Liberating the NHS

The new health White Paper proclaims, in its subtitle, the goal of ‘liberating the NHS’, but the ascendancy of the concept of ‘wellbeing’ threatens to consolidate the tyranny of health over patients and professionals alike.1,2

Having suggested before the election that the abolition of PCTs would be a ‘promising way of saving money and improving primary care at a stroke’,3 I find myself in an unfamiliar position of alignment with one of the more controversial proposals of the coalition government's White Paper. On first reading this hastily produced blueprint for drastic restructuring of the health service, I was struck by the claim that the proposed replacement for PCTs — local GP consortia — would ‘increase efficiency by enabling GPs to strip out activities that do not have appreciable benefits for patients’ health or healthcare’. But my excitement at the prospect of ‘stripping out’ all the sort of ‘health promotion’ and ‘disease prevention’ activities that have such a baneful effect on the health of our patients — starting with the NHS Health Check — was short-lived. These are exactly the sorts of activities that the Equity and Excellence White Paper, whose very title and every page indicate a spirit of continuity with the buzzwords and rhetoric of New Labour (‘transparency’, ‘world-class’, even ‘information revolution’), is determined to pursue, indeed, to enforce on general practice.

The familiar weasel words of ‘choice’, ‘competition’, and ‘empowerment’ thinly disguise compulsion and coercion. The proposed consortia will be assembled by a process of forced collectivisation: GPs will have no choice about the terms on which we compete in the new primary care market. We will also have a ‘duty to participate’ with local government authorities, who will be given major new powers, including taking over many of the functions of the old PCTs. In particular, we will be obliged to surrender to the ‘strategic role’ of the proposed local authority ‘health and wellbeing boards’. (To adapt an old adage, ‘Those who can do, those who can't, take on a strategic role’.) These boards will provide a new base from which the zealots of public health can promote their moral crusades (from ‘safe sex’ to ‘five a day’) and hype up public anxieties with their imaginary epidemics and pandemics.

The expansion of health reflected in the relatively new, but now universally promoted, coupling of ‘health and wellbeing’, has major consequences for society. Instead of being regarded as the absence of disease, the default state of robust citizens in a mature democracy, health has become the transcendent goal of the fragile and vulnerable individuals of the risk society. Wellbeing — like its close relation, ‘happiness’, another policy ‘outcome’ for both Tony's ‘Third Way’ and Dave's ‘Big Society’ —can only be attained through the pursuit of an ascetic lifestyle and regular submission to medical surveillance. The problem for the NHS is that the burden of demand resulting from the health-related anxieties and expectations that are unleashed by this process are unsustainable. The reforms proposed in the new White Paper, like its predecessors, will merely ensure that more and more people, falling short in achieving the desired and promised outcomes of health and wellbeing, will feel ill, fostering spiralling costs in both primary and secondary health care.

• © British Journal of General Practice, 2010.