News from nowhere

Ambition is enough to get the determined person from rags to riches. And a public service like the NHS can turn from an austere, planned machine into a sensitive patient-centred service by determination alone. This romantic philosophy is at the heart of the government’s latest policy statement for the NHS, A service with ambitions.

There is no doubt about the government’s ambitions for the NHS. It cannot be abandoned this side of an election, but its essential characteristics can be redefined to fit an emerging market economy in healthcare, and its guiding principles of equity, efficiency and responsiveness must compete with one another for expression.

What was once a comprehensive service, funded from general taxation and free at the time of need, has changed. Now it is universal in its reach (but not necessarily comprehensive in its provision), and available to anyone who wishes to use it. Clearly, the choice of where to seek medical care is now open, and we cannot take state monopoly for granted. It is high quality, and available on the basis of clinical need, without regard for the patient’s ability to pay. ‘Clinical need’ has to accommodated within limited resources, of course, and must also be prioritised.

While the urgent must not be allowed to squeeze out the important, there is little doubt that the emergency surgery needed to restore the crashed BMW driver to health will continue to take theatre time and beds away from the arthritic pensioner waiting for a hip replacement.

Forget equity as an overriding principle of justice in an unequal society. Local services must now balance equity with efficiency in service provision. Clinicians must balance the interests of individual patients and the community as a whole. The BMW driver is an important, useful and productive member of society whose immediate treatment is more responsive, more efficient and possibly more just than the misuse of resources on an old, unproductive and burdensome individual whose prospects are, well, limited. Not much doubt about how that equation balances, even before QALYs are counted.

GP fundholders are presented as important sources of information, even though the Audit Commission thinks otherwise. And a series of stories about injuries and illness, disability and death, are used to illustrate how the service could become, given enough ambition. No bed crises occur in the minister’s fantasy land, no overloaded services and burned out staff, no vacancies which cannot be filled, no disturbed, damaged ‘consumers’ complicate this sunshine NHS.

There is one positive message within A service with ambitions, though it will not be heard. Its agenda for change cannot be achieved within the limited growth money for the NHS, whatever efficiencies are planned. Investment in staff, training, equipment and IT are needed on a grand scale. Unless the private sector can offer this, the Tory plan for the NHS will fail. So too might the service itself. Who knows, perhaps a modernising government might come by with just enough money.