Experience suggests that there usually is little real major change of political direction of health, as a consequence of change of government. A party is in government, does its thing, establishes issues to be tackled next, fights and loses an election, and the next lot casts its brand that owes more to continuity than to discontinuity. Many examples down the aeons:
· Administrative reorganisations planned by one government and executed by the next.
· The Conservatives brought PFI into healthcare, hated by Labour but ‘rescued’ by it when in government and accelerated into use.
· GP Fundholding to Total Fundholding to Commissioning as practiced by PCTs to Practice Based Commissioning to GP Consortia Commissioning.
· Remember Regions?? From Regional Health Authorities to Regional outpost Offices of the DH, to (small) Strategic Health Authorities to (large and fewer) SHAs, and now to … Regional outpost Offices of DH.
So how might one view the politics of this recent political upheaval following Coalition politics since May?
Well, one thing stands out, and it emanates from the unprecedented investment during the ‘noughties’ to raise the health spend in England from historic average of about 6.5% of GDP to over 8%. Abrupt change in economic circumstances, followed by change of government now heralds quite the opposite. Of course, the NHS has experienced contraction of real-terms funding before, for example during the early 1980s. But everything feels relative to what went before: and what went before this constriction was extraordinary, and therefore this constriction will feel very tight indeed.
But something even more important stands out: general agreement that the previous government’s investment programme was not only massive, it was also inadequately productive. Many reasons are offered: it takes time for major changes to produce the expected better outcomes; too much of the additional money was spent on better salaries, not on better services; even where new and superior designs of health provision were created, rarely did these displace older service models, running instead in parallel to great total cost.
So, is this another example of more continuity than discontinuity? Is the Coalition merely rebranding health policy, or even just recycling older models such as GP Total Fundholding? Or does it herald a genuine new era and, if so, what is new?
Structures are part of the Coalition’s answer, inevitably. We see a mad rush to disband PCTs and to create GP Commissioning Consortia. Regions are disappearing again, or are they?? When reading the little that is available and authoritative about GP Commissioning Consortia, those of us with memories of the Primary Care Groups of 2000-2002 might recall quite a lot that is similar: GPs in the driving seat of commissioning decisions, no closures without their approval etc. We see re-commitment to localism, commitment to reduce ‘micro-management’.
One major point of difference is that PCGs were in charge of setting investment priorities across the system. But now GP Commissioners will need to set disinvestment priorities instead.
And so, this all adds up to one clear issue: a dual commitment, in these financially straitened times, BOTH to growing service quality AND to reducing cost. In previous recessions, politicians, health professionals and the public assumed that less money on healthcare automatically meant lesser or fewer services. Running out of money? Close some wards, reduce the number of ambulance stations, cut estate maintenance and equipment budgets. But this isn’t reflected in what is happening now, and few people believe that such cuts are needed.
The real change is that the pressure is really on to sweat the massive investment made over the last decade, to drive out unprecedented productivity improvements – to do vastly more, with somewhat less.
PCTs may or may not exist, commissioning may or not be GP-led, these things DO NOT matter an awful lot. It isn’t structures, it’s this core task that matters. It matters to every level and each type of organisation in healthcare – NHS or otherwise. It will fundamentally alter how services are strategically planned, commissioned and provided, and how they are chosen and used.
