NHS in traction

Lack of money is the least of the health service's problems under New Labour, argues Dr Michael Fitzpatrick

Professor Rudolf Klein, a leading social policy academic, observed nearly 20 years ago that 'as an institution, the NHS ranked next to the monarchy as an unchallenged landmark in the political landscape of Britain' (The Politics of the NHS, 1983). More recently, shrewdly anticipating the winter flu crisis, Professor Klein commented in October 1999 that New Labour's health policies risked 'generating extra demand on the NHS by raising public expectations'. He pointed out that the government's centralising policies would 'increase the political costs of any failure to meet those demands', and warned that 'the NHS could yet turn into as much of an incubus for Labour as it proved for the Conservatives'.

But the solution to New Labour's health problems is not simply to plough in enough money to prevent horror stories of old ladies languishing on casualty trolleys for days (though after two years of austerity resulting from the continuation of Tory spending limits, these issues will be difficult enough to resolve before the next election). The bigger problem facing Tony Blair is that his government clings to the NHS as it clings to any possible focus of national unity. When most other institutions that once inspired popular loyalty are now, like the royal family, widely scorned, and attempts to foster a collective spirit around football, Britpop, the millennium celebrations and the Dome have proved a big disappointment, New Labour is left with that great standby of Old Labour politicians, the 'jewel in the crown' of the postwar welfare state - the NHS.

The NHS serves as a focus for New Labour's populist gestures to the consumer culture, which it believes to be the authentic voice of today's Britain. It is also a key target of New Labour's modernising zeal, taking on the forces of conservatism in the crusade for quality, transparency and accountability. The NHS is destined to play a key role in the government's drive to foster new bonds of community, through the promotion of collaboration in the name of health among different agencies and professionals. New Labour hopes to take advantage of the prestige of the NHS to advance its project of revitalising the institutional framework of British society, and restoring the links between the individual and the state.

So it was significant that Tony Blair, in an interview on the completion of 1000 days in office, singled out the establishment of NHS Direct, the 24-hours-a-day nurse-led phone line, as one of his greatest achievements. This service, like the provision of 'walk-in' GP centres, was introduced in response to the discovery - from focus groups and other surveys - that there was a demand for rapid, easy access to medical advice and treatment. After cursory pilot projects last year, but before any serious evaluation could be made, the government pushed ahead to implement these services nationwide.

The fact that influential figures in the world of health policy - such as King's Fund supremo Julia Neuberger - seem to believe that NHS Direct and walk-in surgeries will help to reduce demand on services such as the overloaded hospital casualty departments would be funny, if the problems facing these services were not so grave. The 'Beveridge fallacy', named after the progenitor of the welfare state (who anticipated that once the health service was underway its costs would decline as the population grew healthier) has been rediscovered by every postwar generation. In fact, as John Knottenbelt, A&E consultant at Northwick Park hospital in north London, complained, 'this NHS Direct thing is not a good thing as far as we are concerned; all they are telling patients is "if you are feeling ill, go to A&E"' (Guardian, 12 January). (And of course, one additional benefit of all the flu calls to NHS Direct was that they gave Liam Donaldson, the government's chief medical officer, the confidence to inflate the flu figures to epidemic proportions, thus allowing the government to claim exceptional circumstances to justify the winter crisis.)

Services like NHS Direct and walk-in surgeries belong more to the world of political hype than that of healthcare. They create their own demand: if they exist they will be used, but in addition to, not instead of, existing services. The fact that they go down well with focus groups is more an indication of the way such techniques can be manipulated to reflect the prejudices of the New Labour elite, rather than a genuine expression of popular demand.

These sorts of propaganda initiative do not merely divert resources from real healthcare. They help to promote the public preoccupation with fears about disease, and so create a spiralling demand for reassurance. Such initiatives also indulge the consumerist prejudice that access to healthcare can be delivered in the same way as a trip to the supermarket or hairdresser. Transferred to the NHS, these notions are both corrosive of relationships of care and trust, and create aspirations that are likely to be frustrated in any publicly funded health service.

Another example of the abuse of the health service by populist gesture is New Labour's celebrated election pledge to reduce waiting lists by 100 000. The government is on course to meet this target - partly through the expedient of accelerating the treatment of patients waiting for minor surgery while others, some with undoubtedly serious conditions, have to wait even longer for their first outpatient appointment. The latest propaganda target is the guarantee that anybody suspected of having cancer will get an outpatient appointment within two weeks. It was dismissed as 'window dressing' by the leading cancer specialist Professor Karol Sikora, now working for the World Health Organisation. Professor Sikora points out that the problem of British cancer services is not the delay in getting an appointment, but the shortage of specialists and specialist facilities for treating patients once their cancer has been diagnosed.

The commitment to modernise the NHS was the central theme of the White Paper The New NHS, published in December 1997. It has moved apace with plans to impose 'clinical governance', a code for managerial control over medical performance, and, most recently, proposals for stricter regulation of doctors' fitness to practise, requiring periodic assessment and 'revalidation'. In his party conference speech last September, Tony Blair singled out the British Medical Association (BMA) as among the 'forces of conservatism' that were resisting the government's modernisation plans in the health service.

This was rather unfair: a few minor quibbles aside, the BMA, and other leading medical bodies like the General Medical Council and the royal colleges governing different specialities, have actively supported the government reforms. Indeed, in substance, they initiated them. While forces of Blairism dominate the medical establishment, forces of conservatism - indeed any forces of opposition to the government's modernising bandwagon - are very difficult to identify. No doubt the old system of medical autonomy and professional self-regulation sheltered some incompetence and corruption. But it is to be doubted whether the introduction of a system of bureaucratic regulation will be any more effective in protecting patients. It seems inevitable, however, that it will be demoralising and coercive for doctors and that this will foster a climate of distrust between doctors and patients.

One of the most radical reforms New Labour has introduced in the health service is in its rhetoric. Out have gone the internal market, competition and contracts; in have come cooperation, collaboration and partnership. The focus of the government's public health programme - especially its flagship 'health action zones' - is on promoting local networks, interagency working, flexibility in professional roles. The idea is to take advantage of the popularity of primary healthcare services (GPs, district nurses, midwives, etc) to restore the bonds of neighbourhood and community that have been severely eroded by the social and political trends of the past decade.

The GP surgery has been identified as a central focus for all this health networking. The reason for this is straightforward. A Guardian/ICM poll in January asked people to grade various professionals (on a scale of one to 10) according to how they were 'respected by people in general': doctors came in at 8.4, exceeded only by nurses (8.5). Cabinet ministers and MPs tied at 5.5. At a time when other agencies - notably social services - are held in low regard, they would like to dissolve and regroup around doctors and nurses, in the hope that this will increase their public acceptability.

New Labour's initiatives converge with a long-running dynamic in general practice to expand the definition of the job into wider areas of social concern. Thus GPs have taken on some of the roles of social workers and the police in relation to drug and alcohol problems, child protection, domestic violence. Some are now collaborating with social workers, sometimes in voluntary organisations, around family intervention, parenting programmes, and initiatives presented as having a 'preventive' role in relation to concerns about child abuse.

The result of these trends is that GPs are pulled into a more intrusive and authoritarian approach to their patients, in a way that is destined to be damaging to doctor-patient relationships, and inevitably to their professional status. It is rather ironic that, after seeking to take over the management of the social as well as the medical problems of the neighbourhood, many GPs complain of high levels of stress (not to mention a growing inclination among their patients to assault them).

So Tony Blair may be able to find more money for the NHS. But given that he seems to be expecting it to provide feelgood PR, restore community and treat patients, his expectations, as well as those of millions of others, are likely to disappointed.