Guest editorial: What the right gets wrong about NHS reform
Alastair McLellan, editor, Health Service Journal
This piece was commissioned and accepted in the summer by a government-supporting newspaper. After they had sat on it for a month, I offered it to another title with Conservative sympathies. They were keen and said they would “definitely use it”. Two weeks went by, and they were suddenly “too busy” to cut and paste my words into their content management system.
Maybe they both decided it was rubbish after all. Thanks to Mr Cowper, you can now judge for yourself.
For 20 years, I have had a ring-side seat as governments of the left and right have attempted to reform the NHS.
In 2002, I sat opposite Tony Blair in the Cabinet room as he told me he would not give into the demands of NHS medical consultants for higher pay, and that the money they wanted would be used elsewhere (he did, and it wasn’t).
In the autumn of 2015, I was back in Number Ten, sharing a sofa with health secretary Jeremy Hunt and NHS England chief executive Simon Stevens as they celebrated a funding deal which they believed gave them the resources to deliver their new reform package (it didn’t).
From New Labour’s aborted polyclinic revolution and disastrous National Programme for IT, through the Greek tragedy of Andrew Lansley’s 2012 Health And Care Act, and to Sajid Javid’s “NHS is a Blockbuster service in an age of Netflix” – I have witnessed politicians determined that they could make a difference.
Most of these reforms can be broadly classified as emerging from “centrist” political ideas. Even the Lansley reforms, which opponents said would destroy the NHS, were just a belated attempt to complete New Labour’s drive to instil some creative competitive tension into the NHS.
Real NHS reform just hasn't been tried yet
Beneath the sturm und drang of the latest national initiative, there has always been a steady drum beat of demands for “real” reform from the more zealous wings of the Labour and Conservative parties.
For the left, the great bugbear is “privatisation”. Search for “NHS privatisation book” and you will find a wealth of carefully constricted semi-conspiracy theories, suggesting various bad actors have it for the NHS.
Yet, despite 20 years leading the largest team of investigative healthcare journalists, the great 'plot against the NHS' (to quote one such tome's title) is still to reveal itself to me.
Comment is free (alas)
From the right there have been – thank heaven – few books. Instead, the weapon of choice is the opinion piece.
A cogent criticism of the NHS from a right-wing point of view, and the promotion of a practical alternative to some of its methods, would be a good thing. All institutions are better for constructive challenge, especially as they tend to develop groupthink as the decades roll by.
Health is also consistently the most important issue to the public, and one that will inevitably consume more resources in almost every developed country as the proportion of over-70s increases. It is too important a subject to be left to one worldview.
As editor of Health Service Journal, I drown every week under a torrent of ‘how to fix the NHS’ articles. Whenever I spy one emanating from the Daily Telegraph, the Spectator, Conservative Home, or CapX declaring the time is right for “radical reform of the NHS”, my heart beat quickens.
It soon slows.
The non-yield curve
My disappointment follows a familiar curve. The piece will open with a reflection on the latest NHS failure. This theme will be expanded to take in other areas where the service struggles (the favourite being cancer outcomes).
Strengths (most noticeably equity of access) will be bypassed. Various international comparisons casting the NHS in a poor light will be cited; those showing it towards the top of the tree will be side-stepped.
A new favourite is the latest British Social Attitudes survey – which shows a historic fall in satisfaction levels with the NHS. The fact it also reveals no weakening in support for the founding principles of the NHS is not mentioned.
Nigel Lawson will then be summoned from beyond the veil, to remind everyone the NHS is the UK’s “national religion” – and by implication, deemed beyond criticism.
Next comes the suggestion there is an alternative. This is often couched in breathless terms, meant to draw attention to the author’s daring and originality.
Mention is made of “social insurance” – the post-Brexit irony of suggesting the UK scrap its most beloved institution and replace it with an idea popular on continental Europe is not explored.
The piece thunders on towards its climax – “reform is long overdue”. Here comes the big idea…. except it doesn’t. The article ends abruptly with the implication it has made the necessary changes obvious, without having done anything of the sort.
Variability in healthcare
The impression I am usually left with is that the author finds the idea of variability in healthcare, understandably, intolerable – and has jumped to the conclusion the NHS’s funding and operating model is to blame, rather than grasping the well-evidenced concept that variation is an inherent manifestation of highly complex modern healthcare: one with which every developed nation grapples.
That, and the wrong-headed belief the continued existence of the NHS is somehow an affront to political conservatives.
Every now and again, there is a little detail on how things should change. But, again, they disappoint in ways with which I have become wearingly familiar.
First comes the inappropriate comparison. Exhibit A is often a championing of the health system in Singapore – a country with 3.5 million citizens (for reference, this is about half the population of Greater London), and whose supposed free market healthcare system is in fact heavily government subsidised and controlled.
The inconvenient fact is that most social insurance models are – very broadly – just another way of governments ensuring the public pay for healthcare in a consistent and controlled manner. They also tend to have higher administrative costs (and cause much more angst) than simply collecting those funds through tax. They also to tend to end up increasing the cost of employing people – not something you really want at the moment.
That thing that you do
A derivation of this theme are proposals the NHS should do something it already is doing (for example, making significant use of private sector expertise and capacity), or the promotion of an apparent ‘silver bullet’: most commonly, a call for greater use of technology made without any understanding of the upfront costs involved and the length of time before any benefit is realised.
Then there is the decimal point problem. A senior NHS figure is fond of telling me politicians always “put the decimal point in the wrong place” when it comes to the NHS. They assume expenditure in the millions or even tens of millions will make a significant difference when, in a system that expends £400m every day, it will barely touch the sides.
My favourite in this category is the right’s obsession with health tourism – where recovering money spent on the healthcare of overseas visitors costs more than the tiny amount it would raise.
Without exception, proposals will includes cuts to “NHS bureaucracy.” A pity then that it has been demonstrated ad nauseam that NHS management levels are lower than most healthcare systems – and many respected private sector firms.
Political illiteracy
Most irritating of all, is the sheer political illiteracy on show. It can be argued the NHS is the only thing left which still unites the British people. It is definitely the case that nothing else comes even close to matching the level of affection demonstrated towards it.
And this is not just appreciation for “hard-working doctors and nurses,” it is a belief the NHS is something Britain should be proud of. A government embarking on reform of the service would be taking the biggest risk possible with its electoral prospects.
Conservatives have run the NHS for 47 of its 74 years. It now bears their stamp as much as that of its progenitors. The last three prime ministers have all declared the Conservatives “are now the party of the NHS.” Dominic Cummings put the NHS on the side of the Brexit bus for an exceptionally good reason.
The NHS is a great British success story and one of the nation’s true “global brands.”
The service has much to learn from alternative approaches to healthcare – and needs to be more skilled at doing so. Those on the right should assist in helping that happen, instead of continuing to indulge in the fantasy of some brave new healthcare world.
Alastair McLellan is the editor of HSJ. He is writing here in a personal capacity.