Where, oh, where are the reforms going?

James Gubb, 27 September 2007

The ambiguous messages coming out of the government on the NHS have the potential to be highly damaging. Happily munching my cereal yesterday morning, the Today programme introduced a discussion with the Health Secretary, Alan Johnson, and I confess my initial reaction was, oh no, ‘here we go again’. But, while there was the compulsory dose of ministerial squirming, I actually came away reasonably optimistic that the reforms in the NHS weren’t going to be rolled back after all. Even the reverse?!

Mr Johnson talked much of patients being able to choose their GP, and even of removing postcode restrictions to this choice: ‘postcodes in London [meant that] someone living four streets away from a GP that they want to go to, but they can’t because they’re in a different area, this has to be looked at’. Pushed hard by the presenter, Mr Johnson even conceded that this agenda would mean that GP surgeries would be in competition with each other: ‘part of [the focus on patient care] is empowering patients to say, if I’m not getting good care with this GP I can go to another’.
And an more astonishing confession was to come: ‘[There have been] difficulties with booking an appointment… some of that has come from the fact that we introduced a target – some people say you can hit a target and miss the point – we had a target to book an appointment within 48 hours, [then] patients who wanted an appointment 4 days ahead were not able to’. Was this really a confession that targets don’t work and are actually distortionary?
Similarly, when asked about choice in secondary care and whether he had a problem with patients choosing private providers who could meet the NHS tariff, Mr Johnson quite adamantly said: ‘Not at all’. Is competition to be tried properly after all?!
Although a recurrent and somewhat empty statement, Mr Johnson also made a point of emphasising how ‘the NHS developed as a monolithic organisation, a creature of its time…very centrally driven. Nye Bevan once said ‘if a bed pan falls on the floor, it should echo around Whitehall’. This has changed, what we’re trying to do is get doctors looking out towards patients rather than up towards Whitehall for the next tablet of stone, moving to a clinically led, locally driven NHS’. All sounds great.
But then we have the content of his speech, on the very same day, to the Labour party conference – that a leader in the FT was far from alone in interpreting as ‘Johnson signals end of NHS reforms’. The catchy theme ‘national health service that is also a personal health service’ goes well with the gist of his performance on Today – as did recurring statements of ‘moving away from top-down structural change in order that we can dedicate all our efforts to better patient care’ – but noticeably absent were any mention of ‘choice’, ‘competition’, using ‘market-based’ reforms, ‘private sector’ or even ‘contestability’.
The ‘permanent revolution is over’. The speech instead focused on a centrally-drive drive on patient safety – though ‘empowering and encouraging [matrons and nurses] to use their expertise to fight infection on the front line’ – new powers for Ofcare to inspect and intervene on matters of hospital-acquired infection and GP access. The latter embodies the ambiguity on the government’s approach. Mr Johnson listed the following aims:
• ensuring GPs opened their surgeries at times convenient to patients rather than doctors, including in the evening and at weekends;
• allowing people to register with a GP at home as well as one near their work;
• developing the services offered by pharmacies, which could offer routine care such as blood pressure checks;
• working with high street chains such as Boots, which is interested in running surgeries in its shops; and
• ensuring sports centres offered detailed health advice on prevention of injuries.
But nowhere was there any mention of the mechanisms –competition and patient choice – alluded to in his interview on Today by which this would be achieved. On the face of Mr Johnson’s conference speech, Norman Lamb, the Lib Dem health spokesman is quite right in saying: “The Health Secretary has not explained how more personalised care will be delivered or what the role of the private sector will be in delivering it.”
But – as Mr Johnson showed in his interview on Today – he does, deep down, probably know the answers to both, but does he have the bottle to carry it through? Despite an admission that competition is actually ‘about empowering patients’, it is still seen as something of a dirty word – ‘I don’t mind the word’, said Mr Johnson, ‘[but] it just brings to mind ASDA having price wars with Tesco’ – and it’s much easier to grab short-term political points, particularly with the unions, by introducing glitzy new central initiatives. As Niall Dickson, chief executive of the King’s Fund, has said: ‘there is a worry that in their enthusiasm [New Labour] are starting to say we have the answers at the centre’.
So again, we are left with little idea of where things are going – is it to be a market for health care where patients have a real choice and the independent sector have a real role to play, or is it the very monolithic organisation Mr Johnson says he doesn’t want. In the meantime the lack of clarity is not helpful for anyone.