Public satisfaction with the NHS has never been higher, so says the latest annual British Social Attitudes Survey. It seems New Labour worked after all. Our investment in all those extra doctors and nurses and new buildings and equipment changed the NHS for the better. But it is our reforms which really transformed patients’ experience. Waiting times for hospital surgery fell from 18 months to just 18 weeks. If you have suspected cancer you now get seen by a specialist within a fortnight. Deaths from cancer and heart disease have fallen dramatically. Today’s NHS is not without problems but the New Labour formula of resources plus reforms delivered unprecedented progress.
An odd time, then, for the coalition government to be embarking on its self-proclaimed NHS revolution. Labour’s shadow health secretary, John Healey, cleverly calls it a solution in search of a problem. The politics of the changes mystify me. David Cameron’s project was supposedly about decontaminating the Conservative brand. Playing safe on the NHS was central to that strategy. By bigging up its reforms, the government conflates precisely the four words it was trying to avoid – cuts, privatisation, health and Tory. Even here there is confusion. At the outset the reforms were dubbed a radical departure from all that had gone before. More recently they’ve been repositioned as following in the footsteps of my time as health secretary and Tony Blair’s time as prime minister. It can be either revolution or evolution, but it can’t be both.
There are elements of the reforms which I recognise and think Labour should support. Others are bad for NHS patients and should be opposed.
Giving local services greater freedom through NHS Foundation Trusts was a bitter internal battle during Labour’s time in government. Today they are the most efficient and highest quality NHS hospitals so it’s a good idea to rapidly make them universal. What is a bad idea is to let hospitals off the accountability hook by abolishing the national standards and targets that drove better clinical outcomes and lower waiting times during the last decade.
Of course, cutting waste and bureaucracy is a good idea but it is a bad idea to assume that NHS structural change saves cash – at least in the short term – rather than costing it. Abolishing PCTs and creating many more GP consortia to replace them hardly sounds like a recipe for cutting bureaucracy. And there is a chasm between the cost of making change – £1.4 billion – and the cash available for it. The NHS budget will grow by just 0.1 per cent in the next few years compared to 7.5 per cent growth in New Labour’s prime. In reality it’s worse than that. With demand rising and £1 billion of NHS cash being shifted into social care the NHS budget will fall not rise. The NHS has to make £20 billion efficiency savings to make ends meet. Structural change can only distract the NHS from doing so.
Similarly, it’s a good idea to get politicians out of day-to-day NHS management, but it’s a bad idea to move power sideways to a national commissioning board when it should be moved downwards to where health decisions are actually taken, in local services serving local communities. Labour should be making that argument forcibly, not least because the health bill gives the new board far-reaching powers over the GP consortia that were supposed to be the kingpins of these reforms.
Finding ways to get family doctors to own the financial consequences of their prescribing, treating and referring decisions is a good idea. But it’s a bad idea to assume that GPs can easily do the complex business of commissioning local services – and in the process weaken public accountability over £80 billion of public money. Ironically, the original coalition agreement proposed a bigger role for local authorities in commissioning health services, a policy that at a stroke would have improved local accountability over the NHS and bridged the divide between health and social care. Labour should resurrect and champion that idea.
Then there is the move to an any-willing-provider policy which promotes open competition in the NHS. When I first introduced private sector providers into the NHS, some in the labour movement said it would be the end of the health service as we have known it. In fact it strengthened the NHS. One recent study concluded that in those areas where new providers were brought in to provide local NHS services waiting times and death rates both fell faster than where they weren’t. Labour should be far more assertive in arguing that monopolies in any walk of life – public or private – rarely deliver either operational efficiency or customer responsiveness. There should be no preferred providers, whether public, private or voluntary. Quality is what counts for patients. Efficiency is what counts for taxpayers. Labour should promote a legal level playing field based solely on the interests of patients, not providers. But that requires proper planning, not a free-for-all. Market mechanisms can work in healthcare but only when properly managed and regulated. So while it is a good idea to extend competition in the NHS it is a bad idea to allow it to fragment local services or to be on the basis of price rather than quality.
There are enough nitty-gritty policy issues for Labour to get its teeth into here. The bigger question we should be posing is whether this sort of structural change can possibly meet the challenge the NHS faces from an explosion in chronic diseases like diabetes and obesity. That calls for policies that integrate services – between primary and hospital and health and social care – rather than fragment them. It suggests a bigger focus on prevention, not just treatment. Above all else, it argues for patients being empowered to take greater charge and have more responsibility for their own health. This is the future health policy agenda. Labour should own it.
Opposition to change is always easy. But Labour needs to be clear about what we stand for, not just against. It would be unwise in my view for Labour’s stance on the government’s proposals to suggest we are conceding rather than contesting the reform territory. That might be comfortable for now. But it fails to answer the question voters are bound to ask later – so, what do you stand for? The government’s changes provide an opportunity for Labour to earn its spurs as a sensible and credible opposition. More importantly they allow us to restake our claim to be the party of progressive radical reform. It is only when we are that we win.
Very interesting to read Alan’s views on this most dangerous piece of legislation. On his conclusion and his advice for the Shadow Team I am in complete agreement. We absolutely need to be very clear about our challenge to the Health & Social Care Bill for the public will not understand anything else, either personally or then electorally. However I do look askance at him on a couple of points ~ firstly that Foundation Hospital status is the way to go for all, when some are already having grave financial difficulties, and that in combination with a stated wish in some quarters that hospital places actually fall in favour of increased ‘home care’. This formula in the hands of the current government who wish to abnegate the DoH of all responsibility for England’s healthcare, smacks of nothing less than an engineered recipe for failure – individually amongst those hospitals who are unable to make ends meet under the proposed funding formula, and then systemically across the whole of what will be a quasi-NHS. Couple this with putting the onus of financial probity onto 550 largely reluctant GP Consortia – who may eventually gain sufficient expertise in financial management with the help of some lately redundant financial managers, but who nevertheless will find themselves in ongoing direct conflict with patient interest by dint of the introduction of shareholders and non clinical Consortia Boards – and we have a recipe for disaster. PCTs needed to be be boosted by added GP input and possible fusion to reduce numbers – not entirely disbanded. The GP Consortia model is commonly acknowledged by all key medical associations as being lacking in required expertise – particularly where it comes to paediatrics, multiple and complex and long term chronic conditions. These are the areas of high risk which will impact most upon those for whom the Welfare Bill is already a grave threat to longevity. The natural consequence of all this is that corporate survival will then supersede quality, and the temptation for GPs and hospitals alike to introduce top charges will leave patients in this category, for whom top ups will be an impossibility, already as if captured rabbits staring at full beam headlights heading towards us at full tilt, well and truly squished. This is most profoundly a human rights issue. In terms of the overall long term effect on the exchequer, one look at the Marmot report demonstrates that the negative effect on the national economy will be profound. We all know that trickle down was a miserable failiure under Thatcher because stalactites come to a grinding halt – but stalagmites of mass destitution can collectively undermine the stable foundations of any socio-economic infrastructure, and so it will be with the national economy should the most vulnerable be left to perish and suffer untended. Jos Bell FRSM, MRSPH, ConfedNHS Co-ordinator Lewisham SOS NHS
Poor old Milburn on the outside looking in, wishing he was a Liberal or even a Tory, it’s only one short walk mate.