Second opinion: A great leap forward?
In the dog days of the Thatcher regime many observers noted the curious way in which the government took up both the rhetoric and the authoritarian style of the Stalinist era in the Soviet Union. This was particularly striking in the sphere of health, where the Tories promulgated goals and targets in terms similar to the 'five-year plans' of the 1930s. When the health minister appointed a surgeon who had excelled in reducing his waiting list to head a national campaign, echoes of the heroic Stakhanov were inescapable.
In an even more bizarre twist of historical fate, Tony Blair seems to have taken up the mantle of Chairman Mao Zedong, the erstwhile leader of Chinese communism. This identification came to the fore in his monumentally self-important party conference speech in September. It is increasingly apparent as he pursues the long march of modernisation against the forces of conservatism in British society. The NHS appears to have been singled out to experience the full impact of Chairman Tony's cultural revolution.
A government reshuffle has strengthened the Blairite vanguard, placing Alan Milburn as minister of health and giving Yvette Cooper responsibility for public health. These are youthful cadres, steeled in the purges of loony left deviationists, and lacking any prior ideological or political allegiance. They are totally loyal to the great helmsman and fully committed to whatever policy emerges from the focus groups and think tanks supervised by the fervent capitalist roaders at New Labour's Millbank Tower headquarters.
True to the Chairman's slogan '20 years in a day', the great leap forward against the forces of conservatism in health is proceeding at a suitably hectic pace. In the tradition of ritual denunciation of the enemies of the revolution, the running dogs of reaction in the British Medical Association have been publicly abused. Having scarcely adjusted to last year's forced collectivisation in primary care groups, GP leaders pleaded in vain for some respite from the revolutionary process.
Meanwhile, just as ministers due for a reshuffle become the victims of hostile 'off-the-record' briefings from the prime minister's press secretary, doctors suddenly find the media full of disparaging stories about their crimes and misdemeanours. When they are not (allegedly) murdering their patients and forging their wills, they are either summarily removing them from their lists (because they are mentally ill, need expensive drugs, or are just difficult) or fraudulently keeping them on their lists for years after they have moved away, died or emigrated. The medical profession has not yet been despatched for systematic retraining in Tony-Blair-thought, though recent proposals for 'revalidation' seem likely to require the level of political correctness among practising doctors that is now expected in medical schools.
Chairman Tony says that a great leap forward starts from two legs. Thus the New Labour programme combines populist gestures from the health minister and public health initiatives in which the masses are expected to play a full part. The key ministerial measures are NHS Direct - a 24-hour, nurse-led telephone advice service - and walk-in health centres, where people can get instant access to medical assessment and treatment. Though some experts fear that these concessions to consumer pressure will increase overall demand on the health service and destabilise the gatekeeping role of GPs, the Chairman says 'the customer is always right'.
The red guards forcing the pace of the cultural revolution are to be found in the healthy living centres and health action zones, the cutting edge of New Labour's new public health campaign. These initiatives aim to re-educate the masses in the simple virtues of the peasant way of life, promoting hard work, plain food, parenting classes and lectures in Tony-Blair-thought. Bicycles and wide-brimmed hats are not mandatory, but are encouraged as a healthy lifestyle choice. It is expected that the Chairman's 'smart but informal' dress code of shirtsleeves and sensible trousers will become standard among health service workers.
Frank Dobson, Milburn's recent predecessor and now running for mayor in London, left three legacies to the health service. The first was his rationing of Viagra, when he set a performance standard for the nation in frequency of sexual intercourse, for which he will be forever remembered as Frank 'once a week' Dobson. The second was the bill for the great generic drug rip-off, in which the drug companies got around a deal to reduce the price of branded drugs by discreetly fixing the prices of cheaper 'generic' drugs. Doctors are already being asked to change their prescribing habits to help finance this fraudulent public subsidy of drug company profiteering.
The third was the great waiting list initiative, a propaganda exercise worthy of any Stalinist dictator. The government's success in meeting its waiting list target is reminiscent of the apocryphal Soviet boot factory that was rewarded for exceeding its quota by 100 percent: the boots were counted in single units, not pairs - but all the boots produced were for the left foot. British consultants soon discovered a similar scam: they could cut their waiting lists by proportionately increasing the period of time before patients received their first outpatient appointment and got on the waiting list. The net effect is, in one sense, zero - the duration of the wait is unchanged. More importantly, the effect of introducing this sort of vacuous performance indicator is to spread a corrosive cynicism through the health service that is more damaging to the morale of the NHS than the 'cuts' of the past ever were.
The notorious outcomes of Chairman Mao's great leap forward in China were famine and millions of tons of useless pig iron. Chairman Tony may yet find his campaign for a second term weighed down by the damage caused by his ill-advised cultural revolution in the health service.
Dr Michael Fitzpatrick
Reproduced from LM issue 126, December 1999/January 2000