NHS reforms: Is Andrew Lansley's brutal surgery really needed?
Denis Campbell The Observer, Sunday 18 July 2010
How does the Great British Public view the NHS? With appreciation, sentimentality, no little pride and recognition that not everything it does can always be great, but that many things are? Or is it with anger and deep frustration at targets, a lack of choice and faceless bureaucrats allegedly obstructing clever doctors who always know best and, from that, a deeply held desire to change it utterly?
The evidence from surveys of patient opinion and experience, both by the NHS and others suggests that, broadly speaking, most people are pretty happy with it most of the time. Yet Andrew Lansley, the health secretary, last week outlined plans for a major upheaval of the service in England that are clearly motivated by both intense unhappiness with the NHS in its current form and a belief that it needs emancipation from the dead hand of tickbox-obsessed penpushers. Hence the subtitle of the health white paper "Equity and Excellence: Liberating the NHS". Lansley, it would appear, is its self-styled freedom fighter.
Politicians can't stop themselves from tinkering with the NHS. This is either the eighth or ninth "reform" of an institution that is one of the few remaining expressions of pan-UK identity. No wonder many who work in the NHS, especially at a high level, feel dizzy and resentful at the state of near-permanent revolution, and wish it would stop.
No chance. This time Lansley has certainly prescribed truly radical surgery for the supposedly ailing patient. The 152 primary care trusts (PCTs), which currently commission and pay for care for patients, are being scrapped, as are the 10 strategic health authorities. Between them, they employ 64,000 people. Patients will have much more information on who provides good and bad care, and will be encouraged to exercise enhanced choice to go wherever has the highest standards. Poorly performing hospitals, even if they are much loved by their local community, will be allowed to wither away. Competition rules, OK?
Instead of the current system, in which PCTs help decide what treatment a patient should have and where, in future England's 35,000 GPs will do that and become the most important people in the NHS. Instead of each GP surgery being given a budget to employ people doctors, practice nurses and receptionists and run its premises, the partner-GPs who run it will be handed a multi-million-pound budget with which to pay hospitals for treating their patients.
If Lansley drives through his plan, patients may not notice that many changes apart from, with luck, the clinical outcomes closer to the norms in the rest of Europe that Lansley wants to see. The nation's doctors, never easy opponents, have yet to give a considered view of having big changes to their jobs forced upon them by Whitehall, and tension is likely over the private sector's inevitable role, extra money to implement the new set-up and, possibly, demands for more pay for complying. But make no mistake: the changes will dramatically reduce, possibly irrevocably, the state's control over the NHS and the NHS's control over those who actually care for us. That is a long way from both Nye Bevan's guiding principles, and the Tories' pre-election pledges to have no more "top-down reorganisations". As last week wore on, the more people pondered the white paper, from either the right or the left, the more holes they found in it. Dr John Marks, a past chairman of the British Medical Association, quoting Caius Petronius, warned that the revamp could end up "creating the illusion of progress, while producing confusion, inefficiency and demoralisation". On Friday both the Lancet and British Medical Journal published editorials that were unusually critical. Lansley may take all that as the death-rattle of the vested interests.
It may prove to be something else altogether: the start of a coalition of concern that blocks reforms that have precious little evidence to commend them. It is a brave politician who takes liberties with a national treasure or a reckless one.