NHS reform

A MORE than usually terrifying assault on Andrew Lansley’s ragged health and social care bill in the Lancet claims that it is in fact a Trojan horse for private companies taking over key services and ruining the principle that health care should be free at the point of delivery. Naturally Mr Lansley denies this (arguably, his health reforms got so convoluted precisely because he has tried to free up scope for private innovation, while not indulging ideas like co-payment for some treatments, which were already being probed by some New Labour ministers). Your blogger spent some time this week consulting with the private providers the Lancet authors are convinced stand poised to make a killing while sounding the “death knell for a free NHS”. You can read the results in the Britain section this week: but a sneak preview reveals that the private sector is, if anything, rather gloomy about the bill.In particular, key operators believe that the constraints now placed on Monitor, the health regulator, mean that only large, state-backed private operators would stand a chance of passing the fiscal rectitude tests and requirements on equity and debt which would qualify them to compete. In short, far from an onslaught of private companies, seizing patients from GPs and NHS wards, Britain may not be much further down the road to a mixed health economy at all.

The bill has been so badly constructed, sold and prepared for that it is hard even for reformers to defend it in its entirety. A health secretary who ends up starring, if that is the right word, in a vicious mock rap number rudely attacking his plans probably hasn't won the hearts and minds award. Mr Lansley has ended up stubbornly mired in messy amendments, while Number 10, as one former strategist puts it, “was asleep at the wheel” and failed to see a political disaster looming. Had the reforms proceeded without a separate bill, they would, very likely, have proceeded with far less hue and cry, let alone a dedicated rap song.

But beware the cacophony of protest from interest groups who have never welcomed any change to the health service, from GP fund-holding in the early 1990s, to foundation hospitals introduced to allow health managers more autonomy. Many of the same arguments — that this is the end of the NHS “as we know it” — recur every few years. But health systems do need to change to secure efficiencies and respond to changing demographics. The (still unresolved) problem of funding long-term care for a growing number of elderly people is bound to change the shape of health entitlements, so that even this hard-fought bill will need add-ons in the next few years. Meanwhile, the opponents of the changes predict a flood of rapacious private sector operators, while the private sector looks in consternation at the criteria for entry. Many now claim that they would prefer to invest in less constricted health-care markets. They can’t both be right.