Feature

And did they ‘save the NHS’?

Overseas surgical teams, foundation hospitals, PFI, league tables, private sector management, and billions of pounds...Labour’s NHS reforms are dizzying. But will they kill or cure the NHS?

Charles Webster
Author of the official history of the NHS

The government should not be surprised by the lack of public confidence in its handling of the NHS. It stems from a fundamental inconsistency at the heart of government policy. In the first place, collapse of public confidence was largely brought about by Mr Blair himself, as opposition leader, in his effective demolition of the internal market. He created the expectation that there would be a return to the public service ethos that had been consistently espoused by Labour since 1945. It was on this basis that New Labour was elected.

But in practice New Labour shows neither policy nor commitment for revitalising the public sector. It adopted the major themes Tory policy, including market practices and private sector involvement. The first signs came with adoption of PFI. This has been excused by ministers as marginal, unthreatening to the essential public service conception of the NHS. But Mr Blair in opposition warned us to distrust such assertions – so he should not be surprised when the government’s love affair with mutualisation and its schemes for things like foundation hospitals are taken as signs of a hidden agenda that is moving the NHS in the direction of Railtrack and other failed privatisations.

Wendy Savage
Professor of obstetrics and gynaecology

All I can say is that the extra money promised does not seem to have filtered down to the frontline. We need to pay nurses and ancillary staff more and get administrators rather than managers back in post to facilitate the work of health professionals. The civil servants have been affected by almost 20 years of Tory rule followed by ‘New Labour’ and are too politically orientated now. The scandal of suspended doctors which wastes scarce resources and destroys lives needs to be tackled urgently.

Martin Rathfelder
Policy Director, Socialist Health Association

Doing good by stealth seems to sum up Labour’s achievements in health so far. But very substantial improvements in the standard of living of the poor, especially children, and achievements in public health – such as free fruit for schools – have been overshadowed by endless rows about privatisation. Whether this is so that the government can be seen to be tough with the unions is hard to tell, but it is certainly out of all proportion to anything which has happened up to now.

I would like to see a real shift in power from hospitals to primary care but it is important to keep the middle classes in the NHS. Money spent on waiting lists is politically important if it undermines the market in private healthcare. Further improvements in healthcare are dependent on staffing, not money. It is easy to complain, but I haven’t seen a coherent alternative strategy.

Donald Light
Professor of comparative health care systems, University of Medicine & Dentistry of New Jersey

The blueprint for reforming the NHS is among the best and most exciting in the world. It would correct basic flaws and damaging compromises that were made at the founding and have plagued the NHS ever since. The reforms also envision an integration of public health and medicine at the community and area levels. Ideally, the reforms would produce high quality, efficient and patient-centred services.

It has been saddening, therefore, to watch as wave upon wave of orders, standards, protocols and budgetary details have been sent out, all (or at least most) well-intentioned, but crushing in their accumulation. Further, many are contradictory and some are rushed out in shoddy forms.

The government, after turning a deaf ear for months to rising evidence of demoralization and paralysis at the operational level, ‘got it’ and promised to back away from its unilateral, centrist orders. But nearly all the previous ones are in place and new ones still roll out.

One recent example is the CHI reports. Have you read one? They are carried out in an autocratic way and cannot be appealed, even though they are riddled with contradictions, unstated or made-on-the-spot criteria, ad hoc compliments and criticisms that read like gossip, sections whose text does not support the hospital’s ratings, blaming hospitals for realities not of their making, and inconsistent scoring of the same reality from one hospital to another. The intentions – to raise standards and assure patients of quality care everywhere – are noble. The reality is a huge and destructive blame and shame exercise.

Evan Harris
Liberal Democrat shadow health secretary

The good: Quality initiatives (CHI, clinical governance, NCAA, National Patient Safety Agency); and eventually, at long last, this year announcing real increases in NHS spending. Er, that’s it.

The bad: Trite league tables which scapegoat hospitals who don’t have the capacity instead of identifying poor management; a tyranny of targets leading to distorted resource allocation and distorted clinical priorities; triple counting cash for the NHS to give the appearance of a well-funded services when it isn’t, leading many to give up on the NHS as a model; and waiting five years to expand medical schools and increase capacity.

The ugly: Continual structural change in the NHS; policy making by gimmick and posturing, e.g. NHS Abroad, foundation hospitals, fighting one general election promising to ‘Save the NHS’ and not increase taxes, and fighting the next one promising not to increase taxes and then doing so straight afterwards; increasing centralisation with a facade of decentralisation; failure and delay in essential public health measures; and underfunding social services even more than the Tories managed.

Peter Fisher
President, NHS Consultants Association

The Government’s stated intention to raise UK expenditure on health to the EU average is welcome, but it’s also a high risk strategy. If, by 2008, the NHS is not producing results at least as good as those of other comparable countries the opponents of a public service will be in a very strong position. It is essential to use the money efficiently.

Two aspects of government policy threaten its success. First, the insistence on using the private sector through the concordat, PFI, inviting for-profit companies in, and so on. Though there may be a case for this in the short term to ‘bridge the gap’, as a permanent feature it will divert public funds from the NHS to private profit.

And second, the obsession with change and initiatives: costly in time and resources, destabilising and contributing to recruitment and retention problems. The service needs a period to settle down and streamline, not complicate, its processes.

Sue Mason
A&E consultant

The policy changes introduced by the government have certainly raised the profile of accident and emergency medicine as a hard-pressed specialty. But the restrictive conditions attached to new funding have not allowed us to make the most effective use of the new resources. Many of the targets set by the NHS Plan and ‘Reforming Emergency Care’ are unrealistic and do not have a rational evidence base. Many departments are failing to achieve these targets along with others such as those set for treating heart attack promptly. More work is needed to address issues such as the wide variation in waiting times and performance between departments.

Liam Fox
Conservative shadow health secretary

When Labour came to power in 1997, they said they had 24 hours to save the NHS. Five years on, and people have not seen any change. Bureaucrats now outnumber beds. With 60,000 fewer care home places, five thousand patients now languish in hospital beds because there is nowhere to discharge them to. Cancelled operations and emergency admissions are on the rise. People are waiting longer in A&E and waiting longer to see a GP.

Labour have increased health spending but have failed to spend that money wisely. In fact, capacity is stagnant and activity barely increasing. They put politicians’ targets before doctor’s judgements, overwhelming the NHS.

Labour’s centralised style of management has brought the NHS to its knees with a structural year-round crisis. Their incompetence, fiddling of figures and obsession with headline-grabbing initiatives and continually shifting targets, rather than thought-through policy, have undermined the good work done by the NHS.

Aneez Esmail
President, Medical Practitioners’ Union

We cannot deny that the extra funding for the NHS is bound to make a significant difference. Decades of underinvestment have left the NHS decrepit and its staff demoralised. Its important not to underestimate the huge investment needed to bring it up to modern European standards, even before new and much needed developments take place. We also accept the challenge to fundamentally change how public services are delivered – but whose agenda is being followed? If we want a service with patients at the centre, then we should be following a radically different course towards modernisation.

The reality is that special interests – big business and finance, and elements of the medical profession – have hijacked the agenda. We’re not against PFI in principle but believe that under the present system, the public is getting poor value for its investment. We welcome the drive towards increased accountability and the setting up of robust regulatory frameworks. But why the reduction in democratic accountability through the abolition of CHCs and the push towards foundation hospitals?

If you asked me to assess Labour’s record on the NHS so far, I would say 60 per cent good, 20 per cent doubtful and 20 per cent very worrying. Potentially, the bad things could end up destroying some of the most precious aspects of the NHS.

Janet Power and Mark Russell
General practitioners

The main frustrations remain having to deal with a cash-strapped primary care trust unable to invest heavily in development and which is having to divert resources into the black hole of secondary care. Our patients are still waiting up to two years from diagnosis for cardiac surgery, hip replacements and cataract operations.

But it will be wonderful if the new GP contract releases us from out of hours responsibilities. And having to deliver a service based on quality standards seems a reasonable idea.