I started reading policy documents on the NHS in 1969. The first was the Green Paper published two years earlier, which launched the discussion about the first major re-organisation.
It did not take place until 1974. We did things at a more leisurely pace in those days. Can you imagine, in the frantic world of today, seven years of discussion and debate?
Sadly, that careful consideration led to one of the least satisfactory reorganisations in NHS history.
Over 40 years later, I’ve been reading the coalition government’s programme. I could be expected to approach it with world weary cynicism, but my interest in and enthusiasm for health policy remains undiminished.
The tone is set by the prime minister and his deputy in their foreword: “Take Conservative thinking on markets, choice and competition and add to it the Liberal Democrat belief in advancing democracy at a much more local level and you have a united vision that is truly radical”.
There are three clear winners - patients, local government and GPs. There are two clear losers - the centralisation and managerialism of the past 20 years and the managers who lose their jobs and career prospects.
There is much here for patients and the public: directly elected members of PCT boards; control of their own health records; information to enable them to rate hospitals and doctors according to the quality of care; detailed data about performance of providers to be published online; the greater involvement of independent and voluntary providers; and the power to choose any provider that meets NHS standards within NHS prices. There are many service initiatives too: improved discharge; more day-case surgery; community access to care and treatments; elderly people helped to live at home longer; dementia research prioritised; a cancer drugs fund; £10m a year for children’s hospices; per patient funding for hospices and providers of palliative care.
Local government will have more influence than at any time since 1948. They will be appointing the members of PCT boards who are not directly elected, and gain the right to challenge proposed closures, as well as to refer cases to the Independent Reconfiguration Panel.
GPs have gained the pole position - they will be responsible for commissioning care, they will act as the champions for patients and for improving public health, and there will be new incentives to improve primary care in disadvantaged areas. It is unlikely that they have much to fear from the renegotiation of their contract or changes to out of hours and the patient’s right to choose a GP without being restricted by geography.
If patients, local government and GPs work effectively together, the new localism will become a powerful reality.
And so to the losers. Few will mourn the passing of centralisation and managerialism. Many will mourn the impact on individual managers. It is right to reduce management costs and tackle the dead hand of complexity and overbearing performance management. But it is also right to treat the individuals with fairness and compassion.