This article is from the May issue of Total Politics
Perhaps the most puzzling aspect of the reception given to the government’s NHS reforms is how it contrasts with that given to similar changes set in train by New Labour between 2000 and 2005.
David Cameron has claimed in despatch box clashes with Ed Miliband that the coalition is simply building on changes begun by Tony Blair and Alan Milburn. In principle, he is right. The attempt to introduce market dynamics into NHS provision was initiated by a range of Labour policies, notably the introduction of ‘independent’ NHS Foundation Trusts and the significant increase in use of the private hospitals to treat NHS patients through the extended choice network and independent sector treatment centre programme. The brain-meltingly complex payment-by-results system, which provides the currency for around half of NHS work, allows the coalition to make its claim that greater competition to provide NHS care will be based on quality and not cost.
Even the attempt to give GPs control over the design and purchase of NHS care was foreshadowed by Labour’s practice-based commissioning initiative. So, why are the government’s reforms proving so controversial?
There are three reasons. The first is that Labour spent time in the run-up to 2000’s NHS Plan building a consensus around the need for change within the service. When the plan was published it bore the signatures of the chairman of the British Medical Association (the doctors’ union) and the general secretary of the Royal College of Nursing, among many others. It was largely an exercise in ‘apple pie and motherhood’ compared to the more dramatic steps taken from 2002, but it inspired confidence and proved a firm foundation.
Andrew Lansley and Cameron had done a brilliant job in opposition in convincing many NHS sceptics that they had the best interests of the service at heart – which they do. They also made no secret of what the Conservatives intended to do with the NHS once they gained power, as the Autonomy and Accountability proposals of 2007 attest. However, few of its more radical elements were contained in the Conservative Party manifesto or coalition agreement three years later, meaning the support echoed for these outline plans was only skin-deep.
Lansley believed that Labour had wasted its first five years in power when it came to reforming the NHS – a view we now know Tony Blair shares. The new health secretary was not going to make the same ‘mistake’, so he trusted to the relationships he had built in opposition, and went for broke.
The second contrast with the NHS reforms of the last decade is that the New Labour strategists focused on a simple problem that needed fixing and built the reform package around it.
The NHS’s 18-month-plus waiting times were a scandal. What’s more, they were a scandal that the press and the public could readily understand justified radical action. Vested interests in the service kicked up a bit of a fuss about targets distorting clinical decisions, but they knew better than to stage outright opposition.
There are plenty of other areas where NHS performance can still improve dramatically – the variance in the quality of GP care, for example – but they are much harder to explain, and it’s harder to win support for tackling them.
The third and perhaps most important difference between the New Labour and coalition’s NHS reforms is that the former took place in a time of feast, in sharp contrast to today’s financial famine.
The 2002 budget saw the government commit to more than double the NHS budget in 10 years, while, a decade later, the service is currently embarked on an unprecedented efficiency drive that is meant to deliver £20bn of savings by 2015.
Under New Labour, doctors and nurses saw huge rises in both numbers and reward. Quite a lot of opposition was simply bought off, a luxury not available to Lansley. It also left him open to the criticism – most woundingly made by health select committee chairman and former Tory health secretary Stephen Dorrell – that now was hardly the time to embark on distracting reorganisation of the NHS.
So, from the off Lansley had only shallow support from within the service, there was doubt over the justification for his changes, and he could only offer objectors the cold gruel of financial austerity as the once-in-a-generation growth in the NHS budget came to an abrupt end. And he was also required to mess with one of the service’s holy of holies, the NHS pension.
Deep down, many – notably the BMA – had long been uneasy about the direction of NHS reform. Twenty years after its introduction, they still disliked the split between NHS organisations responsible for the purchasing and provision of healthcare. Unsurprisingly, there was also little support within the service for the private sector to take a greater role in caring for NHS patients.
The weakness of the coalition’s position on NHS reforms allowed these concerns to blossom, moving from the usual suspects to engulf the prestigious medical Royal Colleges, and finally spooking the coalition’s junior partners.
Even though the Health and Social Care Bill has now become law it is unlikely that the opposition to the reforms will die away. They have become conflated with the efficiency drive – and every A&E closure, care scandal or financial crisis will have a convenient handle on which to be hung. There is also a huge wave of changes still to come. Secondary legislation and regulations affecting the function of key bodies – clinical commissioning groups, economic regulator Monitor, and the mighty NHS Commissioning Board – are all still outstanding and likely to cause further storms.
Even the government seems tacitly to admit it is struggling for support. Last month, Lansley told a health policy summit: “I’m not here to restore faith in politicians.” It’s a statement you cannot imagine any other cabinet minister making, including the health secretary when he first swept into power, promising to end top-down control of the service, and tearing up targets to show he was serious.
Some NHS staff are highly suspicious of the reforms and will be actively uncooperative in their implementation. The majority will want to do the best for their patients and will simply try to ignore the changes. As with the fag-end of the New Labour years, progress may rely on a small army of enthusiasts, as well as the much-maligned (and rapidly dwindling) ranks of NHS management.
Can the government recapture the initiative? Can it find a way to redefine the narrative of NHS reform? It has one golden opportunity. In late May/early June, Robert Francis QC will publish his report on the inquiry into care failings at Mid-Staffordshire NHS Foundation Trust, a report commissioned by Lansley within weeks of his taking office. The report promises to be one of those once-a-decade events that challenges the culture of the NHS and sparks unstoppable demands for improvement, just as Sir Ian Kennedy’s inquiry into children’s heart surgery at Bristol did in 2001.
The report could allow the government to begin a public debate around issues such as the accountability of healthcare professionals, the importance of dignity in care and the relationship between the NHS and the public. These are hugely resonant issues into which the government could attempt to retro-fit the technocratic changes it has already engineered.
Of course, the report is also likely to highlight the dangers of poorly-handled structural reform in the NHS, giving opponents yet another cause célèbre.
Whatever happens, enough momentum has been created to make NHS reform a live issue for many years to come.
Alastair McLellan has been editor of the Health Service Journal (on and off) since 2002
Note: this article was published before the report into the Mid-Staffordshire NHS Foundation Trust was delayed until October