I had 23 years in the NHS under Conservative, Labour and latterly, Coalition governments. Structural reorganisation was both regular and increasingly frequent. I worked for a Regional Health Authority, a Health Authority and Primary Care Trusts in their pre- and post-2006 incarnations. All abolished (or will be) in turn. The significant difference this time is that it’s the first reorganisation to coincide with financial contraction.
Cameron’s pre-election point, when unpicking both his party’s Thatcherite legacy and Labour’s statism, was that State and Society isn’t the same thing. One of the things that fundamentally unites the Coalition is the belief that the State should be smaller – either because it’s too expensive or because it’s too inflexible and unresponsive. At its best, Labour stands for the State as a means of intervening and managing in favour of fairness. And Society arguably approves because the State also provides for a degree of accountability that is less available in more obviously contractual transactions.
For me, the idea of an NHS is the mark of a civilised society. And it increasingly feels like the last effective redistributive mechanism left – especially as public housing, education and social care seem destined to relegation as provision of a safety net for the poorest. Anyone working in or experiencing the service knows how inconsistent it can be though. The regular and frequent failings, let alone the scandals, tell us that.
In the course of the campaign against Lansley’s Bill, and in parallel against the initial consequences of financial contraction, everyone seems able to articulate what they are against – no reduction in this, no diminution of that, and so on. Since I left the NHS last year I’ve been wondering what we’re for, or rather, what I think we need to discuss to help determine what we’re for. I have the following six main questions arising from reflection on my experience of the last twenty odd years that seem to me central to a renewed Labour Plan for the NHS:
What are District General Hospitals for?
This is about access to services and access to quality services. Ought we not to be specifying nationally what will be provided where and why it is clinically better to do so. Hospitals could then provide facilities to enable the delivery of specific services – in concert with General Practice and social care – rather than being an end in themselves?
If not competition, what mechanism do we propose for delivering improvement?
Variation in the quality of care, whether unexplained or explained simply by poor practice, should be reduced. How? More benign or more marginal competitive forms? Exhortation? Institutionalising different forms of leadership?
Do we think General Practice as currently constructed is fit for purpose?
General Practice is as General Practice does. Accountability is generally poor and the Partnership model doesn’t seem a very robust or sensible means of delivering services let alone commissioning them. GPs at their best are Consultants in Primary Care. How do we make this real?
What is nursing for?
I think it was Ernie Bevin who when asked for his definition of socialism replied ‘whatever the Labour Government happens to be doing at the time’. Overall, nursing feels like that. Perhaps we can be clear on the purpose, and then arrange training and deployment that supports the purpose?
Are we going to set real national standards of entitlement?
Or are we going to continue to devolve blame – and guarantee inconsistency – by leaving the real rationing decisions to people locally? And why wouldn’t we do the same for local government commissioning of social care?
My questions are in no particular order. Nor are they the only questions. Most seem pretty consistent with SHA policy which in turn is pretty consistent with the sorts of things that are the province of the Party’s National Policy Forum, not to mention comments that turn up in these pages. A genuinely strategic view of what sort of health service we want and where it fits with the rest of the national and local State, rather than a focus on the immediately tactical, needs us to remember that strategy = where are we now, where do we want to be, and, how are we going to get there. In the same way the Bill will become law, our tactics have to be driven by our strategy.
Simon Kirk