Schools, hospitals and elites

Britain's national health Service is widely seen as an international model of its kind. By contrast, the state education system in England and Wales (Scotland and Northern Ireland are different) is almost universally decried. Little attempt is made to explain this dichotomy; rarely, indeed, is it even pointed out, so compartmentalised is public discussion of the welfare state. Yet it demands explanation if reformers are to learn from experience.

Class dynamics lie at the heart of the health/education dichotomy, an argument I elaborate on in my book with Stephen Pollard A Class Act: The Myth of Britain's Classless Society. We reached this conclusion after, typically, completing separate studies of the health and education systems. Only when we came to consider the two in tandem did it strike us, forcibly, how much the success of the NHS flows from its success, since its inception in 1948, in reconciling the principles of equal access and state provision with the reality of entrenched class divisions; and how much the failure of the education system lies in its failure, over the same decades, to reconcile equal access, state provision and the class system.

A word first about "success" and "failure." We are not dealing in black and white. Both sectors are about equally afflicted by the rationing of public funding for staff and investment. And while England boasts many good state schools, the NHS has emphatically not succeeded in equalising the health of the nation. Indeed, our study of the health system is a graphic account of class inequalities. A child from an unskilled social class is twice as likely to die before the age of 15 as a child from a professional family, while the life expectancy of a child with parents in the unskilled manual class is more than seven years shorter than for a child with parents from the professional class. Of the 67 "major list" causes of death among men, 62 are more common in the Registrar General's bottom two social classes than in the others; of the 70 major causes for women, 64 are more common in those classes. By some measures health inequality is now greater than in the 1950s.



As for education, there has been unambiguous progress since the Butler Act of 1944, the ambitious end-of-war reform which stands alongside Aneurin Bevan's creation of the NHS in 1948. Compulsory schooling extended to 11 years; a huge increase in the number of children taking and passing public examinations; higher education transformed from an elite to a mass pursuit-these advances have been to the benefit of all classes, however unequally.

Yet judged by the "one nation" intentions of post-war reformers of all parties-particularly Labour-health and education are leagues apart. Bluntly, the NHS created an effective cross-class system of healthcare, while the school system failed to do so. RA Butler said his 1944 Education Act would "have the effect of welding us into one nation..." No objective analyst would say it succeeded. As AH Halsey, a leading educational theorist of the 1960s and 1970s, puts it: "The essential fact of 20th century educational history is that egalitarian policies have failed." Conversely, the "classless" quality of the NHS, however exaggerated, is a source of unbounded national pride. In the (somewhat regretful) words of Nigel Lawson, "the National Health Service is the closest thing the English have to a religion, with those who practise in it regarding themselves as a priesthood."

Britain's health "success" and educational "failure" have three dimensions: institutions, professions and the experience of the working class.

The NHS is a cross-class institution; the education system is not. Of course, standards of hospital and GP provision vary widely. Private health insurance is extensive, covering around 15 per cent of the population (rising to 20 per cent in London and the southeast), which is twice the proportion usually cited for private education. Yet two facts say it all: virtually the entire population uses the NHS as its main provider of life and death healthcare, while virtually no one (beyond the elderly in need of intensive or residential care) moves house purely because of the standard of local doctors and hospitals. Private insurance is largely a top-up service for certain elective operations; even then, its main purpose is to queue jump, not to get a higher standard of care. All of Britain's best hospitals are in the NHS. Much private healthcare takes place in NHS hospitals, courtesy of pay beds and contracts between the two sectors, and most of it is performed by doctors and consultants who work for the NHS, often in the same hospitals. Medical training is an entirely public sector affair.

In two key respects-the working practices of the medical elite, and the division between public and private provision-the NHS represents a grand compromise. Charges to patients are integral to the NHS, even for essential services such as prescriptions, dentistry and spectacles. As for the medical elite, the ease with which consultants move back and forth between the public and private sectors is accepted with an extraordinary degree of tolerance by health managers and their political masters. True, the enthusiasm with which some top consultants double or even treble their £70,000-plus state salaries generates periodic complaints; but everyone involved knows that a radical reform of the consultants' contract is out of the question if the goodwill-and ultimately the services-of the medical elite are to be retained within the NHS. Family doctors also enjoy a special status which dates back to the foundation of the NHS. They are not state-salaried but self-employed practitioners; and although their income comes almost entirely from public funds, the freedom with which they regulate their work, and their ability to maximise income, particularly since the advent of fundholding, gives them an autonomous professional status which they guard jealously.

From this we can explain one stark but little noticed fact. Medicine is Britain's only broadly public-sector profession which has continued to thrive in recent decades in terms of its ability to recruit and retain from the socio-academic elite. Taking Oxford graduates, the number entering the medical professions (including administration) rose from 80 to 123 a year between 1971 and 1994, while the number going on to teacher training plummeted from 236 to 101, as did the entry into central and local government administration (down from 120 to 55). Central to the argument in our book is the rise of the "superclass," Britain's new upper class of top professionals and managers. Centred on the City and the professions which service it (law, accountancy, banking and consultancy), the superclass is an almost exclusively private-sector elite. The one exception is the higher reaches of the medical profession. Three quarters of applicants to medical schools have professional-class parents. According to a 1995 British Medical Association survey of new medical graduates, 38 per cent were educated at independent schools, while a further 17 per cent came from state grammar schools, almost half the proportion that came from comprehensive schools-an astonishing statistic, since there are only 161 state grammar schools left (most of them with affluent catchment areas) but 2,876 comprehensives. Add in the fact that 18 per cent of the graduates came from medically qualified families and the class foundations of the medical elite are fully revealed.

England's schools are so rigidly divided between public and private sectors that the word "apartheid" has become fashionable to describe the education system, as in George Walden's coruscating book We Should Know Better (1996). The 7 per cent of fee-paying parents-who include virtually all the superclass and a fair slice of the professional classes below-are not buying a top-up service: they are opting out of the state sector entirely, buying entry to the best meritocratic academies in the country. In last year's Financial Times survey of the A-level performance of England's 1,000 leading schools, all but 22 of the top 200-educating some 150,000 children between them-were in the private sector. The FT's 1,000 comprised most of the independent school sector but only a fraction of the state sector; yet even within this selective group, which included most of the remaining state grammar schools, the A-level performance of private schools was on average a quarter better than their state counterparts. Virtually all the famous "public schools"-how that tag sums up the catastrophe of modern English education-are in the top 100, so successful is the marriage of money and meritocracy in today's education system. In today's Britain, meritocracy is the creed of the elite, not the mass.

Behind England's educational apartheid lie large disparities in funding. Private secondary school fees now average well over £6,000 a year, which is more than twice the average state school funding of about £2,400 per pupil. The top public schools cost up to Eton's £14,000 a year-about the level of the average post-tax wage. As for the teaching profession, the conventional wisdom about a "crisis of morale" is undeniably true for the state sector, where the number and quality of recruits is a cause of acute anxiety. Within the private sector, however, pay and morale is far higher and the ability to recruit from the top universities unaffected. The figures cited above for Oxford graduates going into teaching apply only to the state sector: the number going into the private sector appears to have risen in recent decades, judging from our enquiries at leading independent schools. Furthermore, within the state system the concentration of able teachers on "good" schools is pronounced-to some extent a legacy of the grammar schools, reinforced in recent years by the local management of schools, which has made individual schools, not local authorities or the state, the de facto employer of teachers.

Which leads to our third dimension: the experience of what used to be called the working class. For all the class inequalities in health, those in education are far worse, because of the failure to raise the "floor" condition of those at the bottom of the social scale. Of course, many from poor backgrounds do succeed in state schools. But in the most deprived areas, from even the poorest of which the great child-killer diseases of yesteryear have now been eradicated by the NHS, levels of school achievement are pitiful. An anti-education culture is pervasive. One in five seven year olds in London state schools scores zero in reading tests. In secondary schools serving the poorest areas, less than 15 per cent of pupils achieve five or more GCSE grades A to C, and the best schools in such areas achieve average GCSE scores which are just one third that of schools in more advantaged areas. These are inequalities quite unmatched in the health system. At a teachers' union conference last year, a teacher from a poorly achieving Nottingham comprehensive-where only 8 per cent of children secured five GCSE passes at grades A to C-created a storm by declaring from the rostrum: "I'm afraid that Darren, Dean, Damian, Liam and Nathan can't do it, never will do it, and frankly would not give a damn if they don't do it at all." Yet he was only paraphrasing, colourfully, the words of Her Majesty's Chief Inspector of Schools, who had written in The Times shortly before: "The failure of boys, and in particular white working-class boys, is one of the most disturbing problems we face."

Class, as the Chief Inspector acknowledged, is the heart of the matter, more or less embracing all the factors described above. Even the contrasting regimes for private provision within the two sectors have a critical class dimension. The professional elite has remained thoroughly wedded to the NHS, as both provider and consumer. It has done so because of the "grand compromise" enabling it to have the best of both worlds: for the consultant elite, NHS training and employment plus private practice; for better-off patients, NHS hospitals and treatment plus top-up private care. In education, however, you are on one side or other of the great divide between public and private sectors, as teacher, pupil and parent, and topping-up is banned in the public sector (as it is not in the NHS). Within the state education sector, there is an almost equally stark divide between the elite of state grammar and grant-maintained schools on the one hand, and local authority municipal comprehensives on the other.

How did it come to be like this? The proponents of English exceptionalism attribute it to deeply rooted historical forces. They are right, up to a point. Britain's public schools are among its most ancient institutions: the strength and character of private education today is incomprehensible without an understanding of the evolution of the public and grammar schools over the past two centuries. The formation of the medical elite also has deep historical roots, although the Victorian age-a critical period for the formation of Britain's modern elite institutions, from the monarchy downwards-never produced a "hospital system" to match the "public school system."

Yet for all their historical roots, today's education and health systems have been shaped fundamentally by governments since the second world war. And it is in the differing approaches to reform since the war that much of the success and failure we have identified is explained. Three reformers stand out: RA Butler, author of the 1944 Education Act; Aneurin Bevan, creator of the NHS in 1948; and Tony Crosland, the prime-although not sole-agent of the introduction of comprehensive schools in the 1960s and 1970s. All three saw themselves as progressive reformers; all three also saw themselves as involved in a class struggle, whatever words they used to express it. In the contrasting reform strategies of the three-Butler the Tory grandee, Bevan the working-class, socialist realist, and Crosland the public school apostle of social democracy-lies much of the explanation for the success of the NHS and the failure of the education system.

Butler, the Tory grandee, made no attempt in his 1944 Education Act to produce an integrated national education system. A "one nation" reformer by inclination, for him the battle with the Tory elite which would have been required to nationalise the public schools was too much. Moreover, although he recognised the perpetuation of separate systems as a social blight, his own background disabled him from taking the crucial initiatives at the end of the war. In 1943-44, in the aftermath of the Beveridge report, he had a crucial opportunity to do so: not only the public mood, but the dilapidated financial state of the public schools themselves, created an opening. Butler recognised it to the extent of appointing a committee under Lord Fleming to examine the future of the public schools. But Fleming was no Beveridge, and Butler-anxious about Tory opinion-was unprepared to take the initiative himself in framing his 1944 Act. Instead, the private sector was left out, Butler noting fatalistically that "the first-class carriage had been shunted on to an immense siding." Instead, he concentrated on expanding the state secondary sector: in particular opening up the grammar schools to broader cross-class entry through the 11-plus.

It was the grammar schools which, two decades later, Crosland set out to destroy in the name of "equality of opportunity." Crosland, the minor public school, Oxford don social democrat, motivated by a social self-abasement so characteristic of his generation of upper-crust Labour politicians, was a disastrous reformer. While Butler recognised the class obstacles preventing the creation of a national, meritocratic education system but could only half overcome them, Crosland convinced himself they could be ignored entirely and a classless education system be simply legislated into existence. Hence his obsession with abolishing the grammar schools (or "fucking grammar schools," as he famously called them) and his determination to replace them with comprehensive schools which, non-selective in intake and modern in their teaching practices, would produce "equality of opportunity" at a stroke.

Even in theory this was a flawed policy, since Crosland did nothing about the private sector, to which the professional classes decamped en masse rather than submit to comprehensivisation. In many cases they literally took their grammar schools with them into the private sector-particularly when Shirley Williams, one of Crosland's Labour successors as education secretary (another upper-crust, privately-educated social democrat) moved to abolish the direct grant scheme, under which the state contracted to buy places in leading private grammar schools. To be fair, Crosland realised the importance of the private sector to his reform objectives. But his bitterly anti-elitist reform strategy left no opening for integrating the private sector by consent, while the strength of the social elite-by now entirely recovered from their wartime crisis of morale and income-made it impossible for him to coerce them. Yet the very existence of so large a private sector reduced, if it did not undermine, the chance of realising the potential of the comprehensive ideal.

Of the three reformers, the red-blooded Aneurin Bevan was by far the most successful at managing rival class ambitions. On the one hand, he was sufficiently radical and undeferential to the social elite to drive through an integration of "public" and "private" medicine into one national system. On the other hand, his awareness of, and his realism about, the class pressures involved in medicine-among consumers and suppliers-gave him a proper sense of the concessions necessary to bring the elite into the NHS. This is not to decry Bevan the socialist, but to elevate Bevan the realist. Indeed, Bevan overestimated the socialist potential of his reforms, believing that private practice would soon die out once the NHS was established with the elite on board. But he never made the key Croslandite error of believing that in a free society the elite could be coerced where its vital class interests were threatened.

A salaried medical service had, before and during the war, been the main priority of the Socialist Medical Association, and the 1945 manifesto committed Labour to a "national, full-time, salaried, pensionable service." Yet for Bevan, it was the hospitals-not the professionals who worked in them-that he decided to nationalise. He saw that there was no chance of creating a unified NHS without a national system of hospitals and primary care; but equally that there was no real prospect of creating a cross-class NHS if the medical profession was nationalised, forcing much of it into the private sector along with its patients and (in due course) a parallel set of institutions. Consultants were thus allowed to retain the right to private practice and pay beds in NHS hospitals, and given substantial representation on the new NHS management committees and regional boards. "I stuffed their mouths with gold," as Bevan put it. Bevan's Labour critics-who spent the next 30 years trying to abolish pay beds and private practice within the NHS-claimed he was too much under the influence of Lord Moran, president of the Royal College of Physicians. Yet the Welsh socialist was no one's poodle, as his battles before and after his service as health minister amply demonstrate. He appeased the consultants because he knew that if doctors were not allowed to combine private practice with NHS work, many would simply not join the NHS, and that then the NHS would rapidly become-if it did not start out as-a second-class service. Explaining his decision to allow GPs to retain capitation payments and independent practices, he said the alternative of a salaried profession was unachievable without massive desertion.

Michael Foot, Bevan's acolyte and biographer, and the archetypal "upper-crust" Labour radical of the next generation, remarks of Bevan's foundation of the NHS: "His outstanding success was the way he applied the anaesthetic to supporters on his own side, making them believe in things they had opposed almost all their lives." Yet two generations later, the NHS is lauded as the single greatest triumph for socialism in British history. None other than Margaret Thatcher had to defend it to the last, for all its offences against her belief in free markets, self-reliance and the small state. Churchill once remarked, "We mould our institutions and they mould us." But some mould us better than others.