Laughing at Democracy

After a quiet few days, there have been some yelps squeaks and barks from UK medical bloggers about the British Medical Association’s SRM (Sham Representative Meeting) called earlier this week to decide the Association’s position on the government’s proposed NHS reforms. Dr Grumble meanwhile has adopted an “I’ve been telling you for years, will you believe me now” tone under a reckless headline on the ways of parliament. Or perhaps it isn’t so reckless after all – for who knows how many tens of thousands will die unnecessarily if the Tory health reforms become reality.

The trouble with all these yelps squeaks and barks (and Dr No has been at it too) is that they are faux-outrage at what is in fact inevitable. It is the inevitable result of what many of us call democracy, but which is in fact nothing of the sort, being instead something which Dr No called Sham Dem eighteen months ago; and the thing about Sham Dem is that it is anything but democracy, by any accepted definition of the term. It is, to give it a more descriptive but less snappy name, serial, or perhaps more accurately, interval, oligarchy. If that sounds a bit technical, Dr No apologises, but hopes to make all plain.

There is a custom in health service research of dividing investigation into three separate but related areas: structure, process and outcome. To put some flesh on these bones, structure might be how many hospital beds, nurses and doctors you have; process how many operations you do, and outcome is how many operations are successful. As a rule, the further along the structure-process-outcome line you are, the more useful is your research. It is – usually – of more interest, and use, to know that one in three of your patients died in hospital after surgery than you had twenty doctors, fifty nurses and five hundred beds.

Now, sometimes the order of importance is reversed. The trouble with the yelping, squeaking and barking, and indeed Dr Grumble’s analysis of parliamentary process, is that they (and Dr No) are all complaining about process, and so, by implication, outcome, when in fact the real villain is structure: the structure of our so-called democracy. The reason this matters is because if we want to do anything about the dreadful process and dire outcome, we need to focus on the real cause of trouble: the structure.

The modern populist view of democratic government is that it is that form of government where every now and then the people are given a chance to vote on who should govern them. So far as it goes, this much is true; but in reality it tells as much about what really happens in a so-called democracy as does observing that traffic lights stop and start traffic flow tells us about what the traffic really does on our roads. Sometimes the lights change, but the grid-locked traffic fails to move. At others, a hot-head crashes a red light. And the fact that a driver filters left or turns right on the green – or indeed the amber – tells us absolutely nothing about where they go after disappearing from our sight. We may, or may not, see them back at the same light. For all we know, some may even have crashed into a duck-house, or – Heaven forbid! – be stranded in a moat.

In much the same way, at election time, governments get a green light (a majority) or an amber (minority, or a coalition), but once past the lights the road is their own for the taking. They can speed up, slow down, overtake obstructions recklessly, take unexpected turnings, crash, burn, U-turn – whatever – and the lights are powerless to control them. And the trouble is, in our political system, the structure, including crucially the traffic lights –the elections – are very thin on the ground, and the road between them unmarked and unmapped. There is precious little structure or form: once past the green or amber light, the man at the wheel can drive where he wants, at whatever speed he fancies – until such time as the next traffic light, or election. Sure there are police – the opposition – but they are armed with water pistols. Even if it is a coalition, those who have jumped on the band-wagon for the ride sit tight, because they fear if they rock the wagon they will be thrown off, into the ditch, flies buzzin’ around their eyes…

And it is precisely this lack of form and structure between the distant controls of elections that allows a government to act not in the interests of the people, but in its own ways and fancies. It drives not for the people, or for the nation as a whole, but for its own ends, and its own purposes.

Over two thousand years ago, the nature of government was scrutinised by Aristotle, and little has changed since. His analysis was simple and elegant. Governments were, he said either good (ruled in the interests of all the people) or bad (ruled only in their own interests); and a further distinction could be made between rule by an individual, a minority or a majority. And so a two by three table, classifying the types of governments can be laid out, and the types of government given names:

Good or Bad?	Rule by one	Rule by minority	Rule by majority
Good (nation’s interest)	Kingship	Aristocracy	Polity
Bad (own interest)	Dictatorship	Oligarchy	Democracy

It is interesting to note here that even a true democracy (where a majority rule in their own interest) is considered a bad form of government . Churchill of course was on to such things in his many quips about democracy. The nominal majority might rule, but what if the minority be substantial, might even be right, or at the very least have rights, and yet be trampled upon?

Be all that as it may, the reality of United Kingdom elections has for several decades been that the winners have been voted in by a minority of the people; so what we call our democracy cannot in fact be a democracy. It is instead pretend – sham – democracy; rule by a minority masquerading as rule by a majority; and in between elections, because of the lack of structure, of accountability, of traffic lights, the government can do pretty much what it wants to do. It can ride rough shod over opposition, crash through red lights, all in the pursuit of its own interests. And a rule by a minority, in the interests of that minority is not a democracy, but an oligarchy. And because it happens serially, one government after another, we may call it a serial oligarchy.

What happens at government level also happens at the professional level. The ‘democratic’ BMA, with its elected representatives, is in just the same way not a true democracy, but a serial oligarchy. It rules not in the interests of all members, but in the interests of its elected representatives who – between elections, some might add even at elections – do not represent rank and file doctors one jot; and furthermore, lacking the accountability of elections, are free to drive their own route through the sands of history.

And so it is that Dr No concludes that it is inherent in the structural nature of our governments, and our professional representation, that we find a form, a structure, so loose that it allows, perhaps even makes inevitable, a divergence between the best interests of the people, and the intentions of government, and professional of representation for much, if not all, of the time between elections.

How, we might ask, do we do anything about this sorry state of affairs in general, and the Health and Social Care Bill in particular? Why – it’s simple! We stop whingeing and moaning about process, and go for the structure. A well placed road block will do the trick just as well as a set of traffic lights…

The Lib-Dems have it within their power to set up such a road block, and bring the coalition to a crashing halt – and so another election; and were that to happen, we might all be weary – and wiser – of Tory intentions. But the Lib-Dems, despite fine words last weekend, appear to have to have lost the will to fight.

The medical profession has the power to do it, by rejecting the Bill ‘in its entirety’. And yet our elected representatives, our serial oligarchs, have failed to represent the will of the profession, and have embarked on a Faustian Pact with the Government.

We, the rank and file of public and profession, have before us many dark days of arduous toil if we are to save our NHS, which we hold so dear. But, as Churchill might have said:

‘I have, myself, full confidence that if all do their duty, if nothing is neglected, and if the best arrangements are made, as they are being made, we shall prove ourselves once again able to defend our NHS, to ride out the storm of war, and to outlive the menace of tyranny, if necessary for years, if necessary alone. At any rate, that is what we are going to try to do. That is our resolve. That is the will of all of us, and of the nation.’

‘The British public and the medical profession, linked together in their cause and in their need, will defend to the death their NHS, aiding each other like good comrades to the utmost of their strength. Even though large tracts of the health service and many old and famous hospitals have fallen or may fall into the grip of the privatisation and all the odious apparatus of Tory rule, we shall not flag or fail. We shall go on to the end, we shall fight in the corridors, we shall fight on the wards and in the clinics, we shall fight with growing confidence and growing strength in the media, we shall defend our NHS, whatever the cost may be…until, in God’s good time, the New NHS, with all its power and might, steps forth to the rescue and the liberation of the old.’