NHS reform : How big a gamble?


What effect will the changes in the NHS have on the service and the Coalition Government?

Nigel Lawson, the former Tory Chancellor, once remarked that for the British the National Health Service was their religion. Tampering with it was therefore about the most perilous activity a politician could engage in. Yet this week the Government has announced changes in the way the NHS is to be run in England that have been described as the biggest upheaval in its sixty-year history. Will they make the NHS an even more cherished part of our national life, with the Government hailed as its saviour? Or will they threaten its very existence and bring political disaster on the Government?

It has come as a bit of a surprise, not least to many Conservative MPs, that the Coalition Government is tackling health service reform at all. When David Cameron became Tory leader he clearly wanted to reassure the public that the NHS was, as Margaret Thatcher had claimed but never persuaded most people, 'safe in our hands'. Not only would the NHS be spared the financial cuts visited on almost all other areas of Government spending but there would be no further ‘top-down’ reforms of the organisation of the NHS which have been such a feature of the last twenty years. With health outcomes improving after the huge increase in spending on the service and public satisfaction with it at an all-time high, it seemed like a moment to let sleeping dogs lie.

Yet the man Mr Cameron put in charge of Tory health policy came to a different conclusion. Andrew Lansley decided that with growth in health spending bound to be less in future than it has been over the last decade, reforms introduced by Tony Blair’s government needed to be taken further if the NHS was not to go into decline.

The Prime Minister has been persuaded. When I interviewed him this week he told me: 'Pretending that there is some easy option of sticking with the status quo and hoping that a little bit of extra money will smooth over the challenges is a complete fiction.'

In simple terms, the reforms which Tony Blair introduced, following on from those brought in by the Thatcher government, were intended to change a system essentially run on state-controlled bureaucratic lines into one in which market forces had much greater sway. This is what the new reforms will take further.

Eighty per cent of the NHS budget of around £100bn a year is to be handed over to GPs to decide how to spend. Primary Care Trusts (PCTs), which currently have the responsibility of buying health care from NHS hospitals and private sector suppliers, will be abolished from 2013 as will the strategic health authorities which oversee them. Consortia of GPs will do the job instead. They will be encouraged to shop around among NHS hospitals and the private and voluntary sectors, which will compete with each other on quality (though not on price). An NHS Commissioning Board will regulate how they do this. Around 24,000 management jobs in the NHS will go, saving an estimated £1.7bn a year after 2014.

How big a change does this amount to? This is itself a matter of dispute. David Nicholson, the chief executive of the NHS, has called it 'really revolutionary' and a change 'so large you can see it from space'. Others, however, including Professor Julian Le Grand, who helped Tony Blair with his health reforms, regards it as merely evolutionary.

The case in favour of the change is that GPs know best of all what patients need so they should be in charge not only of securing it but also of the money to pay for it. Competition will drive down costs and money saved on bureaucracy can be spent on medical care. But the changes are fiercely opposed on several grounds.

First of all, it’s argued that managing budgets and seeking out the best deals in a burgeoning marketplace are not what GPs are about. Their job is to care for patients. What will happen, say the critics, is that GPs, overwhelmed by their new responsibilities, will simply hire in managers to do the job, opening up their consortia to being taken over by private sector health companies which already have the know-how. In short, this is the route to the privatisation of the health service.

Furthermore, it’s argued that privatisation is being given a boost by increasing the scope for the private sector actually to supply the health care the GPs buy.

David Cameron has countered both these objections. He claims that the fact that around 140 GP consortia, amounting to around half the number of GPs in England, are already signed up to pioneering the new scheme is evidence enough that GPs do want this new role. And he told those fearing privatisation to 'grow up': people wanted to know that their healthcare would go on being paid for, as it would, but they didn’t mind at all who actually provided it.

Nonetheless, critics worry that the change could radically undermine the relationship between patients and their GPs. They fear that patients will suspect their doctors of using the new system to provide care on the cheap, putting the profitability of their practice above the needs of their patients. John Healey, Labour’s health spokesman, has dubbed the new system as 'profit-centred not patient-centred'.

But even some of those who think the reforms go in the right direction are worried about the timing of them. That’s because they are to be brought in at the same time that the NHS is being asked to make £20bn of efficiency savings over four years. This itself, they say, will be difficult enough but to impose the reforms at the same time risks what the health select committee has called 'significant institutional upheaval'. The British Medical Association, the Royal College of Nursing and other health unions are more blunt: the changes are 'potentially disastrous'.

Could they be disastrous for the Government too? If the changeover, to be implemented just two years before the next election, turns out to be as chaotic as such transitions often are, then the Government is bound to get the blame.

But some observers point out that even if such temporary chaos is avoided, there is a potential political price even in successful change. That’s because the whole direction of reform, going back through the Blair changes, is away from a national service over which politicians preside (being able to hear in Whitehall, as Aneurin Bevan put it, the dropping of a bedpan in a distant hospital), to one in which all that politicians are responsible for is the insurance system which guarantees free medical care at the point of use. How healthcare is actually supplied will no longer be their direct responsibility; their role will be at arms length.

But if the new system, as is likely, leads to under-performing but popular hospitals having to close, or to the revival of a postcode lottery in which patients are deprived of treatments that are available elsewhere, then politicians may still be held to blame while no longer having the power to do anything about it. If the priests supposedly in charge of Britain’s national religion appear to be washing their hands of responsibility for it, then the laity may get restive.

What’s your view?

  • Do you support the reforms or not?
  • Do you accept the argument that reform of some sort is necessary, or do you think the NHS could go on as it is currently organised?
  • Do you support or not the principle that GPs should be in charge of most of the NHS budget?
  • Do you think this would improve, worsen or have no effect on your relation with your own GP?
  • What do you make of the argument that the reforms amount to the privatisation of the NHS?
  • Does it matter to you who provides your health care so long as you don’t have to pay for it?
  • And what do you think will be the political fallout of the proposed reforms?
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