comment: Service reform is sole justification for increased expenditure, says premier

Published: 07/11/2002, Volume II2, No. 5830 Page 19

During HSJ's 40-minute interview with the prime minister, Tony Blair repeatedly returned to a single theme - the public pressure the government is under to improve NHS care (the HSJ interview, pages 11-13).

It was this pressure, he said, which made the government so intensely determined to drive through NHS reform. 'Obeying that intensity', he admitted, occasionally resulted in bad policy. When that happened he wanted NHS staff to 'understand'. In return, he said, the government would do the same when the service hit out at targets or struggled against over-restrictive central control. He provided by way of affirmation what must surely be the most unequivocal declaration of support for NHS managers to come from a prime minister.

But is the government really under 'immense pressure' from the public to improve the NHS? Of course the state of the NHS will always score highly on any poll of voter concerns. But most polls also show a large degree of scepticism that any amount of money can make a significant difference to the quality and accessibility of care.

What the government is really concerned about is convincing the public that increased expenditure can improve NHS care - and that is almost as big a challenge as reforming the service itself. The mission will become acutely important once the National Insurance rise being used to fund the latest investment boost comes into force in April.

The scepticism is, of course, greatest among those who feel that private health insurance - whether individually purchased or as part of a remuneration package - has become an essential safety net in view of the perceived deficiencies of the NHS. And the biggest deficiency in the eyes of these people - who are used to exercising choice in every other facet of their lives - is having to wait.

The middle classes, who have the option of turning away from the NHS, are the key constituency for a government engaged in major reform of the health service. If growing numbers continue to 'go private', it will become impossible for the government to justify the levels of health spending to which it has committed itself.

The 'intensity', as the prime minister admitted, comes from justifying the expenditure.

Which brings us to the aftermath of the consultant contract vote. Those close to the seat of power are spinning its rejection as a huge tactical blunder by the British Medical Association that could lose doctors one of their biggest advantages - public support. It is also being suggested that the inability to deliver a contract it had previously supported has significantly weakened the BMA's position as a representative body. One senior figure described its consultants committee as 'a busted flush' and suggested that the lack of a national deal will actually make it easier to achieve change.

The clinical excellence award scheme (news, pages 6-7) has been whipped out from under the table, stuffed full of cash and presented as the new tool for reform. The potential link with the new financial flows system could be very significant in embedding this approach in the service. There are also reports of a new 'sub consultants grade' composed of those fully committed to undertaking NHS work.

Doctors have responded with threats of strike action and defection from the NHS.

Some commentators have claimed that the government has made a tactical blunder by picking a fight with doctors because they will start playing hardball over salaries and terms and conditions safe in the knowledge that medics are a scarce resource.

Tempers will no doubt cool and compromises be found. However, the prime minister has made it clear that he 'expects to get something back for his money', and that will mean significant changes to the role of consultants. It appears that Mr Blair is up for the one fight from which even Margaret Thatcher shied away.

Wise managers will know that during this ding-dong between government and doctors, they will have to work extra hard to keep medical colleagues engaged in local reform. However, they will do so in perhaps the unique position of having the direct support of not only the prime minister but also staff union Unison, which this week declared that the BMA should not stop blaming 'health service colleagues' for something which owed more to 'their handling of the ballot'.