The Best and Worst Times for the NHS

The Lansley Bill may not be perfect, but it recognises what the direction of travel must be: towards a mixed market solution. If the health service is to catch up with the systems we now envy, it's time to move, says Tony Hockley, author of A Premium on Patients: Funding the Future of the NHS.

Now is a very bad time to embark on major reform of the NHS. Sadly there is also no better time ahead.  Delay will only make the need more urgent.

The years of plenty for the NHS are behind us, and the price must now be paid for the failure to combine a once-in-a-lifetime NHS funding surge with essential health system reform.

Since the 1980s the new direction of travel for the NHS has been clear: towards a mixed market that would see it rejoin the mainstream of health systems across the developed world. In an era of fiscal austerity, rising possibilities for healthcare, and longer-living and better-informed citizens, the flexibility and honesty of any health system will be crucial to its success. The NHS scores poorly on both counts. A quarter century on from the Griffiths “management reforms”, the English health service is still a rigid centralised and politicised bureaucracy. Even now the Health Secretary feels the need to dictate the specifics of what service providers must do in providing care to patients. NHS professionals are reduced to mere functionaries, leading to a steady flow of stories of neglect in the most basic care of vulnerable patients, as real responsibility remains with in Whitehall.

Central control has two important but morally questionable attributes: Firstly, it allows the Treasury directly to control the total cost of the health system, leading to common claims that the NHS is the most efficient health system in the world. This confuses cheapness with efficiency. Secondly, it limits the scope for local variations in care in order to maintain the longstanding pretence of comprehensive coverage.

The campaign against the Lansley reforms has been based more on emotion than evidence. Many of the same people who have argued that the NHS should be depoliticised are now fighting for the Health Secretary to remain responsible for the service, and for local government too to play a part in decisions.

The ongoing development of competition and choice in the supply of NHS-funded services is attacked in favour of a provider-dominated state monopsony that should have fallen with the collapse of communism. The emotive attacks on competition bear no relation to evidence from the NHS over the past 20 years, or from almost any other European health system. Arguments over private income generation by NHS providers hark back to the dire days of the 1970s debate over “pay beds”, and ignore the financial crisis facing these providers in the years ahead. Easing the cap on income generation is just one small step that may assist in the survival of a few cherished institutions during an era of unprecedented austerity.