Published: 16/05/2002, Volume II2, No. 5805 Page 20

It seems churlish to appear ungrateful following the generous injection of new money the NHS will receive over the coming years. is not this precisely what critics of New Labour's parsimony have fought for since 1997? Well, yes and no.

More money in itself is unlikely to resolve the paradox of modern healthcare neatly captured in the phrase 'doing better and feeling worse'.

1No matter how much money is put into health, the demand will always be for more.

We desperately need a new paradigm to inform health policy, but there are few signs of one being fashioned. The Wanless report offers a lead when referring on several occasions to the need to move upstream and take public health seriously. It warns that health policy risks remain trapped by focusing exclusively on acute healthcare.

The government's statement on delivering the NHS plan falls into that trap, only managing to mention the upstream health agenda in passing.

2If the new investment means 'more of the same', only smarter and faster, the government is just buying itself a bit more time. Before long, the problem - which afflicts all healthcare systems - will return.

The government does not seem to have grasped this. Instead it sees the problem as a lack of capability in the NHS to deliver better healthcare. To remedy these deficits, it looks to the private sector for help. This is destined to play a bigger role in healthcare provision for various reasons, including a belief that it does things better and is a natural innovator, and the government does not really trust those public servants it still regards as the problem rather than the solution.

None of these assumptions is founded on good evidence. Indeed, any evidence there is would caution the government to avoid pursuing a course that risks 'hollowing out' the NHS.We are in danger of creating a shell organisation - a health service publicly funded but increasingly privately provided.

Does this matter? Arguments rage with no clear-cut answer, although it is fair to say that we simply do not know whether private providers are more effective and managerially competent than their public sector counterparts.

A factor in the alleged incompetence of public servants is likely to be the unforgiving political environment in which they operate. Ironically, this is likely to intensify despite the promises of devolution. In any event, devolution has to be 'earned' on the government's terms, which makes a mockery of trusting the periphery. Far from devolution being encouraged, the government cannot afford to take a risk on the NHS not delivering.

The fate of the NHS will determine significantly the fate of the government. It has raised the stakes by insisting that sorting out the NHS is its priority.Odd, then, to choose now to let go and hand power to the fledgling primary care trusts.We know it will not let this happen, as it insists on a new 'tough inspection' regime to ensure compliance with its vision of a modernised NHS.

The obsession with targets, inspection and transparency is fuelled by suspicion and a lack of trust - the theme of the 2002 Reith Lectures. Onora O'Neill points to the 'deepening crisis of trust' and holds the new audit culture responsible. 'Plants do not flourish when we pull them up to check their roots: political institutional and professional life will not go well if we constantly uproot them to demonstrate that everything is trustworthy'.

3If the government wants to see the NHS thrive, it should abandon much of its policy. Far from reforming it, the proposed changes seem destined to reinforce a management culture that is risk-averse because, for all their good intentions, ministers will not be able to stand back and let the NHS breathe.

An interesting dynamic in this context is the private sector.How will it react when the new joint ventures and public-private partnerships are subject to the tough inspection promised? Will it need to?

Once the NHS has been 'hollowed out', the private sector will be able to call the shots.

We are told the Germans have experience of PPPs, although we do not know if they work. Even if European experience is relevant to the UK, the government's role model tends to lie further afield in the US. That deeply unequal society ought to have little to teach us about healthcare policy.

Sadly, some believe otherwise. It could be their biggest mistake. l David Hunter is professor of health policy and management at Durham University.


1Wildavsky A. The Art and Craft of Policy Analysis.Macmillan, 1979.

2Department of Health. Delivering the NHS Plan. Cm 5503. DoH, 2002.

3O'Neill O. Lecture One: Spreading suspicion. BBC Reith Lectures 2002.

A question of trust. Radio 4, April 2002.