It’s a problem familiar to millions: the trials of trying to book a doctor’s appointment. Last week, suffering from a debilitating condition but not an emergency, I called the GP surgery to get it checked out. There were no slots available for that day. Nor could I book an appointment for beyond that day. Trying online, the best I was offered was a telephone call two weeks away. Online slots are so precious that by the time you choose one and input your details, it has already been taken. I eventually ended up in A&E, and thankfully everything turned out fine (fine enough, at least, for me to be able to write this column). It’s a common tale, and one that millions endure every day. There are many reasons, not least the pressures imposed by Covid and lockdowns on the post-pandemic world and, perhaps most importantly, the shortage of medical staff. In the NHS as a whole, there are more than 132,000 vacant posts – almost 10% of its planned workforce. Among GPs, with a planned, fully qualified workforce of almost 30,000, there are more than 1,800 vacancies. And it’s the most deprived areas that are most lacking in GPs. Beyond such proximate causes, however, there lies a deeper reason, too, and one that shapes not just the difficulties in accessing health services but also many contemporary problems, from the rail chaos to the failure to mitigate the impact of soaring energy costs. All are, at least partly, the product of the changing nature of the state. Political analysts have been talking for more than three decades about the shift from the “positive” or “command” state, which was employed in the immediate postwar decades, to the “regulatory state” that slowly came into being from the 1980s. Where the postwar state directly intervened to secure what were seen as desired social and economic outcomes – from creating the National Health Service to the nationalisation of key industries, from railways to coal – the post-Margaret Thatcher regulatory state viewed desired outcomes as best shaped by the market and saw the role of the state less as providing services than in regulating the market and in “steering” it towards desirable outcomes. A state that made rules rather than material interventions. A state that outsourced its capacity to get things done to the market and to non-governmental organisations, whether private or public. Over time, the process of regulation itself has been removed from the direct ambit of the government through the creation of independent quangos to provide the “steering”, from Ofgem to the Low Pay Commission. In his 1997 book The Audit Society, accountant and economist Michael Power argued that Britain was becoming a nation more concerned with monitoring services than with their actual improvement. “Rituals of regulatory verification,” he argued, served as “empty assurances” for a public that had become distrustful of the judgment of professionals. It is a process that has deepened over the past quarter of a century. The regulatory state has actually led to looser regulation and less capacity to achieve socially desirable outcomes. We can see this most dramatically, and tragically, in the 2017 Grenfell Tower fire. The inquiry into the fire has exposed the degree to which private companies not only rode roughshod over government regulations but also the degree to which regulators often colluded with the rule-breakers or at least turned a blind eye to their activities. The rise of the regulatory state has also made it more difficult for government to institute long-term planning, whether in relation to pandemics, energy security or resilience against droughts. At the same time, the outsourcing of government functions, and its reluctance to intervene directly, has undermined its capacity to respond to crises, leading, for instance, to the current paralysis over soaring energy costs, a paralysis that goes far beyond simply the chasm in governance created by the Tory leadership campaign. The regulatory state has also created organisational incoherence and fragmentation. We can see this in the railways, the water industry and the energy sector. Perhaps most perniciously, we can see it in the NHS. The establishment of the “internal market”, the division between “commissioners” and “providers” and the setting up of a multitude of semi-autonomous organisations has all helped to create, in the words of one study, “a highly complex bureaucratic structure, in which responsibility is so widely dispersed that accountability is virtually impossible” and in which even those charged with its administration struggle to identify “exactly who is responsible for healthcare planning”. But, more than that, in the age of austerity, mechanisms of regulation have become the means less of ensuring good services than of restricting access to impoverished ones. That is why the process of booking a doctor’s appointment seems designed to be as difficult as possible in order to limit access to a diminishing resource. Free market policies and the entrenchment of the regulatory state are often celebrated as enabling greater democracy, enhancing choice and empowering the ordinary citizen. What they have really done is place market efficiency and the conditions for profitability above social need. They have also been used in an attempt to insulate public institutions from democratic pressures. That is why the rise of the regulatory state has gone, hand in hand, with assaults on trade unions and the greater atomisation of society. As early as 1975, the Trilateral Commission, an elite non-governmental organisation set up two years earlier by David Rockefeller and Zbigniew Brzezinski, whose aim was to shape global governance, had warned in a report, entitled The Crisis of Democracy, that a problem such as inflation is “exacerbated by a democratic politics”. This is because the idea that “government should be responsive to the people creates the expectation that government should meet the needs and correct the evils affecting particular groups in society” and makes it impossible “to curtail spending, increase taxes and control prices and wages”. The “crisis of democracy”, in other words, was that there was too much of it. It was necessary to shield the state from democratic pressures and to squash the expectation that the role of the government was to “meet the needs and correct the evils” afflicting citizens. The structures of the regulatory state have sought to do just that. And, in so doing, they have turned as mundane a task as making an appointment with your doctor into a tortuous trial while allowing something as monstrous as the energy price rise to hit us without any serious forward planning to mitigate its impact.