News from nowhere

Who is Milburn, what is he? A respected politician who knows his subject, according to civil servants with experience of his past involvement with health. Ambitious and therefore compliant with the Blair agenda, according to New Labour insiders, so those resistant to change should watch out. A new broom ready and able to sweep away the ill-chosen target of waiting list reduction and replace it with a more rationale approach to achieving change, according to assorted NHS-ologists in the press, the Kings Fund and the pressure groups.

healthmatters suggests caution in assessing the new Secretary of State, for two reasons. First, he will be tough on doctors, but will not find it easy to discriminate between allies and enemies, nor between reasonable resistance and conservatism. The New Labour argument that those who oppose change must put a counter-proposal is disingenuous, for only counter-proposals within the policy framework of the government are allowable, so disagreement must turn on technicalities not substance. This is a polarising approach that must politicise health care even more. No bad thing, in the long run, and in many ways exactly what healthmatters would support, but it is a risky strategy. The Blair government has a big majority, but a fickle social base and few organised supporters inside medicine. The BMA is disgruntled and becoming increasingly belligerent. Its sceptical membership is more interested in their own social exclusiveness than in any public health agenda, but they deliver the services that New Labour wants to reform. They know that the NHS is creaking, that its infrastructure has been neglected for too long, and that its management is becoming exhausted. Making an enemy of this professional group may be unavoidable, but is it wise?

One way to undermine professional resistance is to divide it. Bevan did it by recruiting specialist opinion to the new NHS in the 1940s. Milburn may be trying to do it by taking a high-tech approach to heart disease and buying cardiologists’ support at the end of the 1990s. The price the NHS paid for Bevan’s necessary tactic was the underdevelopment of primary care, for decades. What price will health service pay for tactical shifts away from health promotion towards heart surgery and more medication? No doubt Britain has fewer cardiologists, echocardiography machines and bypass graft operations per head of population than its European neighbours, but we also have too little effort against smoking, over-consumption of animal fat and inactivity. Resources are limited and must be targeted somewhere. By choosing high profile, high technology interventions over unglamorous low technology ones, New Labour may be less radical and reforming than it aspires to be.