Feature

What’s left of Labour’s NHS?

Is Labour’s health policy the work of wild-eyed radicals or just another example of New Labour Blurrism? And can Labour win over the activists as well as the administrators? Wendy Moore finds out

Once it was simple. The Labour Party only had to repeat its undying commitment to a free national health service, promise a few extra billion pounds funding, utter the odd threat about Conservative plans for privatisation, and there it was: a ready-made, vote-winning health policy.

Today, the complexities of the reformed NHS coupled with the growing influence of Labour modernisers, mean simplicity is a thing of the past. Labour’s health policy document, Renewing the NHS, published in June, is not so much the ‘third way’ between scrapping or keeping the Tory reforms as Labour leader Tony Blair suggests, as a myriad of criss-crossing strands forming a complex web of views on health on the Left.

Few strongly dissent from the Labour plan which has been largely welcomed by the unions and campaigning groups. Essentially it is a policy of minimum turbulence - keeping in place the basic structures of the market while replacing competition with co-operation - to gain maximum consensus. Rudolf Klein, professor of social policy at Bath University, recently described it in the British Medical Journal as a ‘remarkably skilful document’ offering a ‘policy fudge’ to reassure the party faithful while allowing a future Labour government maximum freedom for manoeuvre.

But behind the broad consensus lies a wide spectrum of views across the Left. These range from returning the NHS to centralised, hierarchical control, through preserving the competitive internal market and the controversial GP fundholding scheme, to beating the Conservatives at their own game and firmly embracing the private sector. So how do the pundits and the punters see the options on health for a future Labour government?

One of the most influential organisations in developing Labour’s proposals has been the think-tank, the Institute for Public Policy Research. Deputy director Anna Coote is a firm believer in the policy of ‘careful experimentation, gradual change, reached through consensus’. ‘What we don’t want is Labour to rush in with all guns firing and change everything,’ she says. ‘Nobody in the health service wants that.’

She backs Labour’s commitment to preserve the split between commissioning and providing, arguing it has proved beneficial despite initial opposition from the Left. She also supports the proposal to build on the fundholding initiative by promising all GPs more say in commissioning healthcare — through various forms of locality commissioning - although she does not believe Labour should immediately shut down all existing fundholders under the current scheme.

Coote also wants to see Labour go further in other areas. She recently called for debate on alternative ways of funding long term care, including compulsory insurance for social needs in old age. And she advocates addressing the ‘democratic deficit’ in the health service by handing over control of commissioning healthcare to local government - a proposal currently enjoying a strong revival in several quarters. Both Labour-controlled Birmingham city council and Tory-held Wandsworth council are among supporters of the policy.

Steve Harrison, reader in health policy at the Nuffield Institute for Health in Leeds, has been exploring the idea for the IPPR. He believes local authority control of purchasing would give democratic legitimacy to decision-making in health, particularly in difficult areas like rationing. At the same time it would end the endless disputes over the difference between social and health care. And it would integrate healthcare with services which influence health, like environmental health and housing.

He answers critics who argue local government is in no fit state to take on new demands by saying: ‘You either believe in local government or you don’t. If local government is at a low ebb we have to do something about it.’

Another think-tank whose influence can be clearly charted in the document is the Fabian Society. Participants at a seminar hosted by the organisation before the launch of Labour’s policies largely anticipated its proposals - extolling the virtues of the purchaser/provider split, commissioning authorities and elements of fundholding. But although the Fabian Society itself maintains a neutral stance, among left-wing activists writing for and working within it, there are some widely divergent views.

Academics Howard Glennerster, professor of social administration at the London School of Economics, and Brian Abel-Smith, who has been around long enough to have advised previous Labour governments on health, called on Labour to maintain and extend GP fundholding in a recent article in Fabian Review.

Fabian Society research director Stephen Pollard has written articles for other organisations, urging Labour enthusiastically to embrace the private sector. Himself a party member and former chair of his local branch, he says he takes a ‘pragmatic’ view.

Although electors are unwilling to pay higher taxes to boost healthcare they are increasingly taking out private health insurance, he points out. ‘People feel completely helpless in the health service’, he says. ‘It is a great public sector monolith people don’t have any control over.’ They choose private health because it offers them some control. Labour should acknowledge this contribution to the total healthcare bill and exploit it. Among his suggestions are that major unions like UNISON should offer private health insurance to recruit members and hospitals could buy more services from the private sector.

Rather more in the mainstream of the Left there is a good deal of support for the Labour document with some differences of opinion on detail and emphasis. Health service union UNISON will be leading the drive to congratulate Labour with a fulsome tribute at the party’s conference in October. Dominic Ford, branch secretary of UNISON’s North Thames branch, explains: ‘Most people just want stability.’ The policy is a ‘reasonable compromise’, he says, which reflects the growing consensus in the labour movement around the advantages of some aspects of the Tory reforms, like the purchaser/provider split and the move towards evidence-based medicine.

Paul Evans, assistant director of the NHS Support Federation, is in broad agreement. ‘Generally we welcome the proposals because they start to put co-operation back at the heart of the NHS rather than competition’, he says.

He believes, however, Labour should give a firmer commitment to increasing healthcare funding. ‘With something like the NHS, where the public have a very strong belief in the concepts and can see at the heart of it there is a lack of funding underlying the problems, more money is the real answer.’ But he warns Labour must also be prepared to face some tough decisions, including rationing and even hospital closures, so long as they result in improvements in services.

Treasurer of the Socialist Health Association Tony Jewell also gives a general welcome to Labour’s plans and he too supports a stronger commitment to increased funding. ‘The NHS is crying out for a little bit of relief’, he says. ‘More money does not necessarily overcome issues of rationing but the NHS does need some respite.’ Labour should put a clear price tag on better healthcare, he says, suggesting increasing health spending to 8.5 per cent of gross domestic product - the average in Europe - as a start.

He would like to see different models of GP commissioning developed but argues that unless these involve doctors in real resource management, rather than simply in an advisory role, they will not work. He is dismayed by Labour’s plan to delay taking a decision on long term care - by proposing a royal commission on the area - because the issues are ‘here and now problems’. And he would like more emphasis on tackling inequalities within a national health strategy overarching NHS policy.

But not everyone wants to preserve the structure of the Tory reforms. Andrew Wall, a former NHS manager who is now senior fellow at Birmingham University’s Health Services Management Centre, numbers himself among a ‘tiny minority’ who favour returning to a simple hierarchy of centralised control with district health authorities managing hospitals.

He dismisses as ‘myth’ the idea that managers are unable to deal with long term planning at the same time as day-to-day administration. ‘If you want policies to stick you must make sure they are implemented by people who have designed them’, he says. He proposes a ‘simple hierarchy’ which offers patients ‘unambiguous accountability’. And he calls on Labour to be less suspicious of managers who, after all, have to make its health policy work.

Others on the Left believe Labour has got its health policy upside down. Instead of focusing all debate on how the NHS is organised, it should begin by setting out basic principles - such as ending inequalities and improving accountability - and then work out the administrative arrangements, says Geof Rayner, secretary of the pressure group Public Health Alliance.

The success of the Beveridge report was precisely in laying out clear principles which commanded wide public support, he says.

‘We must start with a commitment to the health of everyone - not just the health of the nation but health for all’, he adds. ‘Then we work out how to do it’.