‘What do you call a man who ignores medical advice? Mr Clarke’.1 It is more than 20 years since the BMA tried to rally public opinion against Ken Clarke, then Mrs Thatcher's health minister, pushing through plans to introduce the internal market, hospital trusts and GP fundholding. The BMA's pompous ‘doctor knows best’ slogan was a spectacular flop and the Conservatives' market reforms were imposed on a divided medical profession and a largely indifferent electorate. Although the public lacked much enthusiasm for the reforms, people were also fed up with being patronised by doctors and taken for granted by public sector union barons, so few rallied to the ‘save our NHS’ banners.
Now Ken Clarke is back – as Lord Chancellor in the coalition government – and Andrew Lansley takes over his roles as the reformer of the health service and tribune of the people in defiance of the intransigence of the medical profession. Like its Thatcherite predecessor, the coalition government retains the initiative on healthcare reform because of the weakness of its opponents, whose arguments often appear defensive, reactionary, and self-interested.
One of the main themes of the government's critics is that the pace of reform is too rapid. But this implies that the problem is merely the speed at which reform is proceeding, not its direction. This concedes the moral high ground to Lansley and Cameron and indulges their posture of being dynamic and innovatory. This recalls the image skilfully cultivated by Labour under Tony Blair for whom the rhetoric of modernisation legitimised every measure to extend the role of market forces within the public sector.
Calls to ‘save the NHS’, or to ‘keep it public’ in face of the incursions of private enterprise, are familiar slogans of the enemies of health service reform. But, to many, these demands appear conservative and backward-looking. They take no account of the experiences of many patients and users of public services, who have often received a poor quality of care and a poor standard of service. Nor do they have much appeal to many health service workers who are only too well aware of the scale of waste and inefficiency in the NHS.
Gloomy editorials lament ‘the end of our NHS’ and the ‘catastrophic break-up of the NHS’.2 Others warn of the dangers of fragmentation of services and increasing competition.3 But the NHS, as the nationalised healthcare industry introduced during and after the Second World War, for better and for worse, came to an end in the 1990s. Health services are already fragmented and primary care trusts have not distinguished themselves in their slavish pursuit of central government diktats.
I have no confidence that consumer choice and market forces will improve the health service. I have even less confidence that GPs, who have a very uneven record in providing primary health care services, can run the whole system. But sentimental appeals to the good old days of the NHS, with its arrogant doctors, squalid hospitals and surly staff are not a convincing alternative to the Lansley reforms.
- © British Journal of General Practice, January 2011