An interesting (to me, but I hope to others) question is exactly why there has been so much opposition to the NHS reforms. When I ask this I don’t mean in terms of their content, which seems to me to be entirely unworkable. What I want to ask is why are we complaining now, when most of the things Lansley wants to are continuations of what Labour were doing in the 2000s. Let’s consider the most contentious elements of the reform package, which we might take to be competition, the pace of reform, the delegation of budgets to GP consortia, problems with accountability, and the dangers of services becoming fragmented. I’ll deal with each (briefly) in turn.
Competition isn’t new. We tried to introduce it between public providers in the 1990s, but it didn’t work out because of the lack of alternative providers of any particular service, but also because GPs didn’t refer to new providers and patients wanted to stay local. We extended competition in the 2000s by allowing private provision in, but it’s still small – less than 5% in the areas where it has made the most impact. The present bill wants to expand private provision, but complaining now seems to be odd – wasn’t the time to complain in the 2000s when private providers were subsidised into the marketplace? It might be that we are reaching some kind of tipping point now, but that isn’t the way the debate is being conducted – it’s as if non-public providers have never been in the NHS before. That simply isn’t the case.
The pace of reform is certainly pretty alarming, especially as we don’t have a final Bill yet. But when did NHS reform proceed at a leisurely pace (post 1970s anyway)? Governments want to get things done quickly – they are working on short political cycles and want reforms in place so that they aren’t still being implemented during elections. So no real surprise here.
The delegation of budgets to GPs is striking, but again, hardly new (remember GP fundholding and practice-based commissioning?). The innovative bit was to (initially) not allow any other commissioning form, but that’s entirely gone now with what looks like an increasingly big bureaucracy developing around GP consortia and the National Commissioning Board. And PCTS used to have over 80% of the NHS’s budget, so it’s not like we haven’t delegated budgets before.
Accountability problems in the new structures are everywhere. It’s not clear how anyone is going to hold any particular NHS body responsible (to me at least). It’s a mess. However, it’s always been a mess. The NHS has always been terrible at complaints (look at Judith Allsop’s work) and trying to hold local health providers to account has never been easy. This isn’t an excuse for the NHS’s lack of accountability, but I don’t think the new structures are much of a change here really.
Service fragmentation is an issue that the reforms raise because of the increased use of an increased number of providers. But again, we’ve had a marketplace spanning public, private and not-for-profit providers for some time now, so this is an expansion rather than a new thing. Equally, we can’t really say that the boundaries between health and social care have ever been particularly well dealt with, even when entirely in public hands. So yes, maybe a small change, but hardly one to warrant the level of complaint and protest that we’ve seen.
So in sum, what we are seeing is a continuation of what Labour did in the 2000s rather than anything new. Why are we getting so vexed?
Now I’m genuinely interested in thoughts on this, as I’m going to try and write about it in my academic life, so please leave comments. But here’s a few initial thoughts.
Are we cross because it is the Conservatives reforming the NHS and not Labour? If you accept my argument that most of what is involved in these reforms is not new, then is it because it is the Conservatives suggesting market-based reform that makes us upset? I think there are two parts to this.
We might object to Conservatives proposing reforms that we’ve not criticised under Labour because we believe that they are being conducted in bad faith in some way – that they are meant to lead to privatisation or to undermine the NHS in some other way. So we trust Labour more with NHS reform than the Conservatives, even if they are proposing many of the same ideas.
Objecting now might also be due to the frankly awful way the reforms have been handled, so that the initial White Paper was all rather secretive until it appeared – contrast that with the NHS Plan of 2000 which came with a raft of medical signatures on its front. Then the Bill seemed to go further than the White Paper in terms of competition meaning that it looked more radical and perhaps we all felt misled.
Now please let me make myself clear – I really don’t think reforms based around competition can work in the NHS whether they are being introduced by Labour or the Conservatives, and have written along those lines for nearly ten years now. But I do want to ask why we didn’t get angry about this in the 2000s in the way that we are now?