Comment: The NHS is unsustainable, but these reforms won't fix it

Malcolm Prowle: 'Some believe that a tax-funded NHS, free at the point of use, is unsustainable in the longer term.'
Malcolm Prowle: 'Some believe that a tax-funded NHS, free at the point of use, is unsustainable in the longer term.'

Once again, the NHS threatens to make the Tories toxic.

By Professor Malcolm Prowle

After years of trying to de-toxify the Tory brand and assure the general public that the NHS is safe in their hands, the Conservative-led coalition government has ended up between a rock and a hard place as a consequence of the troubles it is having with its health and social care bill.

To understand this problem there are two key issues. First, there is no doubt that the NHS is in desperate need of reform. In spite of all the various changes that have taken place over the last decade or so, the reality is that large parts of the NHS are unsustainable in their present form for the longer term.

Some believe that a tax-funded NHS, free at the point of use, is unsustainable in the longer term.

The situation has been exacerbated by the dire state of the UK's public finances and the impact of public expenditure reductions. Although the NHS is deemed to be protected from the brunt of the cuts it is still charged with finding £20 billion of efficiency savings over the next four years in order to meet the growing demands of an ageing population and new medical developments. This level of savings is a pipedream. The NHS has always, since its inception, had annual growth in resources and not too long ago it was having annual real terms growth in excess of seven per cent per annum. In other words, the NHS is adept at consuming huge increases in funding each year and it is naïve to think that it can suddenly switch into a mode where it can deliver such huge efficiency savings.

Second, the NHS is hugely resistant to change. Nigel Lawson once said that the NHS is the established religion of the British people and politicians have to tread warily when proposing change.

We have the internal constraints, represented by the trade unions and more importantly the various health professions (especially the medical profession), who see change as a threat to their established positions. The general public, prompted by the media, opposition political parties (of all types) and the health professions are virtually always suspicious to change in the NHS. Even the closure of the most decrepit, outmoded and ineffective hospital will prompt campaigns to "save our hospital" and fill MP's postbags with protest letters.

Into this world stepped Andrew Lansley, the new health secretary. Many people were taken aback by his reform proposals incorporated in the health and social care bill. There are many changes included in the bill but the most publicised and contentious issue was the proposal to transfer responsibility for the commissioning of hospital and community services from the Primary Care Trusts (which were to be abolished) to general practitioners working together in commissioning consortia. Whereas some health reform proposals might generate public opposition it is worth fighting for them because they are likely to work and be beneficial in the longer term. An example here might be the creation of foundation trusts

However the problem with Lansley's proposals regarding commissioning was that they were likely to promote huge opposition (which they did) and, in the view of those of us who have worked in this field for 30 years and seen many attempts at GP involvement in commissioning, they didn't have a snowball in hells chance of working. Most GPs like spending their time with patients not sitting in meetings discussing commissioning, strategies, contracts funding etc. There are exceptions to this but they are exceptions.

So where does this leave Lansley's proposals and the secretary of state himself? Well it seems inconceivable that the bill will not pass through parliament and become law. However, the main content of the bill regarding commissioning and competition are likely to have been so emasculated as to become virtually useless. Pity the NHS managers and civil servants who have to implement this half-a-bill. This will be hugely embarrassing for the government and it is difficult to believe that there won't be a new health secretary soon.

The tragedy of all this is that the NHS is still in need of urgent reform but this fiasco has probably closed- off any chance of radical reform for the remainder of this parliament. What happens when the NHS doesn't deliver the £20 billion savings?

What lessons can be learned from this? It is alleged that the Lansley plan was cooked-up at Conservative central office in opposition, and served up as a finished white paper just two months after the election, without any robust analysis of its feasibility, prospects of success, risks etc.

This chimes with one of the authors who was a Labour health adviser in the 1980s, but still observed the newly-elected Labour government thrashing around in the late 1990s for a workable health service policy after 18 years in opposition. What is it about opposition parties that even after more than a decade in opposition they still come to government with half-baked policies? Is it a lack of resources or a lack of focus? Too often, in our view, opposition parties of all colours fight shy of developing workable policies while in opposition and prefer to focus on slogans - the main ones of which are to reduce administrators, spend more of our money (now in short supply) and employ more doctors and nurses. It is time they started thinking about what doctors and nurses actually do, not how many of them they are. Surely the Mid-Staffs health scandal taught us that.

Professor Malcolm Prowle and Dr Don Harradine work for the Health and Social Care Finance Research Unit at Nottingham Trent University.

The opinions in's Comment and Analysis section are those of the author and are no reflection of the views of the website or its owners.


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