Second Opinion

Dr Mike Fitzpatrick

New Labour New NHS?

The striking difference between the 1989 White Paper 'Working for Patients' that launched the Conservative internal market reforms (introducing hospital trusts and GP fundholding) and the New Labour document is the public response. Whereas the Tory White Paper provoked a storm of protest from the medical profession, opposition MPs and the media, New Labour's was quietly received. Even leading fundholding GPs and Tory MPs could scarcely raise a protest.

Perhaps as a result of the lack of controversy, the new White Paper's claims that the internal market was to be abolished and GP fundholding replaced have been taken at face value. 'In fact', as LSE social policy experts Howard Glennerster and Julian LeGrand pointed out, 'the key elements of the old internal market will be retained' and the proposed GP-led commissioning amounts to 'the ultimate extension of fundholding' (Guardian, 10 December 1997).

The key element in the new plans - a central role for 'primary care groups' of GPs in commissioning healthcare services for local populations of about 100 000 people - marked the triumph of the 'locality commissioning' model which has emerged in parallel with fundholding over the past five years. Whereas GP fundholding became established in rural and suburban areas, various forms of commissioning services through collectively held budgets developed in inner-city areas, with encouragement from the Labour Party. The new White Paper in practice proposes to consolidate the reforms introduced by the previous government.

The general approval of New Labour's plans for the NHS reflects the development of a new consensus around the concept of a 'primary care-led NHS', officially sanctioned in a report from the new NHS executive in 1994 ('Developing NHS Purchasing and GP Fundholding: Towards a Primary Care-led NHS'). This document pursued the logic of the internal market reforms by further encouraging the initiative of GPs in both rationing services to patients and in imposing a degree of market discipline on their hospital colleagues:

'The aim is for decisions about purchasing and providing healthcare to be taken as close to the patient as possible by GPs working closely with patients through primary healthcare teams.' (p5)

'The New NHS' is even more explicit:

'For the first time in the history of the NHS, the government will align clinical and financial responsibility to give all the professionals who make prescribing and referring decisions the opportunity to make financial decisions in the best interests of their patients.' (p9)

The White Paper continues on the familiar themes of 'cost effectiveness' and 'tough choices'. It calls for 'big gains in quality and big gains in efficiency', emphasising that 'the two go together' in a 'modern and dependable healthcare system that will once again lead the world. A new NHS for a new century'.

It does not however detail the wider context created by the new government's pre-election endorsement of Tory public spending projections, which mean a drastic squeeze on health resources over the next two years. According to the Institute for Fiscal Studies, this will be 'more stringent than anything the Conservatives managed in their 18 years in power'.

Though 'The New NHS' recommends a retreat from the fragmentation produced by the full rigours of market forces unleashed by small scale fundholding, it proposes to retain and strengthen the operation of commercial principles. Furthermore, by making participation by GPs in primary care groups compulsory and by introducing stricter mechanisms of monitoring and control, the new scheme has a distinctly authoritarian dynamic. As two health policy analysts noted in an editorial in the British Medical Journal, 'the proposals amount to three main things: softening the harsher edges of the internal market by increasing collaboration and openness; involving all general practitioners in commissioning/purchasing; and strengthening central control over the quality of, and access to, clinical care' (27 December).

It is remarkable that the concept of a primary care-led NHS should have become established - apparently without question - in such a short period of time. Whereas the authority of the hospital in the post-war NHS was based on its remarkable clinical achievements over the preceding 300 years, what has ever been achieved in general practice? It seems that the rising prestige of the GP is based partly on the general disillusionment with hospital medicine, partly on the contribution of primary healthcare to the new modes of regulating behaviour (diet, exercise, smoking, drinking, safe sex, etc) and partly because of GPs' role as gatekeepers to NHS resources.

The paradox of the White Paper is that at a time when GPs are complaining of unprecedented levels of stress and hardship, phoning help lines, taking early retirement and facing a recruitment crisis, New Labour plans to give them a central role in enforcing a new regime of austerity in the NHS. Can they do it? No doubt many are willing and have been working away in locality commissioning groups and other pilot projects anticipating the events of the past 12 months. Whether the proposed restructuring can be achieved within the allocated budgets seems doubtful. That the consequence will be a reduced quality of healthcare for many seems inevitable.

A new NHS? Certainly. Progress? Not.