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Title page
Contents
About the author 13
Preface 14
Acknowledgements 15
1. Why governance matters - analysing systemic failures in the NHS 17
1.1. The Bristol babies' scandal 18
1.2. If Bristol was the problem, was clinical governance the answer? 22
1.3. Mid Staffordshire - from clinical governance to market and regulatory failure 23
1.4. Diagnosing the causes of systemic failures in governance of the NHS 26
1.5. The structure of this book - political settlements and their fault lines 29
2. Economic and geographical fault lines 37
2.1. A mediaeval pandemic and the divergence of inclusive and extractive societies in Europe 38
2.2. From serfdom to a maximal state 40
2.3. Governance and corruption effects in Western Europe 42
2.4. Social capital, governance and innovation 46
2.5. The institutions of capitalism in the UK and Germany 48
2.6. Oldham and Oxford: divergent development in the UK 52
Conclusions 59
3. The interwar period and the Attlee settlement 69
3.1. The roots of the problems - Britain before 1939 70
3.2. The problem of unemployment 72
3.3. The economic freeze of healthcare, education and housing 76
3.4. Foundations laid by the wartime coalition government 81
3.5. The post-war Attlee settlement 87
Conclusions: Attlee's legacy 94
4. The Attlee settlement's failures: stagflation, slums in the sky and educational geography 106
4.1. Stagflation and the failure to control public expenditure 107
4.2. Public housing and 'slums in the sky' 109
4.3. Schools, universities and educational geography 114
Conclusions 118
5. Neoliberalism and the new Thatcher settlement 124
5.1. The ideology of neoliberalism 126
5.2. Monetarism 128
5.3. The Global Financial Crisis: made in Chicago? 132
5.4. The financialisation of the UK's economy after Thatcher 138
5.5. Financialisation of housing in the UK 141
Conclusions 144
6. The 'make or buy' decision: the UK's 'parastate' after privatisation and outsourcing 154
6.1. Privatising industries - coal and steel 157
6.2. Privatising key service industries 161
6.3. The makings of the Challenger tragedy 167
6.4. Outsourcing and the UK's parastate 173
Conclusions 178
7. Marketisation in education 188
7.1. Designing social segregation by schools in Chile's voucher system 190
7.2. Did England's quasi-market for schools deliver equity through choice? 193
7.3. England's search for an optimal and equitable university system 197
7.4. Back to the Attlee settlement? 202
Conclusions 204
8. Healthcare: to marketise or not to marketise? 212
8.1. Equity and cost control in Canada but not the US 213
8.2. An internal market for hospitals: a concept lost in translation? 217
8.3. Designing public reporting systems to improve performance 221
8.4. Managing the commons 226
Conclusions 228
9. Playing the opening and middle games against Covid-19 235
9.1. The opening game 236
9.2. 'Following the science' 238
9.3. Making astrology look good 241
9.4. Hindsight bias and fighting the last war 242
9.5. Herd immunity by default in England 247
9.6. Lockdowns - a later part of the opening game 251
9.7. Failures of outsourcing 255
9.8. Vaccines - the middle game against Covid-19 257
Conclusions 261
10. Afterword: re-engaging with public governance 276
10.1. Pathologies of neoliberalism 276
10.2. Second thoughts on markets and quasi-markets 279
10.3. Governing by reciprocal altruism 281
10.4. A new political settlement 284
Selected bibliography 291
Figure 1.1. NHS spend as a per cent of the UK's GDP, from 1960 to 2019 28
Figure 2.1. The Krokodil nail factory cartoon 42
Figure 2.2. Map of the European Quality of Government Index scores at regional level, in 2017 43
Figure 2.3. Map of Renaissance Italy, 1350 to 1600 45
Figure 2.4. Regions in European countries with lower GDP per capita than former East Germany in 2017 50
Figure 2.5. GDP per capita in 2019 in euros for the UK, Italy, the former West Germany regions, and the former East Germany regions 52
Figure 2.6. Which places in the UK are most left behind? 55
Figure 2.7. Residents' view of wellbeing in Oldham and Oxford are very similar (in 2021-22) 56
Figure 2.8. Ratio of house prices to residence-based earnings across local authority districts in England and Wales, in 2020 57
Figure 3.1. John Maynard Keynes by Gwen Raverat (c.1908) 71
Figure 3.2. UK unemployment rate, 1919 to 1939 74
Figure 3.3. Relative unemployment rates in Britain in local areas as a percentage of the national average, for 1927-31 and 1931-36 75
Figure 3.4. UK real GDP per capita and public expenditure per capita in the interwar period (1919 = 100) 77
Figure 3.5. The organisation of health services recommended by the Dawson Report in 1920 79
Figure 3.6. William Beveridge and his report (first draft) 82
Figure 3.7. UK unemployment in the first 31 post-war years (1946-76) compared with the 20 interwar years (1919-39) 88
Figure 3.8. UK real GDP per capita and public expenditure in the postwar period (1946-76) 89
Figure 4.1. Annual percentage increases in the UK Consumer Price Index (CPI), 1970 to 2000 108
Figure 4.2. The percentage share of UK public expenditure financed by borrowing, 1970 to 1990 109
Figure 4.3. Total new housing completions in England, 1946 to 2020 110
Figure 4.4. The percentage mix of public, social and private housing in new completions, 1946 to 2020 111
Figure 4.5. Effects of the explosion at Ronan Point tower block on 16 May 1968 113
Figure 5.1. Conservative campaign poster for the 1979 general election 125
Figure 5.2. UK unemployment, 1946-2015 125
Figure 5.3. Annual percentage increases in the UK money supply and in price levels (two years later), from 1946 to 2016 130
Figure 5.4. The exchange rate of the pound in terms of US dollars 130
Figure 5.5. The distribution of UK employment across industrial sectors from 1996 to 2016 131
Figure 5.6. Five ways to maximise shareholder value (MSV) 133
Figure 5.7. GDP per capita for the UK as a percentage of that in Germany, France and Italy, in 2016 and 2022 140
Figure 6.1. A market with low transaction costs 157
Figure 6.2. UK coal production (in millions of tons), from 1945 to 2003 158
Figure 6.3. The numbers of coal mines and thousands of mining employees, from 1945 to 2003 159
Figure 6.4. NASA diagram showing tang, clevis and O-rings in its Challenger booster rocket 169
Figure 6.5. Seven questions that indicate where a market may fail 171
Figure 6.6. A market with high transaction costs 172
Figure 7.1. Private schools and three state systems 191
Figure 7.2. England's school funding formula 194
Figure 7.3. Requirements for an effective quasi-market for schools on Williamson's criteria 196
Figure 7.4. The desired and actual outcomes of the English market for undergraduate education 200
Figure 7.5. The percentage of students achieving more than five good grades in GCSE at 16 in England and Wales, from 1993 to 2007 203
Figure 8.1. Healthcare systems in the United States and Canada 214
Figure 8.2. Healthcare expenditure as a percentage of GDP in Canada and the US, 1965 to 2021 214
Figure 8.3. The NHS as a hierarchy (in 1980) and its 'internal market' form (in 2012) 218
Figure 8.4. Causes of high transaction costs in contracting with hospitals 220
Figure 8.5. Describing the high transaction costs of contracting with hospitals 220
Figure 8.6. Waiting time targets (in weeks) in England and Wales 223
Figure 8.7. The Tuscan system dartboards displaying the health performance of two regions, Tuscany and Marche, in 2015 225
Figure 9.1. The National Covid-19 Memorial Wall in London 237
Figure 9.2. Estimated excess deaths and confirmed deaths from Covid-19 in 2020 243
Figure 9.3. Organogram of pandemic preparedness and response structures in the UK and England - August 2019, UK Covid-19 Inquiry 246
Figure 9.4. The fireside chat between PM Boris Johnson and Dr Jenny Harries 249
Figure 9.5. Dominic Cummings (Boris Johnson's former chief of staff) giving evidence to the joint session of Health and Social Care Committee and Science... 252
Figure 9.6. The cumulative numbers of people in England who died with Covid-19 from March 2020 to April 2023 254
Figure 9.7. Daily new Covid-19 cases and deaths per million population in the UK and Germany, March 2020 to June 2021 255
Figure 9.8. The high transaction costs of outsourcing Test and Trace 256
Figure 9.9. The percentage of opinion poll respondents in 2018 who said that the vaccines in use were safe across European Union countries 259
If every system is perfectly designed to get the results it gets, what is wrong with the design of the systems that govern Britain? And how have they resulted in failures in housing, privatisation, outsourcing, education and healthcare? In How Did Britain Come to This? Gwyn Bevan examines a century of varieties of systemic failures in the British state. The book begins and ends by showing how systems of governance explain scandals in NHS hospitals, and the failures and successes of the UK and Germany in responding to Covid-19 before and after vaccines became available.
The book compares geographical fault lines and inequalities in Britain with those that have developed in other European countries and argues that the causes of Britain's entrenched inequalities are consequences of shifts in systems of governance over the past century. Clement Attlee's postwar government aimed to remedy the failings of the prewar minimal state, while Margaret Thatcher's governments in the 1980s in turn sought to remedy the failings of Attlee's planned state by developing the marketised state, which morphed into the financialised state we see today.
This analysis highlights the urgent need for a new political settlement of an enabling state that tackles current systemic weaknesses from market failures and over-centralisation. This book offers an accessible, analytic account of government failures of the past century, and is essential reading for anyone who wants to make an informed contribution to what an innovative, capable state might look like in a post-pandemic world.
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