Scotland’s independent think tank
Scotland’s independent think tank

Choice is the key if the NHS is to enjoy a healthy future – Tom Harris

This post by Tom Harris, which first appeared in the Sunday Times on 30 August 2015, is a summary of a chapter from a forthcoming publication, ‘Reforming Scotland’, produced by Reform Scotland.

So frequently repeated has the phrase about the NHS being Britain’s national religion been that it has become a cliché as well as an accurate observation. And it’s the deference with which the health service is regarded by politicians, media and citizens that is its greatest strength and weakness. Strength because it is unassailable; no party would dare undermine or threaten the central concept of free health care at the point of use, paid for from general taxation and available to all irrespective of income.

Yet after 30 years of knocking on voters’ doors and speaking to them about their actual experiences as patients, of 14 years listening to constituents’ complaints about their treatment at the hands of NHS staff, I am only too well aware that the NHS’s perception as a “religion” is also its greatest weakness. For its critics are too often reviled as apostates and heretics.

Julie Bailey is a good example. The Mid-Staffs whistleblower, whose own mother’s death led to the exposure of appalling standards of care at the hospital at the end of the last decade, is regularly the target of abuse from defenders of the NHS who believe Ms Bailey’s criticisms should have been made privately or, preferably, not at all. That the Labour government of the day initially refused to hold a public inquiry into the scandal says much about how far away the government had by then drifted from the principle that the patients, not the staff, must come first.

Instead of its mealy-mouthed “lessons learned” approach to the inquiry that was finally instigated by the Conservatives, Labour, the self-proclaimed “party of the NHS” would have helped restore confidence in that claim if it had instead called for criminal charges against the incompetent, lazy and malicious staff who caused such misery to those for whose care they were responsible.

But such an approach would have sorely vexed the public sector unions whose members were in the firing line and whose political contributions fund the Labour Party.

Because of its historic role in founding the NHS – a role of which its members are rightly proud – it is Labour that finds itself in the most difficulty when it comes to reform. And too often it sides with the vested interests of the producers, rather than the consumers.

When David Cameron, flush from his unexpected victory at the polls in May, proposed a seven-day NHS, Labour’s over-cautious reaction reflected its reluctance to take on the BMA and the health unions. While the party was hesitantly scratching its head, the public were scratching theirs in bewilderment: You mean there isn’t a seven-day service already? How on earth did that happen…?

As with the living wage and devolution, the Conservatives are now edging Labour off its traditional political ground and claiming it for itself. For the official opposition, there are two dangers here: first, that they lose their reputation for radicalism in the service of patients; and secondly, that the Conservatives, once they’ve gained the public’s trust over their handling of the NHS, will feel they have the freedom to introduce rather less cuddly reforms, reforms which Labour will have more confidence to oppose. But by then it may be too late.

Reforms that Labour should feel relaxed about include the dreaded word “private”. Because we’re all private healthcare users. Every one of us. And that is not the result of any new Blairite or Thatcherite innovation; it’s been the case since the NHS was born. Your local doctor is not an NHS employee. He or she is a business person, contracted by the NHS to provide a service – a service from which your doctor makes a tidy profit.

Similarly dentists and opticians and a range of other services, are all provided by private companies (or contractors, if you prefer).

No-one cares. And no-one is calling for that system to be replaced by one in which GPs are directly employed by the NHS. Nor should they.

Patients who are given life-changing treatment by a private company operating as a contractor to the NHS simply do not care who performs the surgery. They want efficient, quality care and they don’t want to pay for it. Beyond that, they have more important things to be getting on with – like life, for instance.

Change is always resisted. It’s what happens when you have a 70-year-old monolith whose creators would prefer to preserve it in aspic than make it fit for the future.

How can it be, in the early part of the 21st century, that choice remains a dirty word in Scotland’s NHS?

In 2012, Reform Scotland published “Patients First: Improving Access to GP Practices”, an attempt to persuade the medical profession and politicians that primary care needed to become more flexible, with patients’, not professionals’, needs put first. Patients should be able to choose between surgeries, even if it meant their preferred practice being outwith their local catchment area. And, as has already happened in England, private companies should be allowed to set up local GP practices.

Inevitably, the report, although fairly modest in its recommendations, was scathingly received by some influential figures in the medical profession and little progress has been made on it from a political perspective.

Yet, as new technology continues to transform almost every public service, the very idea that it should be up to NHS bureaucrats, rather than citizens themselves, to decide who should provide their treatment, starts to look as outdated as the closed shop. Whatever the objections of GPs and health boards themselves, this feels like one of those debates on which history will pour scorn, rather like looking back on the 1980s in astonishment that smoking used to be allowed on airplanes. Why shouldn’t anyone who is able to travel that extra mile (literally) sign up at a practice that is not quite as local as another practice with which that citizen is dissatisfied? If the preferred surgery’s patient list is full, they can always refuse the application on those grounds. If it’s not full, what difference does it make to treat someone from outside the local area?

It’s all faintly depressing. It seems that even the professionals, in whom the public place so much unqualified trust, are reluctant to say or suggest anything that might seem even a little controversial or at odds with the health consensus that prevails in Scotland.

And yet, when another consensus is developing – one that concludes that the NHS is indeed about to reach a crisis point in terms of resources – isn’t this the best time for our professional health bodies, and yes, even politicians, to risk public disapproval by offering some new and challenging solutions?

Since devolution, ministers of both parties have enshrined a form of conservatism when it comes to public service reform. While Scotland peers with contempt at academies and free schools south of the border, at the growth of private health providers within the NHS, it further entrenches the ultimately doomed philosophy that the answer to every problem is more cash, not reform.

Not only is the private sector already entrenched in the NHS, and has been since its inception, it simply could not function, could not provide all the services we expect of it, were that not the case.

And yet instead of acknowledging and approving of this concept, politicians prefer to recite the “public good, private bad” mantra, however misleading and dishonest that is.

Tom Harris is a member of Reform Scotland’s Advisory Board, the director and founder of Third Avenue Communications and a former Labour minister for transport.