National health, local democracy

Who envies the next health minister? The problems of the NHS are so profound and so wide-ranging that even secretary of state for Northern Ireland looks like a softer option. What could a new minister do, given the changes of the last 18 years?

There is almost certainly no going back to the old ‘command and control’ structure of the NHS. Instead, the emphasis must be on stabilisation, with slow, incremental changes in most areas of policy but an enthusiasm for making the most of some of the paradoxical opportunities unwittingly created by the ‘reforms’ of the Thatcher and Major administrations.

The purchaser-provider split has taken direct control of strategic planning away from hospital chiefs and in principle allows resources to be redirected towards community-based services, or even further upstream, towards health promotion and preventive action. Powerful hospitals can still dominate the planning agenda and short-circuit the resource allocation process but their renewed orientation to their communities is itself a gain.

The continuing rationing debate strengthens the position of strategic planning agencies, provided they are willing to reduce their ‘democratic deficit’ by approaching and engaging with their local populations. This cannot happen through the distribution of glossy brochures full of histograms, but through developing relationships with civil society—the schools, churches, trades unions and other ‘voluntary organisations’ that form the skeleton of local communities. This may take effort, but without it the emotive power of the local hospital will overwhelm any far-sighted planning.

Fundholding has a potent capacity to destabilise the health care market and an in-built bias towards inequity in provision. It will not last in its present configuration, but the emergence of multifunds that eclipse the remnants of HAs is a distinct possibility. The fundholding experiment must be terminated to restore stability, preserve equity and keep long term planning as close as possible to democratic power and as far as possible from commerce. The invaluable expertise of fundholders, however, is a commodity needed by the NHS, and should be recruited for the locality planning structures that are emerging. Fundholding unity will dissolve if the leading figures get the jobs, roles and resources they seek, and their mouths stuffed with power rather than with gold.

The need to draw social and health care together has been evident for decades, and has now been made possible by the purchaser-provider split. The Right favours total purchasing by fundholding GPs, who will evolve into a hybrid of Health Maintenance Organisations and mini-health authorities through merger and economies of scale, but without a shred of public accountability beyond an overview by ‘outposts’ of the vestigial NHS Executive. As a compromise a Right-wing health minister might settle for interim total purchasing by the present commissioning agency quangos, while pumping resources into general practitioner multi-funds. A Left health minister should favour the gradual transfer of all purchasing to local government.

Professional hostility to control by local government will not vanish, but councils will not employ clinicians nor own hospitals or practices, so the old feud between doctors and the local state may not reappear. A greater risk is that Conservative local governments will attempt to impose divisive and inequitable requirements on local health services (like discrimination against drug users or AIDS patients), or simply try to save money. Such maverick activity could be avoided by insisting on adherence to national guidelines and targets. By an irony of history the Conservatives have created conditions in which an old socialist objective—local government control of the NHS—could come about and be protected against local subversion through mechanisms like Health of the Nation and the Patients’ Charter.