It had to come sooner or later, and it has come sooner. Christopher Smallwood, chair of St. George’s University Hospitals NHS Foundation Trust, writing in the Guardian on Monday February 8th, claimed that the “free at the point of use” mantra has had its day. It is time to allow insurance to play a part in funding the NHS, he said. This is no dodgy dossier from a right-wing think-tank, picked up briefly by the Tory press. It is a serious view from a senior NHS figure, published in a centre-left newspaper and included in a Guardian-sponsored public debate. And it dovetails with the call made by Alan Milburn, Stephen Dorrell and Norman Lamb for a cross-party commission to examine how a national health and care service should be organised and funded. A new common sense is struggling into being, in which the continuation of the National Health Service as we use it depends on a transformation in the way we pay for it.
Christopher Smallwood’s argument is that the junior doctors’ dispute is driven by the funding shortfall in the hospital sector, engineered by the present government. No argument there. In his view this shortfall can only be put right by a substantial and sustained increase in taxation, or by moving to a European-style comprehensive insurance system. He favours the latter as a way of mobilising money that citizens are seemingly reluctant to pay as tax but are presumably willing to pay out for individual or family gain.
The shift to an insurance based funding mechanism for health services has been an ambition amongst Conservatives since the Carlton Club conference of 1983, which saw an expanded National Insurance as the likely insurance vehicle. The conference anticipated a slow change, preceded by full costing of the health service and the creation of an internal market – a thirty year strategy of attrition, in other words.
The Carlton Club scenario now looks like this. The English NHS is squeezed financially and services begin to fail. The government does some fire-fighting to prevent hospitals from collapsing, but will not relent on the overall budget. Conflicts between NHS management and professionals escalate, and working relationships are damaged profoundly. A series of junior doctor strikes are followed by similar actions by consultants, also aggrieved by contract changes. General practitioners begin a work to rule, launch a fierce attack on the Care Quality Commission, and threaten mass resignation. Recruitment of nurses is harmed by daunting student fees, and retention of nurses worsens, whilst migration controls limit recruitment from outside England. Other professional bodies express their concern about the deterioration of services, waiting lists and times grow, and the right-wing press exaggerates where it does not distort. All parties proclaim their blamelessness and project all faults onto their opponents. As the 2020 general election approaches the new conservative leader, listening to worried leading figures from the medical Royal Colleges, opens the debate about “ditching ideology” (Smallwood’s words) and rebuilding the NHS around an insurance base, in order to save it.
Interestingly, the photograph accompanying Christopher Smallwood’s article shows masked junior doctors with a home-made placard saying “Patients before Politics”. The slogan ‘Patients before Politics’ has form. It was the headline of a document, published in the BMJ on April 3rd 1976, which stated the BMA’s absolute opposition to the then Labour government’s plan to eliminate private practice from the NHS, and to licence private hospitals. The slogan became the rallying cry of the Campaign for Independence in Medicine, a BMA front organisation. The 1976 BMA statement ended: “The Government’s proposals will take away a freedom enjoyed by patients and by doctors, and will damage the National Health Service, already in a parlous state” (my emphasis).
“Already in a parlous state” gives it away, I think. NHS politics is manipulative and populist when it is not scheming and bureaucratic. The Right and the Left share a common political culture. The NHS is always gripped by crisis and in need of saving (or reforming), freedoms are constantly being endangered, safety is repeatedly compromised, shrouds are waved endlessly, catastrophism mushrooms. In another piece of BMA-inspired common sense, what is good for the doctor is good for the patient, allowing any professional grievance to be pursued as if it were in the public interest. In 1976 “Patients before politics” was a warning to the state not to mess with the medical profession, and the message is the same today.
The message has been heard, but the Carlton Club strategy is paying off and Conservative politicians are prepared to take risks. All that is needed is for the professions to believe that the present funding system cannot bring them more money and resources. The move to an insurance-based system will occur when the medical profession gives up on a tax-based NHS. The public – which trusts doctors more than politicians – will follow.
On the Right, politicians watch and wait calmly for their moment, quietly anticipating the end of ideology. Their focus is shifting. Christopher Smallwood’s article prompts them to think of how best to manage the demise of the old NHS and assist in the birth of the new. On the Left, Labour and the trades unions are mesmerised by the ebb and flow of contracting out, and are looking in the opposite direction. Will they turn in time?