In May 2010 the Conservatives and Liberal Democrats agreed, and then published, a coalition agreement as the bedrock of their governing programme. The health section included the pledge, ‘We will stop the top-down reorganisations of the NHS that have got in the way of patient care.’ It also stated: ‘We will ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local primary care trust’ and went on to describe in detail how the new PCTs would work as a champion for patients and commissioners of NHS services.
By July, the government announced that, far from being patient champions, the PCTs will be abolished, as part of the biggest top-down reorganisation of the NHS for a decade. Seventy billion of the NHS budget will be handed over to GPs to commission treatment from healthcare providers, including private suppliers. So what happened between May and July?
It seems likely that Andrew Lansley had a clear idea of the health service reforms he wanted, and felt in no way bound by the terms of the coalition agreement. If the Liberal Democrats put up a fight to defend elected PCTs, it is obvious they were walked all over by their Tory masters in the coalition. On health, as on so much else, it is clear that the Tories are calling the shots, and the Liberal Democrats are merely providing political cover for hard-right policies.
There is an obvious bear-trap set for Labour. The danger is that Labour is seen to be opposing any reform of the NHS, as though it was a perfect institution. The changing health needs of the population and the rapid evolution in medical technology and pharmaceuticals mean that the NHS cannot stand still. The NHS still fails the poorest communities. It was Labour’s bold reforms to the NHS, such as foundation hospitals and independent sector treatment centres, which delivered low waiting lists and fast treatment for cancer and heart disease.
More NHS hospitals than ever were delivered thanks to the private finance initiative. If we pretend the way to improve the NHS is to pour money in, without reforms which increase productivity and performance, then we fail to understand our own record in government. Investment and reform went hand in hand. Indeed, when the foot was taken off the accelerator of NHS reform after 2007 it contributed to the sense of drift and sclerosis which lost Labour so many votes in May 2010. It was a missed opportunity that Labour in government never introduced bottom-up democratic accountability into the NHS. Elected members of PCTs, alongside local councillors, could have been a welcome addition to the shape of the NHS. It was proposed, and vetoed, by No 10.
Labour’s health policy will have to be based on the NHS that we will inherit in 2015 or 2020, which will be radically different from the NHS today. Would an incoming Labour secretary of state want to reinstate PCTs? It will depend on the success of GP-led commissioning. It may be that the new system works, and, if so, Labour’s approach should be one of amelioration, not further structural reform. Addressing the democratic deficit in the NHS should be a priority for future Labour policy. One solution might be a greater role for elected mayors in the strategic direction of the local NHS, particularly public health. Whatever our NHS ‘offer’ is in 2015, it can’t be based on harking back to the good old days, or promising to spend even more money.
Yes, Labour will need to consider it’s opposition to the NHS at the time of the next election on the basis of the evidence. Yes, local elected mayors would be one way of bridging the democratic deficit in the NHS,especially around public health issues susceptible to the influence of community based cultural norms and expectations (e.g. nutrition, exercise, smoking, and drinking) . But the question still remains as to whether GP-commissioning will, or can, enable genuine bottom-up accountability in the health service over the next five years. Is choice of GP and/or GP consortia sufficient to force the system into being responsive to patient’s needs? To what extent does it allow patients to work with health professionals to achieve better outcomes (at lower cost)? Where does GP commissioning lead where PCTs and SHAs have struggled before? These are the questions that can guide Labour in opposition, before it takes a measured view of the success or failure of the system and can respond credibly and constructively accordingly.
Agree that ‘opposing reform’ is a trap. However I also think it’s a trap to suggest that reform = more markets and independent sector (that’s where the Tories have ended up, despite the rhetoric). ISTCs have contributed, through increased capacity and some contestability, but they don’t do many cancer or heart operations (which you rightly cite as major achievements). Progress in these areas were mostly driven by clear targets, service coordination and local redesign. I’d also be interested in your evidence that the Brown years were when Labour lost the public’s confidence on healthcare. It would appear that Labour scored the worst – ever – on NHS in 2006. http://www.ipsos-mori.com/researchpublications/researcharchive/poll.aspx?oItemID=26&view=wide