Regular readers will know that I try (not always successfully, to be sure) to avoid judging ideas more on their provenance than on their content. So despite my inbuilt suspicion about nifty ideas on the National Health Service emanating from the Conservatives, I think the principles which inform their latest such idea deserve more than a merely tribal, allergic rejection. Indeed, I think there are aspects which belong in each of the categories in this piece’s title.
So, from the top – what’s good in these ideas? First is the primacy of outcomes over process and procedure. One of New Labour’s most damaging legacies has been the usurpation of professionalism by managerialism. Whether in education, the health service, social services or housing, the Labour administration consistently valued auditors over practitioners. Targets, league tables, tick-box inspection régimes, uniformity masquerading as equality: the past 13 years has consistently focused attention not on effectiveness, but on the appearance of effectiveness as measured by proxies of one kind or another. Doubtless much of this was driven by the best of motives, and in a sense Labour was trying to provide a bulwark against the protestations of their “tax and spend” tormentors in the media by smothering them with statistics, and what were presented as “evidence-based” justifications for the massive increases in spending over which the administration presided. Unfortunately too much of that investment went straight into feeding the machine of inspections, auditing and the rest. In any event, the motivations are not in the end the important factor – the plain fact remains that all this superstructure has cost too much, and distorted delivery too much. If the new government’s proposals really do provide a way out of this vicious circle, then they are to be welcomed on those grounds alone.
There’s more good stuff in these proposals. The central relationship of trust in health provision is surely that between doctor and patient. If your doctor makes the decisions about your care and treatment, then at least you know with whom to remonstrate if you are unhappy about those decisions. But if these decisions are in fact taken by managers responding not to individual patients’ needs, but to averages and cost data, then those patients will not be able to engage effectively. This is double-edged, of course. Doctors in the proposed dispensation will be the ones doing the inevitable rationing of treatments that all health care systems have to undertake. There’s no point in beating around this bush. The health service will always have a limited budget for supply, whilst health demand will always be limitless. If this imbalance is not to be corrected by pricing mechanisms (and it surely must not be) then it has to be managed by rationing. And this is where the proposals run the risk of metamorphosing from the good to the bad.
Given that the trust between patients and their physicians is critical, sowing the seed of doubt in patients’ minds that their doctors’ decisions may be based not on what’s best for them as patients, but on what’s best for the GP consortium’s balance sheet, is likely to corrode that trust. There’s no easy way out of this dilemma, but I suspect that one of the trade-offs that patients will have to make is that in order to be closer to where decisions are taken, they will inevitably be closer also to the dilemmas, and sometimes the unpleasantnesses, of the reality of rationing.
And if we’re not careful, the bad will in turn slip into the ugly. If general practitioners are going to have to expose their patients to some difficult lessons in the language of priorities, those lessons will be very much more unpalatable if they are seen to include considerations of profit and loss for the doctors themselves. I might reluctantly concede that I must accept a less expensive treatment in order to ensure that fellow patients can also be treated: but not in order to increase the profits made by GPs and their consortia. I do not believe that profit and health care can be made to mix in a morally acceptable way. This is where the government’s proposals come unstuck. The last administration thought that quality could be driven by managerialism. The new one thinks it can be driven by market forces. Neither is true. We need a new commitment to health care as a social good, and not, on the one hand, as a weapon in political warfare or, on the other, as an engine of profit.