Rather like Tony Blair before he became prime minister, David Cameron had much more to say about education than health in the run-up to the election. He’d got a plan for freeing up schools from local authority control and giving parents the power to set up their own schools. The education world would never be the same again. But as for health, his message was simply one of reassurance. The NHS would be safe in Conservative hands and its budget would be protected from the axe that would fall inevitably on almost every other department.
Now, however, barely two months into office, his health secretary, Andrew Lansley, has announced a radical overhaul in the way the NHS is to be run. His white paper, published this week, heralds the sixth reorganisation of the NHS in twenty years and is arguably the most far-reaching since the NHS was founded in 1948. But is it the right reform? And can the NHS take yet more reorganisation and upheaval?
The fact that the NHS has been subject to so much change for so long reflects a largely unresolved dilemma that goes right back to its origins. In the post-war world of the growing welfare state it became pretty much universally accepted that access to health care should not depend on how much money a person in need of it could raise to pay for it. Instead, we should all be insured for health care, no matter how poor we might be. The state would act as insurer.
The disputed issue was whether the state should also actually supply the health care – owning the hospitals and recruiting doctors and nurses as paid employees – or whether it should simply buy the care from a privately-owned and run health sector.
The era when the NHS was founded was one that by and large believed in the power of the state and government planning. It was state planning, after all, which had seen us through the second world war. And Attlee’s Labour government believed in it for ideological as well as pragmatic reasons. So it seemed obvious that the new NHS should actually supply healthcare rather be just a state health insurance system.
Yet some free-marketeers (and opposition Tory MPs) at the time thought this a bad move. They feared it would lead to bureaucracy and waste and that it would stifle what they regarded as efficiency-creating competition among health professionals. In any event a compromise of sorts had to be agreed because most doctors did not wish to become employees of the state. Instead, GPs were allowed to remain in private practice, selling their services to the NHS.
This arrangement might have continued undisturbed for years had the now famous prediction of the NHS’s founder, Aneurin Bevan, come true. He said that widespread fears that the NHS budget would balloon out of control were unfounded. There would be a bit of a bulge in the early years as the backlog of poor health was tackled, he said, but thereafter costs would fall as we all became healthier.
Alas, wishful-thinking. Instead, of course, the NHS budget has indeed rocketed, not least because new treatments have created new demands and increased longevity has put greater pressures on the service. The result has been that governments have become alarmed about the sheer cost of the NHS. And many of them have come to believe that the original model of a state-run, essentially bureaucratic organisation is no longer viable.
Margaret Thatcher’s government was the first to have a go at reform. Her health secretary, Kenneth Clarke, introduced the ‘internal market’ into the NHS in order to try and inject an element of competition. In particular GPs were offered the chance to become ‘GP fundholders’, with control over how to spend money on behalf of their patients. Labour denounced this as the beginning of privatisation and Tony Blair’s government abolished GP-fundholding. Instead a system of strategic health authorities and primary care trusts was introduced to try to shift decision-making in the NHS away from Whitehall. Targets were set for them to meet. The era of NHS ‘target culture’ began.
But the Blairites started to have second thoughts, believing that more competition and more patient choice was needed. Some of the Blair/Brown rows we are now hearing about all over again were about the NHS and issues such as foundation hospitals and how much independence from central control they should enjoy.
Now the new government proposes a very radical change. The target culture is to be cast into history. Most significantly of all, the power over the purse is to be given to GPs. They are (again) to become fundholders, commanding 70% of the NHS budget, and commissioning care (from hospitals and the like) directly. The difference with Ken Clarke’s old scheme, however, is that all GPs will find themselves in this position, not just those who volunteer.
Strategic health authorities and primary care trusts will be abolished in three years time. Around 20,000 NHS managers will lose their jobs. And hospitals will be encouraged to move to a status somewhere between the public and private sectors, selling their services to GPs. As Mr Lansley put it, he is “looking to a world where the department of health does not own hospitals”.
Inevitably, these radical plans have come under attack. The most fundamental objection is that GPs don’t want this role thrust on them. They are clinicians, not businessmen, it’s argued, and they won’t want to have to spend their time shopping around for the best deals. The government counters this by proposing that GP practices be amalgamated into 500 consortia employing managers to do the shopping around for them. But, say the critics, this could leave them prey to existing private sector healthcare organisations, many of them American. In short, say the critics, this is a stage towards privatisation of the NHS.
There is also the issue of accountability for the spending of public money. The government proposes setting up both a new economic regulator for the NHS and an independent commissioning board to issue guidelines on best commissioning practice. But sceptics see this as just a different form of bureaucracy from the one we have now.
Perhaps the most basic objection to the plans is the simple one about upheaval. All reorganisations of the NHS, as of any huge organisation, cause vast disruption. The question is: is it worth it? The government obviously believes it is. But Mr Lansley knows that in being so ambitious he is also taking an enormous risk.
What’s your view? Do you think the NHS needs a new reorganisation or should be left alone? Do you think giving GPs control of the NHS budget is the right reform or not? Do you worry or not that the proposals could lead to GP practices being taken over by private sector healthcare companies? Do you think the department of health should ‘own’ hospitals or not? Do you think the plans will lead to chaotic upheaval within the NHS as they are implemented or do you think the new shape of the NHS will be the one that will become established for years to come?
