Looking to the longer term

What should Labour do about the NHS? When it returns to power in 1997 it will be faced by a semi-privatised health service, punch drunk from successive ministerial initiatives and shifting departmental priorities, and in which the structures of the internal market will have been embedded for six years.

Sensibly, Labour recognises that it is neither possible nor desirable to recreate the monolithic structures of 1979 from the fragmented remains of the 1990s. Instead, it proposes a pragmatic and incremental approach which will temper the worst excesses of the Tories’ healthcare marketplace without a thoroughgoing restructuring of the service. Thus, out will go contracts and trusts as Labour ushers in its ‘Comprehensive Healthcare Agreements’ and ‘Local Health Services’. With the change of name will undoubtedly come a change of emphasis but not, in the final analysis, a move away from the fundamental features of the 1991 reforms. It is only in winding down GP fundholding that Labour makes a decisive break from Conservative policy.

Of course, there are good arguments for this ‘softly, softly’ approach to the NHS. Yet more reorganisation and inevitable destabilisation would do nothing for the care of patients nor the morale of staff, already disoriented by the constant stream of health authority and trust mergers. Piloting and evaluation of bright new ideas-such as alternatives to fundholding-will come as a refreshing change from the ideologically-driven policy edicts of recent times.

Yet Labour seems to lack a sense of the longer term. Once the excesses are curbed, the ‘Tory placemen’ removed, the language changed, what then? What should be the strategic goals for Labour health policy? Of course, Labour will give a welcome new emphasis to public health and health promotion. It will ban tobacco advertising and appoint a Minister for Public Health. But it could do more. In retaining the purchaser-provider split, Labour leaves the door open to a longstanding goal of the Left-and one which was frustrated in 1945-that is, local government control of the NHS.

The 1991 reforms have allowed the idea of local authority purchasing of health care to become thinkable once more. The two traditional arguments against the option have always been that doctors would vociferously oppose-as they did in 1945-any attempt to make them employees of ‘the local state’, and that the NHS was far too big and complex an undertaking to be left to the amateurish hands of local authority officers and councillors. Now that hospital doctors work for trusts, and health authorities have been boiled down to a collection of commissioning teams (with policy and public health add-ons), such arguments lose their force. It seems entirely possible to imagine health authorities being brought under the wing of local government.

The arguments for such a policy goal are strong. First, it is right that health services should be subject to local democratic control, and while listening to ‘local voices’ may be important, it is no substitute for the ballot box. And second, the location of vigourous teams of public health and health promotion specialists within local authorities would at last allow them to achieve their historic potential to pursue strong public health policies at local level. Just as arguments over the boundary between health and social care would become irrelevant, so the division between health promoting and illness treating strategies could begin to be overcome.