A grim future foretold

In his introduction to his interim report on the future of the NHS, surgeon Ara Darzi claims that he is a ‘doctor not a politician’.1 Although Lord Darzi has only recently joined the government, his report confirms how rapidly he has learned Labour's cynical doublespeak. The report's bullet point sentences provide the familiar rhetorical cover for the centralised command and control policies through which the government has sought to impose what it regards as ‘populist’ reforms in the NHS. Proclaiming its commitment to be ‘ambitious’ in raising the ‘quality of care’, the report insists that the NHS must ‘respond to the aspirations of patients and the public for a more personalised service by challenging and empowering NHS staff and others locally’. As Neville Goodman memorably observed in his critique of an early New Labour policy statement on ‘clinical governance’, it would be possible to rearrange the clauses in this sentence in several ways to produce an equally meaningful (or meaningless) result.2

Who is going to ‘challenge and empower’ NHS staff? (And, in passing, who are the ‘others’ who are similarly objects of these ominous verbs?) As any government initiative to ‘challenge and empower’ can only come from above, the adverb ‘locally’ is here used in the New Labour sense of ‘centrally’. How are NHS staff to be challenged? Presumably GPs will be challenged by competition from Darzi-style polyclinics run by Tesco and Boots. The result, as Iona Heath has argued, is likely to be the fragmentation of primary care services that may challenge budgets without ‘empowering’ anybody, least of all those in the greatest need of high quality health care.3

Darzi-style ‘empowerment’ is not just for NHS staff. Patients too, are to be ‘empowered to make their decisions count within the NHS’. In a radical rhetorical flourish, the Darzi report insists that we must ‘change the way we lead change’. How? Well, by the expedient of ‘the response to patient needs and choices being led by clinicians’. Although this sounds like the same old process of change being led by hospital consultants — like Ara Darzi — in reality, it is just another combination of weasel words to disguise bureaucratic diktat. Who is to decide what any particular patient needs? What is the meaning of choice for a sick person, afflicted with an inherent deficit in medical expertise and confronted with a range of equally unsatisfactory care options? While the Darzi report may satisfy the new prime minister s need for a high-profile initiative on the NHS, its proposals are based on a profound misunderstanding of its current predicament. Take one example. An underlying theme of both his current report on the future of the NHS and his earlier ‘Framework for Action’ on health services in London is that the dramatic increase in the numbers of patients turning up at hospital A&E departments is the result of restrictions on access to GP surgeries. It is perhaps not surprising that, as a tertiary care hospital specialist, he has not noticed that the rise in A&E attendances over the past 20 years has taken place in parallel with an expansion in the availability (and quality) of primary care services. Both these trends have a common origin in the medicalisation of society: medical entrepreneurs and political opportunists, bureaucrats and journalists have combined to promote awareness of every medical condition from AIDS to yaws, while anxious citizens have embraced health as both a transcendent goal and focus of existential angst. Just as NHS Direct has provoked more attendances at A&E and surgeries, more surgeries staying open for longer will attract and create more patients, and even more patients of GP polyclinics will end up in A&E and other forms of hospital care. Lord Darzi may win more votes for Gordon Brown, but at the cost of increasing the burden of health care on the exchequer — and of making more people ill.

• © British Journal of General Practice, 2007.