Integration and flexibility: those appear to be the watchwords of a new consensus that is emerging about the future of the NHS.
They were the key words that appeared in the Lib Dem public services policy in 2014. They are also the words that Andy Burnham uses to describe his commitment to a new NHS. They are also the words used by Lib Dem health minister Norman Lamb to describe his policy at the Department of Health.
Lamb’s approach has meant in practice a major handbrake turn for the policies pursued by Conservative ministers at the beginning of the coalition. They are also a departure from the inflexible tramlines of NHS thinking laid down by successive Labour ministers during the Blair-Brown years, which emphasised centralised targets, privatised suppliers and PFI contracts.
I am not a spokesman for the Lib Dems. I am not even a member of their policy committee, though I was member of the commission which wrote the party’s new public services policy.
The new policy of integration is being done from the bottom up, partly because nobody knows what model will work best – even if one answer means anything in a diverse nation like ours, where different models work for different people. Bottom up experiment and innovation makes sense to Lib Dems because centralised re-organisations, as we know to our cost, are disruptive and alienating.
Integration is also only possible when devolution of power happens, as it is in Manchester and Sheffield. Because it is only when we can put together budgets across public services that we have any hope of providing the kind of flexible, human-scale and above all effective system that the NHS needs if it is going to be sustainable.
Where I would take issue with Andy Burnham is as follows:
- Burnham gargles with the word ‘flexibility’ at the same time as he proposes a whole raft of new targets and rights for people – including the right to get a GP appointment within 48 hours, without apparently learning what happened last time this happened – and apparently without realising how it is the centralised targets imposed by New Labour that has caused much of the inflexibility that now makes the system as expensive as it now is.
- It isn’t good enough to pretend that fewer, bigger providers will be enough to integrate the system. There is no point in integration if it drives out diversity. If we are going to tackle chronic conditions – which the NHS does so badly at the moment – we will need a diversity of suppliers, some of which are bound to be from outside the NHS. Diversity is vital if the NHS is ever going to support a diverse population. Not everyone is the same, and it has been the major error by Labour over previous generations that has shaped our services as if they were.
- Burnham’s concentration on the Health and Social Care Act 2012 misses the point about it. For one thing, he forgets to mention that it wasn’t passed as intended. The original draft was blocked by the Lib Dems and what remained simply accelerated the contracting out of services that had begun under Labour (but added in some safeguards to prevent conflicts of interest and to rule out competition on price). For another thing, there are elements of the new law that must be kept, particularly the involvement of local government in healthcare, if it is ever going to be integrated with social care.
I was asked to write this article to examine whether there was any prospect of co-operation between Labour and the Lib Dems over the NHS. It is a peculiar question with a paradoxical answer, made more peculiar by the contradictions at the heart of Labour’s current position on the NHS.
On one hand, the Labour record on the NHS stands in the way of co-operation. Labour may not have invented PFI contracts, currently extracting resources for the NHS for large new hospitals which may or may not be effective at that size, but they turbo-charged them. They also didn’t invent centralised targets, but they drove them forward and expanded their power throughout the Blair and Brown years until they had sapped the NHS of its initiative, and shifted resources, energy and imagination into innovative ways of meeting the targets rather than treating patients.
On the other hand, there is clearly room for co-operation given the two parties’ shared commitment to the idea of the NHS – enacted by Bevan (Labour) and imagined by Beveridge (Liberal) – free at the point of use, managed in the public interest, and a shared commitment to reach beyond that to go beyond its role now of tackling symptoms and begin to tackle the causes of ill-health too.
There is a potential joint endeavour here – and to deliver the twin Lib Dem priorities of support for mental health and support for carers. What stands in the way is not policy, but it is the habit the Labour party has of flip-flopping on its position on health according to whether they are in government or opposition. The two stances bear very little comparison.
But if they can stick to it after the election – the new era might just come to fruition, and it’s called flexibility and integration.
David Boyle is a former member of the Lib Dem federal policy committee and the independent reviewer for the government’s Barriers to Choice Review.