhaps most importantly, the shortage of medical staff. In the NHS as a whole, there are more than 132,000 vacancies – almost 10% of its planned workforce. Among general practitioners, with a planned, fully qualified workforce of almost 30,000, there are more than 1,800 vacancies. And it is the most underserved areas that lack GPs the most. Beyond such proximate causes, however, there is a deeper reason, which shapes not only the difficulties of accessing health services but also many contemporary problems, from rail transport chaos to the failure to mitigate the effects of rising energy costs. All are, at least in part, a product of the changing nature of the state. Political analysts have been talking for more than three decades about the transition from the “positive” or “mandatory” state, which was used in the immediate post-war decades, to the “regulatory state” that has been slowly emerging since the 1980s. Where the post-war state intervened directly to secure desired social and economic outcomes – from the creation of the National Health Service to the nationalization of key industries, from the railways to coal – the post-Margaret Thatcher regulatory state saw the desired outcomes as best shaped by the market and saw the role of the state less as providing services than in regulating the market and “driving” it towards desired outcomes. A state that 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, private or public. Over time, the process of regulation itself has been removed from the direct context of government through the creation of independent quangos to provide ‘guidance’, from Ofgem to the Low Pay Commission. Grenfell fire inquiry reveals extent to which private companies flouted government regulations In his 1997 book The Audit Society, accountant and economist Michael Power argued that Britain was becoming a nation more concerned with monitoring services than actually improving them. “Rituals of regulatory verification,” he argued, served as “empty reassurances” to a public that had grown distrustful of professional judgment. It is a process that has deepened over the last quarter of a century. The regulatory state actually led to looser regulation and less ability to achieve socially desirable outcomes. We can see this most dramatically and tragically in the Grenfell Tower fire of 2017. The investigation into the fire revealed the extent to which private companies not only flouted government regulations but also the extent to which regulators often colluded with the offenders of the rules or at least turned a blind eye to their activities. The rise of the regulatory state has also made it difficult for government to enact long-term planning, whether in relation to pandemics, energy security or drought resilience. At the same time, its outsourcing of government functions and its reluctance to intervene directly has undermined its ability to respond to crises, leading, for example, to its current paralysis over rising energy costs, a paralysis that goes far beyond the gap . in the government created by the Tory leadership campaign. The regulatory state has also created organizational incoherence and fragmentation. We can see this in railways, the water industry and the energy sector. Perhaps most devastatingly, we can see this in the NHS. The establishment of the ‘internal market’, the separation between ‘commissioners’ and ‘providers’ and the creation of a multitude of semi-autonomous bodies have contributed to the creation, according to one study, of ‘a highly complex bureaucratic structure, where responsibility is so dispersed that accountability is virtually impossible’ and in which even those responsible for its administration struggle to determine ‘who exactly is responsible for health care planning’. But, more than that, in the age of austerity, regulatory mechanisms have become the means less of ensuring good services than of restricting access to the poor. This is why the process of booking an appointment with a doctor seems to be made as difficult as possible in order to limit access to a dwindling resource. Free market policies have placed market efficiency and conditions of profitability above social need Free market policies and the entrenchment of the regulatory state are often touted as enabling greater democracy, enhancing choice, and empowering the common citizen. What they have really done is place market efficiency and profit conditions above social need. They have also been used in an attempt to insulate public institutions from democratic pressures. This is why the rise of the regulatory state went hand in hand with attacks on unions and the greater individualization of society. As early as 1975, the Trilateral Commission, an elite non-governmental organization founded two years earlier by David Rockefeller and Zbigniew Brzezinski whose aim was to shape world governance, had warned in a report, entitled The Crisis of Democracy , that a problem like inflation is “exacerbated by a democratic policy.” This is because the idea that “government should be responsive to citizens creates an expectation that government should be responsive to needs and correct ills affecting particular groups in society” and makes it impossible to “limit spending, increase of taxes and the control of prices and wages’. . The “crisis of democracy,” in other words, was that it was too much. It was necessary to shield the state from democratic pressures and to quell the expectation that the role of government was to “respond to the needs and correct the evils” that befell the citizens. The structures of the regulatory state sought to do just that. And, in doing so, they’ve turned a mundane task like making an appointment with your doctor into an ordeal, while allowing something as monstrous as rising energy prices to hit us without any serious forward planning to mitigate its impact. Kenan Malik is a columnist for the Observer
