Ignore the conspiracy theorists, the government’s reforms are not ‘the end of the NHS’

Some in Labour would rather hark back to a mythical NHS than analyse its real problems.

Steve Illife is an emeritus professor of primary care for older people at University College London.

This month marked an important moment in health and social care policy. The government’s announcement of its intention to reverse the Lansley reforms and (allegedly) introduce social care reforms suggests that the health and social care system is about to enter its third era, as the second era of markets and competition collapses.

A minority from the Programmatic tendency of Labour (think Foot, Benn, Corbyn) wishes to use this moment to argue for a return to an idealised first era, marked by central control; by Bevan and bureaucracy.

This presents a problem for Labour’s Strategic tendency, currently in the ascendant (think Wilson, Blair & Brown, Starmer). For the last decade, a disproportionate focus on denouncing privatisation and predicting the imminent death of the NHS have threatened to hinder Labour developing a coherent health and social care policy. 

The same voices – factions within assorted NHS defence organisations – are denouncing the government’s white paper which removes much of the damaging imposition of markets and competition from the NHS.

Oddly, they expect the decline in market mechanisms to foster more privatisation.  Likewise, formalising the establishment of Integrated Care Systems in England, which already exist in Labour-led Wales and in Scotland, have ludicrously been described by some as Americanisation and the end (yet again) of the NHS.

Having organisations outside the public sector delivering publicly funded healthcare is a serious problem, but not the only one needing some thought; and it is not new either.   While news of crony procurement contracts infuriated many, the public remains generally indifferent to private sector involvement in the NHS so long as it does not lead to charging for care. Nobody in Labour is championing more private provision but remove all of it and the core problems of the NHS remain.

Repeatedly, the NHS does reasonably well on international comparisons but with aspects of care like prevention, early detection, and quality of outcomes it is not amongst the best. There are growing concerns over health inequality where the NHS sometimes appears to make things worse rather than better. And the byzantine complexity of who is responsible for managing, and crucially, paying for treatment of people with multiple conditions, frailty and dementia frustrates patients and their families. 

Genuinely radical reform requires hard analysis, but for some in the Labour Party it verges on blasphemy to say this. 

Better care requires the removal of the long-standing operational barriers between hospitals, general practices, community services and social care, with the health system also working far more effectively with local government and the third sector to tackle the broader determinants of poor population health – something the most ambitious forms of integrated care aim to do. The Welsh Labour Government has begun to achieve this through the Wellbeing of Future Generations Act 2015.  Yet many in the Labour Party in England denounce integration as a (yet another) route to privatisation.

How to achieve integration without the pain and waste of huge top-down reorganisations is a puzzle to solve but the benefits of better joined up care are overwhelming in terms of quality of outcome, quality of patient experience and efficient use of public resources. 

The value of public health, and the damage done to pandemic-readiness by a decade of cuts, have been shown vividly during the covid-19 crisis by how much more effective local solutions were for the test and trace programme. The pandemic has also shown that NHS and social care provisions are not easily separated, so new policy must embrace the entirety of the care system.  

There is broad consensus about the main problems facing the care system , like under-funding, limited social care, workforce shortages, resistance to integration, and haggling for favourable resource allocations. However, a minority continue to take the easy route of fabricating conspiracies that bear little resemblance to reality.  For these factions, analysis of the current, woefully poor White Paper on integrated care is much harder than repeating slogans.

Nobody in the Labour Party disagrees that sustained revenue and capital investment in health and care will be vital. Despite the amounts involved looking modest compared to the £400bn devoted to Covid-19, when normal politics returns the single biggest political challenge for Labour will be to convince voters to back a major sustained increase in funding to make the NHS work better, to reduce growing waiting lists and to fix social care. This will be a difficult task. We should not be distracted from an in-depth and rational discussion of NHS reform by conspiracy theories.

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