The NHS: no turning back

This election marks a watershed for the NHS, signalling the final collapse of the post-war consensus on health policy. The electorate is presented with a stark choice between the commercialisation and creeping privatisation of the Tories and the continuing support for a comprehensive NHS promised by Labour and the Liberal Democrats. This contrast is clear enough. But behind the rhetoric of opposition to the government’s reforms of the NHS, little attention has been paid to exactly how these parties would tackle the major issues in health policy if they were to gain power.

The policy statements from the Liberal Democrats and Labour are remarkable not so much for their differences as for their striking similarity. In particular, the indelible mark which the Thatcher years have left on all welfare policy is unmistakeable. For example, the split between planners and providers is accepted by the opposition, as is the move towards performance measurement, decentralised management, the importance of quality and the emphasis on consumerism. The world within which health policy is made has changed permanently, and the revolution heralded by Working for Patients is complete.

Despite the clear similarities, there are three distinct areas in which party policies differ fundamentally. The first is in the role of the provider market, with the Conservatives contending that competition between providers will improve both the efficiency and quality of services. Second is the emphasis placed on public health and health promotion by Labour and the Liberal Democrats - both make firm commitments to reducing health inequalities and improving access to health care.

The third area concerns the question of who runs the health service and the accountability of the medical profession. The Conservative reforms directly challenge medical power through the strengthening of general management and the creation of business-style health authorities. This is the logical development of the market model, where professional interests are subordinated to customer satisfaction and the corporate good. In contrast, the Liberal Democrats give an unreservedly strong commitment to a democratic NHS run by locally-elected authorities. They emphasise the broader public interest and encourage community participation in the task of improving health.

Both the Conservatives’ consumerism and the Liberals’ participatory democracy challenge the medical dominance of health service planning and development and show a commitment to making the NHS more user-friendly. But Labour merely offers to take us back to the pre-reforms world of central policy directives and appointed health authorities with the tokenistic promise to improve ‘consultation procedures’. This is a dismal prospect made more unpalatable by the intention to give general practitioners a veto over local service agreements.

If the NHS is going to meet the challenge of the 1990s and genuinely improve the quality of patient care there can be no turning back to the dark days of paternalistic, unaccountable and medically dominated decision-making. For this reason alone Labour’s claim that it has a patient-friendly and forward looking health policy is questionable, and the nagging doubt remains: would a change of government would really improve the NHS?