John Barnes, Historian

© John Barnes

Revised version

23 August 2000

EXECUTIVE GOVERNMENT

in the LATE 20TH CENTURY:

THE OECD EXPERIENCE

Chapter I

This chapter contrasts the record of the American and British political systems in dealing with proposals for health reform in the late 1980s and early 1990s. In terms of its capacity to act with speed and decision, the British system appears to come out as markedly superior. That accords well with the conclusion of a great many American political scientists, from the future President Wilson on, that the Parliamentary model and, more particularly, the British version of it was inherently superior to the American in its capacity to govern effectively. A number of capabilities are highlighted, above all the ability to innovate when old policies are seen to have failed and the ability to impose losses on powerful groups when the public weal is at stake. There can be no doubt that these are widely perceived to be essential to good government. Inherent in the ability to innovate successfully is an accurate diagnosis of the problems with which a particular community is confronted, the identification of possible solutions and the devising of a practicable answer. That may well involve not only the taking of advice but heeding it if the solution is one that is going to operable when the process of implementation takes place. That these are key capabilities can scarcely be doubted, and what follows speaks to them. However, it is worth bearing in mind, even at this early stage, that they are not the only capabilities necessary to good government and that there are many in the course of the last quarter of the 20^th century who would argue that government itself is part of the problem. Nevertheless, there are lessons to be learnt from making the comparison.

In September 1994 the Democratic Majority Leader in the American Senate, George Mitchell, proclaimed the demise of the most important initiative taken by President Clinton during his first term. Health Security was a carefully crafted plan, which had been entrusted to a task force headed by the President's wife and a business consultant friend, Ira Magaziner. The programme met an obvious demand, was popular when announced and well received by the five congressional committees to whom it was presented in October 1993. Few expected the plan to be legislated in its original form, certainly not its designers who had built in substantial room for compromise. The general anticipation, however, was that it would prove a satisfactory basis on which to go ahead and agree a compromise. What went wrong?

One can discount immediately allegations that the proposals were excessively liberal. That was no more than successful conservative propaganda. Even if Clinton had wished to be fiscally generous, he was hemmed in by his campaign pledges to reduce taxes on everybody but the rich. More important still, his proposals had to conform to the tight "paygo" budget rules that had been institutionalised over the previous decade. These required that, if legislation was to go forward through normal congressional processes, the Congressional Budget Office (CBO) would have to certify its cost neutrality so far as the federal budget was concerned.

It is worth noting in passing the parallel that the American political scientist, Theda Skocpol, draws between the CBO and the Supreme Court in terms of the effect they have on those drafting social legislation. During the New Deal period those framing legislation had to bear in mind the obvious willingness of the Supreme Court to strike it down and the need therefore to make it proof against judicial intervention. More recently they have had to make social legislation CBO proof.

Skocpol's is a trenchant account of the reasons for the failure of Clinton's health reforms. Many of the factors to which she points have to do with the changing American political scene, more particularly the decline in voter participation; the growth of pressure groups that concentrate on single issues and specialised constituencies and which are led by professional advocates; the increased cost of campaigning; and the increased differentiation among politicians in response to these trends. Building coalitions is hard when there is ample room for one group to undercut another and when the prime concern of each group is to press its own narrow negotiating agenda. To compound the problem, Clinton could not roll up the issue with the budget, was reluctant to publicise his plans lest they cost him key votes in the budget struggle, and was then unable to devote as much attention to promoting his health scheme as he might have wished since he had to concentrate on pushing the North Atlantic Free Trade Area through the system.

These factors would not have been crucial in a different polity. Skocpol points to the absence of peak level associations with which a government secure in its parliamentary majority could broker an agreement. She discounts the possibility that an alternative way of formulating the proposals, the appointment of a bipartisan commission to generate them in the first place or, perhaps more acceptable to the President, to review and amend what the task force put forward, would have helped achieve a successful reform. After all a considerable part of Clinton's problem was the presence of alternative proposals in the political arena, some of them sponsored by Democrats, which could be taken up and worked on by the relevant legislative committees.

There appears to have been no sense in the Democratic majority in Congress that, because of their narrow majority, they needed to unite around a proposal, nor was the structure of Congress conducive to such a realisation. "By the early 1990s," Skocpol writes, "Congress had an unusually large number of committees (and subcommittees) claiming health jurisdiction. Each and everyone of those expected to have 'a piece of the action' during 1994, Congress people on those committees and subcommittees wanted to be the ones to make deals and 'concessions' to business and health interests. They wanted to do those as various health bills - not just the President's, but alternatives to it, including many from Democrats - were drafted and redrafted, combined and recombined in the various committees."¹ The chairman of the Senate Finance Committee that had to sign off on enactable action was Daniel Moynihan. He made no secret of his view that Clinton should have tackled welfare reform prior to health reform and no one in Congress seems to have been altogether sure that Senate Finance would act. The Democratic majority had no enthusiasm and its leaders lacked the authority to go for some special omnibus committee. Instead the latter deferred to the Labor and Human Resources Committee and Finance Committee in the Senate and to the Energy and Commerce Committee, the Education and Labor Committee and the Ways and Means Committee in the House for many months as health and care bills made their painstaking way through them.

In Allen Schick's opinion, even this might not have been fatal had the committees been able to manoeuvre their way towards well-compromised bills which had a hope of gaining a majorities in the House and Senate, but it was not easy for them to do this, as Skocpol makes clear, because of the rigid CBO rules. Costing out was a time-consuming process and one that was in the end fatal to one fancied alternative, Jim Cooper's so-called Clinton-lite bill. Because it envisaged market-oriented managed competition without any guarantee of universal coverage it was unacceptable to Clinton; but it allowed business, insurance and health industry interests to signal a continuing interest in health reform despite their reluctance to endorse effective cost controls or the kind of funding needed to ensure universal coverage. When costed out, however, it proved ironically to be more costly to Federal funds than Clinton's supposedly more liberal measure. More serious was the decision of those who favoured single-payer legislation to persist with the Wellstone-McDermott bill, less because they thought it stood a chance, but in the belief that they were in a position to push for more from the President (he was prepared to allow states to go their own way on the question). They did not seem to realise the true position, that they were in fact a necessary part of an inadequate coalition for universal coverage. Another problem identified by Skocpol was the existence of a great many - too many - Senators and Congressmen who thought themselves at least the equal of the President in generating policy and who were pursuing personal agendas of their own. Equally damaging, most Democrats had worked out longstanding relationships with particular constellations of business and advocacy groups on whose support they relied for re-election. One particularly critical example was Congressman Jim Slattery, who was running for governor in Kansas and refused the final vote needed to report out a bill modifying Clinton bill from the House Energy and Commerce Committee lest it offend small business in his state.

The inability of the Democrats to unite around the Clinton bill or any alternative to it meant that all became "grist for protracted bargaining over this or that provision and.... fodder for infinitely complicated legislative manoeuvrings."² Four committees eventually reported out bills, but none had any hope of gaining a majority so new variants continued to be brokered and endlessly discussed. In sum even the groups clustered in and around the Democratic party who favoured some form of universally inclusive reform "pushed and pulled in irreconcilable directions as each group sought to bargain on behalf of its own constituency. Multiple committees and ambitious politicians in Congress gave points of access for the full range of conflicting groups and positions" and the endless manoeuvrings served only to further undermine public understanding of what Clinton was proposing to the point where public opinion turned against the Clinton bill even though an unlabelled counterpart with the same provisions still found public favour. By the time the Republicans came out in all out opposition to Clinton's proposals in July 1994, they had already become an albatross hung around the neck of the Democrats.

In marked contrast the British Government was able to generate and place its reform proposals on to the statute book in 1990 in the teeth of opposition from the medical and nursing professions and without any support from public opinion. Where Clinton's bill was the result of a specially created task force, the British government's policy was the outcome of a review conducted by a ministerial committee, which was chaired by the Prime Minister. Publication of a White Paper, Working for Patients, in January 1989 was followed by the introduction of legislation in November and the NHS and Community Care Act received the Royal Assent in June 1990. However, it was possible to implement much of the reform package by executive action without taking any fresh legislative powers.

This was in fact the second such review conducted by the Thatcher Government, but the earlier examination had led the then Secretary of State, Norman Fowler, to conclude that in terms of containing costs the existing system of finance was more effective than its continental counterparts. When professional and public concern about the financing of the NHS mounted to new heights in the latter part of 1987, Fowler's successor, John Moore, came to the conclusion that major reform was needed. He was reported to have sent briefings to the Prime Minister in mid January and to have met her on the 22nd to urge that there should be a review. Margaret Thatcher's reaction was very cautious, but Moore had an ally in the Chancellor of the Exchequer, Nigel Lawson. The Treasury had come to the conclusion that additional spending on health was inevitable, but it wanted to be sure that it would yield real value for money.

On the night of Sunday 24 January 1988, in the course of a routine meeting to discuss the upcoming budget, Lawson suggested that it was time to launch a review and the Prime Minister appeared to agree. On the following morning she met with Moore and the Chief Secretary to discuss the possibility and that night, in a BBC Panorama interview, she announced that there would be a review. She dismissed the alternative of a Royal Commission on the grounds that it would take too long. Although true - she was looking to come up with an answer by July at the latest - her answer also reflected her belief that Royal Commissions were fruitful territory for vested interests. Nor did she consult either the Cabinet or the relevant Cabinet Committee. The review team was intended to become a Cabinet Committee in its own right, but it was never constituted formally. That did not matter since the relevant departmental minister was throughout fully on side. In addition to the Prime Minister herself, it consisted of Lawson, Major, Moore and the Health Minister, Tony Newton. In attendance also were Sir Roy Griffiths, whose 1983 report had led to management reforms in the NHS, and John O'Sullivan from the Prime Minister's Policy Unit. Detailed work for the review was done by the DHSS, Treasury and Policy Unit. Much material from Conservatively inclined think tanks was fed in via Moore himself and O'Sullivan. Although the review was conducted in private, its existence was widely publicised and precipitated a wide-ranging public debate on possible reforms.

Moore commissioned twelve background papers from his department, including one on the scope for increased charging, which the Treasury was urging. By February the review was concentrating on three main options: Brittan's suggestion that the NHS should be funded through compulsory national insurance (in effect a hypothecated tax) but with the possibility of individuals opting for private insurance cover providing equivalent or greater benefits; American style Health Maintenance Organisations, which were being advocated by David Willetts at the Centre for Policy Studies; and an internal market. By then it was already becoming clear that the DHSS was in difficulties. It could not generate the kind of data about the NHS which the review required, and the Treasury found that they had to do much of the necessary analytical work using a hand-picked team of officials led by Hayden Phillips, on secondment from the Home Office for the purpose.

In March Moore produced an options paper which identified possible reforms to both the finance and structure of the NHS. Mrs Thatcher used two seminars at Chequers, the first consisting of hand-picked doctors, the second health service administrators, to sharpen up the options. The second of these seminars, held on 24 April, had five main proposals in front of it, all of them developed from the options under consideration in February. Moore's next paper in the middle of May brought together the results of this activity and concentrated on two main proposals, an internal market and tax breaks for private health insurance. The ideas were reported to have found a general welcome from the review team, but in fact the Treasury strongly objected to the idea of tax breaks. Lawson concluded a note in July 1988: "If we simply boost demand, for example by tax concessions to the private sector, without improving supply, the result would not be so much a growth in private health care, but higher prices. The key is the supply side, as we have recognised in other areas of policy." He was fearful also that pay increases in the private sector would spread to staff costs in the National Health Service "and we would end up getting less value for money."³ Mrs Thatcher was insistent and Lawson compromised: he would concede tax breaks to the over 60s. Had he known Clarke was about to be appointed Secretary of State, he has since confessed, he would not have conceded any ground on the issue.

Since the Treasury had already ruled out any form of hypothecation, it is not altogether surprising that the Prime Minister began to suspect a Treasury/DHSS plot to rule out radical change. Even so, it was her decision that the review should concentrate on structure and she determined to bring a fresh Secretary of State into play by splitting the DHSS and relegating Moore to run Social Security. Clarke was appointed to run the Department of Health with David Mellor as his Minister of State.

The new team was undoubtedly less to Mrs Thatcher's ideological taste, but Clarke had already shown his calibre as Health Minister and he brought a practical mind to bear on the question of how best to change the dynamics of the existing system. He was more than ready to endorse the idea of the purchaser/provider split which was central to the idea of an internal market, but he gave it a new and more radical twist by insisting that GP budgetholders should be at the cutting edge of purchasing. Although he seems to have come to this idea quite independently, it was not new and already had support inside the No 10 Policy Unit. In her wish for some radical shift, Mrs Thatcher embraced the idea. The Treasury was less than enthusiastic. The Chancellor, who had always wanted the review to concentrate only on the hospital sector, was doubtful whether GPs could manage budgets and suspected that they were creating a brand new lobby for health spending. But the idea fitted in well with the notion of giving the consumer choice and the Treasury's objections were overruled.

Clarke recalls "seven or eight meetings at which the Prime Minister, the Chancellor, John Major and I met, with Richard Wilson [then deputy Secretary in the cabinet office] keeping a note. There were ferocious debates over the detail of the reforms and they were hacked out in considerable detail, much of which later found its way into a series of government papers. It was high temperature stuff at the time, not always pleasant, but very enjoyable in retrospect. At the end of the process, full Cabinet was a doddle, Margaret and Nigel trundling things through for me."⁴

In their evidence to the review the BMA had made clear their dislike of change. They were genuinely concerned that moves to an internal market would destroy the delicate web of assumptions, loyalties and relationships which had built up since the inception of the NHS, but their major concern was the way they had been marginalised in the review process. Hitherto they had been central to policy-making and had enjoyed what amounted to a veto on proposals that they did not like. They were also conscious of the shift in power in the NHS, away from themselves towards the new breed of general manager, and deeply disliked what was happening. However, Clarke could point out, not unfairly, that few of them wanted to take on managerial jobs. There were also material concerns, which were not part of the review but were part of the background to their response. They were angry that the Thatcher Government was interfering in the work of the Pay Review Bodies and questioning long-standing practices over merit awards for consultants. They disliked performance-related pay and the proposal that the new hospital trusts would take over the employment of consultants. However, where they idealised the divorce between their professional obligations and finance supposedly achieved by the NHS, Clarke was well aware of the competition between consultants which was the norm and cynical, perhaps overly so, about the medical profession's concern for its wallet. When he made a light-hearted reference to this at the annual dinner of the Royal College of General Practitioners, the anger was intense.

Academic observers like Rudolf Klein found the medical profession's opposition to the changes out of all proportion to what was actually proposed, but many of the profession convinced themselves that the service was about to be commercialised: some undoubtedly saw the changes as the thin end of the wedge with privatisation not far behind. The Joint Consultants Committee expressed their alarm at an all day meeting on 28 February 1989, while the consultations with their members undertaken by the BMA culminated in a Council decision at the beginning of March to "take steps to inform the public, press and Parliament of its serious concern at the consequences that many of the proposals will have for the health of the nation."⁵ The first blast in what was to prove a controversial campaign was the despatch of a leaflet, "SOS for the NHS", for use in all GP practices. The public were already deeply suspicious of the changes. A week after publication of the White Paper only 30% believed that the changes would improve the service and that figure had fallen to just over 10% in late March. There were early protests from Conservative MPs about the morality of seeking to involve patients in the campaign which found considerable echo amongst GPs, but special representative meetings of the BMA endorsed the line the Council was taking. Aligning themselves with the Labour opposition to the reforms, it ran a massive advertising campaign against the Government. Clarke was accused of wanting to introduce a new spirit of competition into the NHS, the health of the patient versus the cost of the treatment, and Mrs Thatcher was pictured as a road roller with the caption, "Don't let her steamroller the White paper through. Write to your MP today." The last in the series was the most striking: "What do you call a man who ignores medical advice?" The answer was "Mr Clarke". Not only the Conservative press but the Independent also took the BMA to task for this personalised assault, but Clarke had the last word. Quoting the question at the Conservative Conference in October, he gave his own reply, "Healthy".

By now there were murmurings inside the BMA that they were going a bridge too far. The Government was engaged in rolling out the reforms and those professionally engaged in the NHS were having to respond. A great many hospitals were seeking self-governing status, although a large number were doing so without the support of their medical staff. Perhaps as many as a quarter of the GPs were expressing interest in having their own budgets. Since non-cooperation was the only strategy open to the medical profession if the Government was prepared to defy public opinion, this sort of response a major threat to the BMA's campaign. It might complain of pressure and black propaganda - it could certainly point to considerable doubts and fears - but nothing could stop the drift towards collaboration. If there was some degree of opportunism involved, there was also a growing sense that Clarke would not rush hospitals into self-governing status before they were ready. There were clear indications from the Department that what he had in mind was not outright competition but a managed market. However, more provocatively, they were accompanied by an announcement that the support of hospital staff was not necessary for a hospital to become self-governing.

When the BMA came together for their annual meeting, they endorsed the continuing campaign. Its leaders could take comfort from commissioned Gallup polls which showed that 75% of those polled thought the reforms would result in cuts in services and end in the privatisation of the NHS. Fewer (65%) thought that the service was not safe in Conservative hands but this included about a third of those claiming to be Conservative voters. The BMA's Chairman, John Marks, was sure that they were winning the propaganda war and had "got it right politically". To signal that there would be no change of course, he was invited to stay on for an extra year as chairman.

However, the initiative was still with Clarke and not all that he was doing was unpopular. He had persuaded Mrs. Thatcher to accept the Griffiths Report on community care, including the unpalatable recommendation, that the task should be given to local authorities - no purchaser/provider split here. When 82% of GPs rejected the new contract that had been negotiated with their representatives, Clarke simply imposed it, As both he and the GP's Chairman, Michael Wilson, expected, the move was not countered by mass resignations. The great majority of those engaged in general management within the NHS was now working towards the implementation of the proposals for self-governing hospitals. Even among the consultants, despite strenuous efforts by their leaders to keep them in line, a significant minority was ready to endorse the changes. When the National Health Service and Community Care Bill was introduced on 22 November, Clarke's speech was notable for the way in which he softened the language in which the reforms were pictured. He had not given an inch on substance. Nor was he forced to do so in the debates which followed. 900 amendments were tabled, but the Government majority on the standing committee, which considered the Bill, held firm. By the end of February, when the last clauses were approved, Clarke was sufficiently confident of the outcome to risk the bold claim that both the Opposition and those in the NHS really favoured what he was doing. Although public support for the reforms had now fallen to 11%, the leaders of the health service organisations began to sense defeat. Their best hope was to slow the introduction of the reforms in the hope that Labour's spokesman meant what he said when he promised to abolish the internal market and return local hospitals to DHA control. The course chosen was to suggest piloting the reforms in two regions and to back this with a lobby of the House of Lords. The latter was designed to win support in the second chamber for amendments based on their new policy document Way Forward for the NHS.

By April, it was clear that this strategy too had failed. Although Clarke conceded - perhaps in the hope of dividing the consultants from the BMA - a monitoring body, the Clinical Standards Advisory Group, whose task it was to ensure that the reforms did not damage patient care, he could now concentrate on implementing his proposals. Successive tranches of hospitals were to move to Trust status. Fundholding was proving increasingly popular with GPs, although their ability to secure speedier service for their patients led to Opposition charges that Clarke was building a two- tier service. To that he had an obvious counter: the best way to avoid that was for every GP to volunteer for budget-holding status. As Marks's successor as chairman of the BMA, Jeremy Lee Potter, concedes, trading blow for blow with Clarke had won his predecessor the argument, but had "lost the battle, because the only remaining weapon the doctors had was the nuclear one of resignation from the NHS, and they were not going to use that."⁶ The profession had to return to the negotiating table therefore and, ironically, they profited by doing so. It helped perhaps that they were no longer dealing with Clarke, but with his successor, William Waldegrave. Whatever the reasons, they were clearly able to do much to modify and adapt the proposals in what had now become "an institution which would invent its own future in a process of trial and error."⁷

What this analysis brings out is that the effective debate about the reforms in Britain was confined entirely to the ministerial committee, that the Treasury exercised considerable, although not absolute, veto power and that once the ministerial team was agreed, there was nothing else in the British system to stop them. The BMA could have forced the Government to modify its proposals only by convincing Conservative backbenchers that to persist with the proposals was electoral suicide. Although a number were doubtful about the reforms and at least one bye-election went against the Government as a result of the BMA campaign, the Government's majority was too large and the Conservative party too disciplined for the strategy to have any hope of success. There was only body who might have slowed the process, the second Chamber, but to the intense disappointment of the BMA, substantial majorities in the Lords gave the NHS Act a fair wind. Little or nothing of what was being legislated could fairly claim an electoral mandate, hence the hopes of the BMA that they might interfere, but the whole debate had become too partisan for the House of Lords to stand in the Government's way.

The contrast between the outcome of health reform in Britain and the United States underlines the extent to which political institutions and conventions determine the capacity of governments to act effectively. In the light of this failure to secure health reform, not by any means the first, and other similar examples of gridlock, it is small wonder that some students of the American system of government have come to the conclusion that it is just not up to the job.⁸

Richard Rose comes to that conclusion from a slightly different angle. "Politics", he writes, "is about the representation of conflicting demands; government is about resolving these conflicts authoritatively and to a nation's benefit. In principle, the two activities should be complementary. In practice, politics and government can be in opposition, for what people want or what interests demand may not be what government can (or should) provide."⁹ In comparative perspective, "the American system stands out because it maximizes politics. The institutions of government incorporate the representation of popular demands into the very structure of governance" and Rose suggests that "a President is almost a bystander in a system of government that so values the representation of particular demands that it provides hardly any institutions to make collective decisions."¹⁰

What matters is not just the subdivision of legal authority nor the operation of checks and balances which subdivide political authority, but the emergence of sub-governments which engross political power and whose tentacles extend throughout the federal system. The political journalist, Douglas Cater, was the first to coin the term to characterise the way in which, in "one important area of policy after another, substantial efforts to exercise power are waged by alliances cutting across the two branches of government and including key operatives from outside. In effect, they constitute subgovernments of Washington comprising the expert, the interested and the engaged." They "are not to be confused with factions. Within them, factions contend to greater or lesser degree. The power balance may be in stable or highly unstable equilibrium. But the subgovernment's tendency is to strive to become self-sustaining in control of power in its own sphere."¹¹ Particular policies are made by a process of partisan mutual adjustment. This may be entirely satisfactory where a large number of small-scale decisions have to be made, but, as Rose notes, where sub-governments dominate, "there can be no expression of the collective will of government. Major policies are likely to emerge gradually as the unintended byproduct of many separate decisions taken by interested parties comprising different subgovernments."¹²

There is also, as we have seen with health reform, the danger of gridlock. Elaborate legislative procedures in both houses, each of which has to pass a bill in identical terms, "have become so well developed", that in the judgment of Guy Peters, "it is difficult for legislation to be passed. Typically, a bill must be passed by a subcommittee, a full committee, and by floor action in each house.... conference committees will be necessary to reconcile the two versions. Given the possibility of using more arcane procedural mechanisms such as filibusters, amendments, and recommittals, legislation can be slowed down or killed at a number of points by failing to attract the necessary majority at the proper time. Or, to put it the other way round, all that the opponents of a bill have to do is to muster a majority at one crucial point to prevent the passage of legislation."¹³

When White House officials seek to put pressure upon a particular subgovernment, they quickly learn why they are dubbed "iron triangles". There is strong resistance by all participants to any attempt by the White House to interfere. Since neither Congress nor independently-minded bureau chiefs can be ordered around, the White House is reduced to pressure politics and the deployment of public opinion. The President, as "the one officeholder.... concerned with government, that is, linking concerns divided up among many subgovernments or left out of their calculus altogether",¹⁴ faces a major problem: in marked contrast to the resources available to a Prime Minister in a Parliamentary system of government, there is no collective authority to hand ready for his use. The people whom he can most readily command, those in the White House, do not have their hands on the operating agencies of government.

It is difficult for outsiders to understand this. Surely, they might argue, the political patronage involved in the "spoils system" will give the President control of the bureaucracy. In practice, however, the relationship is one of "institutional estrangement".¹⁵ Many of the Presidential appointees as they get to grips with their work inevitably come to terms with the officials already in place and learn to look to their clients and to the congressional committees which appropriate monies for their programmes. Others remain zealous, but inexpert passengers, who serve simply to block effective communication between the White House and the departmental experts. Yet others become frustrated, not least at their lack of contact with the White House, and resign. The turnover of appointees at a rate of nearly half each year reduces the administration's already limited cohesion and effectiveness.

Even at Cabinet level, the bulk of a President's appointees are best seen as no more than intermittent allies. The most that a President can hope is that they will keep out of trouble and stay loyal. But their interests are not his. They are not looking for promotion within the administration, but to their own reputation, or, worse still, "a ticket to the greater rewards available in the private sector".¹⁶ It is scarcely surprising that many go native. Those in the inner Cabinet - State, Treasury and Defence - are in a different position. They deal with matters of high priority to the White House. They may be rewarded by being given the lead on matters of major White House concern, but they can be undercut if a President comes to believe that the issues that they deal with are too important to be left in their hands. At State and Defence they have to compete in any case with the National Security Staff. The Secretary of the Treasury is in rather better case, while the Attorney General's main problem is that he is usually consulted only after the President has got into a tangle, which lawyers are then required to justify.¹⁷

If this somewhat jaundiced analysis is correct, it follows that the President is not really a chief executive, but a chief - a chief in the sense that he is the leader of a small group kept together by personal loyalty. They are attempting to take over the government of the United States and in doing so they may well find that even the Executive Office of the President has to be persuaded to follow their lead.¹⁸ The task of the President, therefore, is "to create government, that is, to discover how to use powers and institutions at hand in ways that increase his collective authority". While he is learning how to do so, the likelihood is that the willingness of other powerholders in Washington to cooperate with him is decreasing. Neustadt reckons that it takes some two years for the Oval Office to learn how government works and how the White House can direct it to secure the President's ends. In the third year the President is best able to govern since his fourth year will be spent campaigning for re-election. If successful, he will have another two years in which he is personally effective. He will then be relegated gradually to the status of a lame duck.¹⁹ If Neustadt is right, in the 55 years since Roosevelt's death, Presidents have only been fully on top of their job for just over a third of the time. It is little wonder perhaps that Presidents are tempted by the thought of "going international" The issues are of supreme importance and increasingly subsume large parts of the domestic scene; his powers are greater than in domestic affairs; and dealing with world leaders seems a welcome contrast to the wheeling and dealing involved in securing Congressional votes.²⁰

Rose argues that the major difference in parliamentary systems is that government is already present, organised and capable of collective action. The task of an incoming Prime Minister is to give it a sense of direction. In part, so far as Britain is concerned, that job will already have been done. The civil service will not only take note of the manifesto on which the winning party has won the election but will have already done some preliminary work on how it might best be implemented. The main advantage of the system, as Rose sees it, is the existence of the Cabinet as the central mechanism in Parliamentary government. Like its American counterpart it is composed of the heads of the principal government departments, but there the similarity ends. It is the Cabinet, not the Prime Minister, which is responsible collectively for the activities of government.

Why does Rose think this important? In his eyes the sheer range of government activities in Europe might have been expected to make departmentally based subgovernment more of an obstacle to collective authority than it is in the United States. Nor is the position wildly different so far as pressure groups are concerned. They are "neither ignored nor are their wishes necessarily frustrated. Ministers are politicians who wish to be popular and, partisan values aside, they would rather say yes than no to a claimant group. Moreover, on both sides of the Atlantic, civil servants know that it is much easier to administer policies if, within limits, they are adapted to meet the particular concerns of affected groups.... In short, Cabinet government incorporates many sub-governments." Rose also notes that MPs, although less influential individually than congressmen, can be vocal advocates for particular interests and ministers are not precluded from taking a whole mass of decisions within their particular bailiwick. But, as members of the Cabinet, ministers are constrained to look at a broader picture and they take their cue from the Cabinet. Wherever money is involved - and very few policies do not involve money - ministerial decisions have to be cleared with the Finance Ministry and if there are conflicts with other departments, they are resolved in Cabinet. Despite Rose, it is not strictly true that ministers derive their authority to act departmentally from the Cabinet, but it is certainly true that the existence of the Cabinet provides "a single collective authority to reconcile disparate demands. Cabinet deliberations bring politics into the center of government.... The authority of Cabinet does not eliminate politics; instead, the Cabinet permits the fusion of government and politics."²¹

Of course, the Cabinet is more than a mechanism. "A common bond of collective political interest is the force that gives a Cabinet the effective authority to make binding decisions reconciling diverse political demands." Party is the central force behind Cabinet government and party discipline is what it enables Cabinet to be sure that Parliament will endorse its actions and decisions. In fact what Rose pits against Presidential government, American-style, is less parliamentary than party government. Inevitably he postulates it as an ideal type in the full knowledge that there are likely to be departures from the model in every particular case, and that these are more likely to restrict the government's authority than not. Nevertheless, he believes the juxtaposition between the two systems to have much explanatory force, and, in the light of the very different outcome of the attempts at health reform in Britain and the United States, it would be difficult to deny his claim considerable validity.

Faced with division and deadlock in the American system, it is not surprising that a number of political scientists have concluded that Presidentialism is not a good model for modern government. Even in the United States questions about the collective capacity, responsibility and accountability of the federal government have fuelled an ongoing reform agenda. However, it is only fair to add that there is still a vigorous academic debate about the "perils of presidentialism". Further, a number of those, like Sartori, who accept the weaknesses of pure presidentialism are inclined to make a strong case that the semi-Presidential system (or premier-presidentialism, as Shugart and Carey term it), addresses those weaknesses successfully.

What should give us pause also is "the Janus-faced nature" of parliamentarianism. Not all Parliamentary democracies offer a picture of stable and effective government. Fourth Republic France, for example, had no less than 24 governments between 1945 and 1958. Their average life was no more than six months. De Gaulle put an end to this with a set of institutional reforms, which were not only successful in themselves but suggest strongly that institutional structures contribute decisively to the stability and effectiveness of governments. Italy continued to afford a similar picture of instability for another third of a century. Between 1945 and 1994, by which time the underpinning party system was in a state of terminal decline, there were no less than 47 governments. They lasted a year on average in the period 1945 to 1970 and thereafter for about four fifths of a year. There was admittedly rather more stability of personnel. Nevertheless, as Pasquino notes, "Italian coalition governments have usually been rather weak, divided along party and factional lines, often litigious, frequently caretaker minority governments. Their ability to govern, that is to make choices and implement decisions, has generally been restricted to the phase of their inauguration. Most of the duration of the parliamentary mandate has been wasted in internal bickering and jockeying for electoral position."²² Percy Allum suggests that this is the result not of coalition government as such, but of the numbers of parties involved.

It was undoubtedly this kind of reflection that led the Italians in their turn to undertake reform. In the conviction that political instability was the outcome of a wholly proportional electoral system Italian voted for a move towards the first past the post system as it operates in Britain. Three quarters of the members of both Houses of Parliament are elected on the basis of one-ballot single member constituencies, with the remaining quarter continuing to be chosen nationally by proportional representation. A four per cent threshold was set for elections to the Lower House, the Chamber of Deputies. There was a widespread expectation that three "poles" would dominate the new parliament elected in 1994, but in the event it was dominated by the right wing "Freedom Pole", an electoral cartel that united the television magnate, Silvio Berlusconi's new Forza Italia party with the Northern League and National Alliance. The centre was badly squeezed and polled only 15%. Given the contradictory nature of the ideology and interests of Berlusconi's main allies - the National Alliance is southern-based - the right wing government did not look all that stable and it collapsed when Berlusconi was indicted for corruption. A government of technocrats headed by Lamberto Dini lasted twelve months. However, it was then evident that fresh elections were required and in April 1996 the left-wing Olive Tree alliance led by Prodi's Democratic Party of the Left emerged as the new government, although they required support from the Communist Refoundation to win a vote of confidence.

It is tempting at this point to draw a line and to agree with those who see in responsible party government the best chance of combining responsiveness to the wishes of the electorate with political stability. However, that would leave us with a fairly major question unanswered, why coalitions, which, following Bryce, most Anglo-Saxons see as weak, unstable and inefficient, are the norm in Europe, and proportional representation the dominant form of election system?

In fact, it is far from clear that coalition governments can be seen as inevitably weak and unstable. In Germany, for example, in the last thirty years the political system has generated an SDP/FDP coalition that lasted from 1969 until October 1982, a CDU/CSU/FDP government which held office from that date until October 1998, and an SDP/Green coalition that, despite an initially bumpy ride, has already lasted two years. Coalitions are clearly able to produce stable and effective government. While Germany is the best, it is arguably not the only significant example. In fact, as we shall see, there are distinguished political scientists who dismiss all forms of majoritarian government, whether Presidential or Parliamentary as less satisfactory than that obtaining in what they describe as "consensus democracies".²³ These are questions, therefore, which merit further examination. But there is one other substantial qualification to Rose's argument, which needs to be dealt with immediately.

The generation of effective policy changes may not be all that is willed by those who frame a constitution. Indeed, it can be argued that the American constitution was "designed to counter ambition with ambition and to inhibit tyranny."²⁴ In Britain Lord Hailsham was far from alone in worrying about the consequences of the "elective dictatorship" which results when the powers of Crown and Parliament are united under a strong administration.²⁵ Since he wrote the Courts have become more of a check on British government, although their activities in this role are less substantial than the picture presented in many accounts of the British system. Incorporation of the European Charter of Human Rights and the increased scope of the European Court of Justice are likely to further strengthen the role of the judiciary. In marked contrast, although its formal powers are still intact, the part played by the Commons in influencing the government and holding it to account has clearly diminished in recent years. The same can be said about the other element of representative democracy in the system, local government. Although the Blair administration has devolved considerable powers to the Scottish Parliament and, to a lesser extent, the Welsh Assembly, its grip on England remains strong. The drive to erode the role of local government, which began under Mrs Thatcher has continued, although it sits somewhat uneasily alongside measures to modernise local government and make it more responsive to local opinion. The only measure, which in any sense runs counter to the trend, the creation of an elected mayor for London, also embodies substantial constraints on his power. More serious still is the growing impatience with the Parliamentary process displayed by the Blair Government. Mrs Thatcher may not have attended the Commons quite as much as her predecessors, but she respected its constitutional role. In marked contrast, influenced perhaps by his belief in inclusive politics, Blair seems tempted by plebiscitary notions of democracy and there is a real danger that the modernisation of the British Parliament may also involve its emasculation. Strong government may not always be good government.

But a cry for limited government is not to be confused with a call for ineffective government. Nor is effective government to be confused with activist government. There may be some force in the contention that we favour efficient government because we think it will govern well, but it would be wrong to think that inefficiency is the best or only safeguard against bad government. Inefficient government is perfectly capable of doing harm through failure to act where action is necessary, by sheer inadvertence and by the misallocation of resources. An effective government has the capacity to implement the policies it pursues, but it may choose to remain inactive or to withdraw from activities that governments have hitherto pursued. In marked contrast an impotent or inefficient government may be unable to accomplish what it wants to do. An effective government may be able to undo or dismantle what has hitherto been done, whereas an activist government is prone to think that there is no problem, which it cannot solve. Effectiveness in government is therefore a question of structural capabilities. "Performances depend on performers", Sartori observes, but "performers need structures that allow them to perform. So, we cannot get decisive government without a decisive prime minister; but even a decisive prime minister cannot be decisive if the decision-making machinery is clogged and works against him."²⁶

However, before we can settle what institutional configurations may provide effective government, it is clearly necessary to establish what constitutes effectiveness.