OBSERVATIONS

BODY POLITIC Nigel Hawkes Choice—a love Labour’s lost Tony Blair’s NHS reforms worked, so why does Labour now oppose Andrew Lansley’s plans, which are heirs to Blair’s?

There was a telling moment at the Brown obstructed—not out of principle blood to suck. Things did not fall apart; launch of the King’s Fund’s new and but pique. We knew, of course, that there the centre held. excellent analysis of Labour’s NHS were clashes, but until pretty late in the This does not surprise me, as a reforms, Understanding New Labour’s day we had no idea how petty, dark, and supporter of the reforms. They were Market Reforms of the English NHS (BMJ malevolent they were. If you don’t believe modest in scale, covered only part of 2011;343:d6179). Adam Oliver of the me, read the books. the service, and were bound, in the face London School of Economics wondered This background makes Labour’s of the system’s monumental inertia, to aloud why Labour had not made more successes over the NHS the more have a limited effect. But what effect of its biggest success, the reduction in remarkable. It also explains something they did have, the King’s Fund finds, was waiting lists, in the 2010 general election that puzzled me at the time: why the in the direction intended. Those health campaign. reforms dribbled out piecemeal, without secretaries who drove the reforms in the He got his reply instantly from a a clearly articulated plan ever being put face of Treasury obstruction and dirty

member of the audience. “Because by before the electorate or parliament. tricks—Alan Milburn, Patricia Hewitt, and then choice had become a dirty word in This was partly the result of Blair’s John Reid—deserve congratulation. None,

Number 10,” hissed Patricia Hewitt, as if disorganised mode of working but “To forget your of course, remains an MP and, as Dr Oliver driven to give witness by forces beyond also because it denied the stage for a failures may be remarked, their successes did not adorn her control. Ms Hewitt, of course, was showdown with Brown he feared he Labour’s banners in 2010. To forget your “sensible“ politics; Labour’s health secretary from 2005 to might lose. failures may be sensible politics; but to

2007, in the middle of an unprecedented This may have been the only way Blair but to bury your bury your successes strikes me as idiotic. three terms of Labour government, which could advance his ideas, but it is now successes strikes Does this sad tale tell us anything

the party is now trying to unremember. his successors—and, paradoxically, me as idiotic about the road ahead for Lansley’s Prime ministers who serve lengthy the Conservative health secretary, reforms? It is no good asking Labour terms often suffer a crash in reputation Andrew Lansley—who are paying the or the many vested interests that have afterwards, but you would not have price. Because the policies were so “ joined the bandwagon. They are simply heard a Conservative conference at any personal and never argued through and revelling in the opposition they believed time boo the mention of Mrs Thatcher’s incorporated into doctrine, they can they were denied by Blair. True, the name as last week’s Labour conference now be disowned. The opponents of Lansley reforms go further—but not that booed Tony Blair’s. Here is a man who Lansley’s reforms either seem oblivious much further. Inertia is every bit as strong delivered to Labour what it had always to the fact that most of them are heirs to as it was. The first conclusion to draw wanted, a long period of comfortable Blair’s or see that as another reason to is that the reforms, if enacted, will have parliamentary majorities, but who is now anathematise them. Lansley’s error was much less profound effects than some an embarrassment. to be honest about what he wanted to do, hope for and many fear. Reading the history of those years rather than devious. Much could have The most damaging effect of the in the words of Blair himself, or of been achieved without legislation and, way Blair worked is that it has made the former Cabinet minister and Blair had he been more Machiavellian, would impossible a bipartisan approach to the loyalist Peter Mandelson, or of the have been. By his artless honesty he has NHS in England, in spite of the parallels political columnist Andrew Rawnsley provided Labour with the showdown Blair between what Labour did and the (or, no doubt, of the former chancellor denied it. coalition hopes to do. Those on the left Alistair Darling, though I suspect my The King’s Fund report card on the think they were dragged unwillingly down appetite for books about New Labour’s Blairite market reforms is positive. a road they did not choose. Those who internecine struggles is now sated), They enabled the NHS in England to did the dragging are out of parliament generates both sympathy and anger. advance more rapidly than the health or silenced. The party is led by a former As a journalist my anger is directed services in Wales or Scotland, without member of Team Brown, in spite of the first at the political correspondents a reduction in quality of care and with fact that when the chancellor finally did who played the spinmasters’ games, at least a nod towards the interests of elbow his way into Number 10 he turned content to take their stories at dictation patients, so long regarded as an irritating out to have no distinctive ideas of his own speed from either Number 10 or Gordon obstruction to the smooth operation of bmj.com at all. Brown’s rival court at the Treasury. But we the service. Waiting times fell fast; dark The reforms worked. But the politics of ЖVisit the BMJ NHS should also be angry at the chancellor’s warnings of fragmentation and growing Ж the reforms was a disaster. reforms• bmj.com microsite for all dreadful behaviour. From first to last, inequity proved exaggerated; and Xxl dltgf dl fgld gfld fgld Nigel Hawkes is a freelance journalist, rational argument took second place to a private companies accused of seeking the latest BMJ articles London gld gld gld gfueid gld gld baseless grudge and a misplaced sense to suck the blood of the NHS to feed their on the NHS reforms [email protected] of entitlement. Anything Blair favoured, shareholders found there wasn’t a lot of bmj.com/nhsreformsgld gld gld gld gld gld g Cite this as: BMJ 2011;343:d6319

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MEDICINE AND THE MEDIA Secret filming shows deep problems in general practice Random inspections would improve patient safety, says Aneez Esmail, who advised a television programme that covertly found that “failing doctors routinely slip through the system”

t was a comment that I made in an Critical to my agreement to take part was a who had taken cases to the GMC or to the interview for BBC Radio 4’s File on 4 realisation based on my research that there was medical defence unions. These patients had programme that caught the attention of poor and dangerous practice that the public sought action and sometimes compensation producers at Channel 4’s Dispatches. I were completely unaware of, and that the when doctors had failed to make the correct had been speaking about the problems quality of general practice was variable—and diagnosis. The cases we used were not difficult Iof understanding patient safety in general frankly very poor in some areas. I also knew to diagnose and most doctors would have easily practice and how little we knew about issues that the monitoring of general practitioners recognised the symptoms. related to wrong diagnosis and misdiagnosis. I who had been brought before the General Overall I think Dispatches painted a picture also raised the question of who would monitor Medical Council and criticised for poor of general practice where there are still general practitioners in the brave new world of performance was grossly inadequate. In my fundamental problems with the monitoring commissioning. Would I, they asked, be willing view, the over-riding public interest justified the and regulation of doctors, especially those to take part in a documentary that would open secret filming. who give cause for concern. The Shipman the lid on some of these issues? In 1993, as part of our research, my inquiry cost £25m (€29m; $39m) and Improving patient safety in primary care is colleague Sam Everington and I used false lasted nearly six years. It was the most one of my research interests. I have investigated résumés to prove that many Asian doctors were comprehensive investigation of the state of the main problem areas and how we can being discriminated against. Although we were primary care since the creation of the NHS. monitor and improve things. As the medical heavily criticised by the medical establishment Sadly many of the recommendations that adviser to Dame Janet Smith on the Shipman and accused of professional misconduct by the related to safeguarding patients are still to be inquiry I was part of the team that attempted GMC, we exposed a gross injustice. Because of implemented. This is despite consensus from to put in place systems to prevent general the furore that followed, the previously all the medical professional organisations practitioners harming their patients. I have a unacknowledged problem of discrimination and political parties—until the 2010 general keen interest in identifying poor and unsafe was brought into the open. The research election at least. practice—not to shame and blame but to show ultimately led to changes in the recruitment of So what have we learnt? The secondary these problems exist, and that we can and doctors, in the way that the GMC investigated school for which I am chairman of governors should have mechanisms for improvement. and dealt with complaints, in the selection of was recently inspected by Ofsted, the When I was asked whether I would be willing students to medical school, and in the way in government’s monitor of teaching. We were to be involved in consulting on the secret which aspects of doctors’ remuneration were given three days’ notice of the inspection and filming of general practitioners my first reaction determined through the allocation of clinical more than 60 lessons were observed by the was to run a mile. How could I justify being excellence awards. inspectors. Where is that same scrutiny of involved in this kind of I helped the Dispatches team develop case general practitioners? During the Shipman subterfuge? What were the ethics of it all? scenarios based on examples of patients inquiry we were given examples from Canada, where part of the monitoring mechanism The secondary involves random visits to practices to assess school for which the quality and safety of care. Do we really I am chairman know how safe general practice is? And where of governors we identify problems, what mechanisms was recently do we have to ensure that the poor practice identified in the programme is tackled? inspected by The secret filming showed that there are Ofsted. We were mechanisms to identify poor practice. If we given three can do that, then can we begin the task of days’ notice, improving standards and safety. and more than First published as a blog on http://blogs.bmj.com/bmj/; not 60 lessons were externally peer reviewed. The Dispatches programme “Can you trust your observed by doctor?” was first shown on Channel 4 on the inspectors. 3 October 2011. It is available at www.channel4.com/ Where is the programmes/dispatches/4od#3236726. same scrutiny Aneez Esmail is professor of primary care, University of general of Manchester [email protected] practitioners? Cite this as: BMJ 2011;343:d6392 BLOOMIMAGE/GETTYIMAGES

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