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Test tube politics

1 March 2004

The government wants a national standard for the availability of medical interventions such as IVF, but it also wants local people to have a greater say in the provision of services in their area. This paradox will not resolve itself for so long as national politics remains the only show in town.

The political strains created by the tension between centralisation and devolved power are nowhere more graphically illustrated than in the provision of health services. The principle of giving people control of their local services is in direct conflict with the perceived evils of post-code prescribing, under which certain medications and interventions are available in some health authority areas but not in others.

An example of this was highlighted last week, with government proposals to standardise the availability of in vitro fertilisation (IVF). This "test-tube baby" treatment, which is not, at present, offered by every health authority, will now be provided across the country. Couples will receive at least one cycle of treatment, although not necessarily the three cycles recommended by the National Institute for Clinical Excellence that significantly increase the chances of success.

A footnote to the announcement explained that the government was looking to the health service "to give local priority to couples who do not have any children living with them." This detail of the new policy, which seems, on the face of it, entirely reasonable, is more significant than it appears. For it reveals that the thinking behind the policy intervention is to give as many couples as possible a "chance" to have children, irrespective of the relative chance of success. This objective is quite distinct from that of increasing the overall number of live births to otherwise infertile couples. If that had been the objective, the priority would have been to treat those with the highest chance of a successful outcome. This group could be expected to include those who had already undergone successful IVF treatment and now wished to do so again.

This distinction is relevant, in turn, to the debate about local and national priorities. The country's birth rate is essentially a national concern. It plays into an economic debate about wealth production. At a local level the birth rate is less important since population flows between localities occur easily in response to economic need. A policy intended to maximise the number of live births would therefore sit naturally at a national level.

But the policy of spreading as widely (if thinly) as possible the chance to attempt IVF is driven by social ideals that relate to the care that infertile couples deserve. It is the attempt that is important; the couple should feel that they have received appropriate help, have been well treated and given a reasonable try at the treatment. In a real sense, the policy is dealing with their psychological health.

A decision to offer treatment on this basis could be taken on a national or a local level. It is one of many ways of spending money to help and support people, and choices are needed. If these choices are to be made in a way that is representative of the public perception of need, the decision must be taken at the level of society (local or national) at which that need is measured. The incessant political chatter about localism would suggest that need can be measured locally, and that these are precisely the sort of decisions that should be taken at a local level.

The principle seeking to establish itself through this argument is that spending needs reflect local situations. Since taxation goes into a big pot, the way it comes out of that pot ought not to be compartmentalised but reflect a local community's pressing priorities. On this argument, the debate about IVF spending should not simply reflect a choice between this form of treatment and some other, such as geriatric or emergency services, but should range much more widely over social needs. In some areas people might choose a new flood defence scheme over spending on IVF, because that is a more effective way of reducing the sum of human misery in their community. Given the social, psychological and financial devastation that flooding can cause, this would not necessarily be a wrong decision.

The tension between social needs and the resources available to meet them goes to the heart of government in a peaceful social democracy. How resources are allocated is as much a consequence of custom and acquired expectation as a utilitarian calculation of the greatest good. There is no logic in the proposition that people should, in many cases, pay to have their teeth seen to or their eyes tested, but have their heart rate, blood level or cholesterol checked for free. But from the political point of view there is a practical desirability about it, since dental care and spectacles are relatively cheap and open heart surgery very expensive. Like prescription charges, getting people to pay directly for smaller things makes more money available to provide services that they could never afford.

The problem with this approach is that it only allows change by small increments. There is a fixed assumption that the services which are freely available, simply by virtue of being so, are the appropriate ones for the state to offer and should be available as of right. The question is then reduced to whether these services are satisfactory in quality and extent. A government that offers (in principle, at least) both flood protection and IVF treatment, is open to criticism both in areas where the flood protection is inadequate and in areas where IVF is insufficiently available. The utilitarian principle of calculated choice becomes subverted to the point where the greatest good can only be achieved if everybody has access to the highest standard of every service that is offered.

The promotion by central government of localism in the allocation of services is partly a pragmatic step intended to re-assert the principle of necessary choice; to focus people's attention on to the reality that, as a group, they can only have what they can afford. This is an intelligent and workable approach to a serious political problem, but, in order to succeed in its task of confronting people with the reality of choice, the government must recoil firmly from the dirigiste tendency that takes fright whenever people complain.

The dirigisme arises because the national level, in Britain at least, is the one that has the greatest resonance politically. This means that it is the national government that suffers when people are discontented by social, political or economic matters, irrespective of where the source of that discontent lies. The rise in the last decade or so of other large political entities, such as the European and Scottish parliaments, and the Welsh Assembly, points in the direction of new identifications. The British political establishment stands on the cusp of a long and long overdue process of evolutionary change in this area of political accountability. But change will not come quickly. Elections to these new bodies illustrate, through their low level of voter participation, the extraordinary difficulty of re-directing established political habits of mind.