Rejuvenate or retire? Views of the NHS at 60 Editor: Nicholas Timmins This is the biggest single experiment in social service that the world has ever seen undertaken. Aneurin Bevan, 7 October 1948. Rejuvenate or retire? Views of the NHS at 60 Editor: Nicholas Timmins In association with “All the key players of the last decades are here, recalling the perpetual struggle to keep up with patients’ ever-rising expectations, to squeeze value from every pound spent and to prove the NHS idea can outlive us all. Succinct, pithy and memorable, this is a riveting window on the ever-revolving and -evolving NHS debate.“ Polly Toynbee, journalist and social commentator Published by The Nuffield Trust, 59 New Cavendish Street, London W1G 7LP Telephone: 020 7631 8450 Facsimile: 020 7631 8451 Email: [email protected] Website: www.nuffieldtrust.org.uk Charity number 209201 © The Nuffield Trust 2008. Not to be reproduced without permission. ISBN-13 978-1-905030-34-7 Designed and typeset by Michael Roberts at Susan Rentoul Design Printed by Q3 Digital/Litho and Modern Colour Solutions The Nuffield Trust The Nuffield Trust is a charitable trust carrying out research and policy analysis on health services. Its focus is on reform of health services to increase the efficiency, effectiveness, equity and responsiveness of care. CONTENTS Foreword 5 Chapter 3: “For the good of the patient” 122 – medical leaders Overview: the NHS at 60 – 8 calm before the storm? Sir George Alberti 123 Dame Carol Black 126 Chapter 1: “The greatest experiment” 32 Sir Graeme Catto 130 – politicians Sir Cyril Chantler 133 Sir Liam Donaldson 136 Lord Patrick Jenkin 33 James Johnson 138 Lord Norman Fowler 38 Bernard Ribeiro 141 Rt Hon. Kenneth Clarke 44 Lord William Waldegrave 54 Chapter 4: Outside views 144 Baroness Virginia Bottomley 57 Rt Hon. Stephen Dorrell 61 David Costain 145 Baroness Julia Cumberlege 67 Karen Davis 147 Rt Hon. Frank Dobson 71 Val Gooding 151 Rt Hon. Alan Milburn 75 David Green 153 Rt Hon. Patricia Hewitt 81 Chris Ham 155 Nicolaus Henke 158 Chapter 2: Speaking truth to power 86 Julian Le Grand 161 – government advisers and senior Alan Maynard 163 civil servants David Mobbs 166 Lord Adair Turner 169 Sir Kenneth Stowe 87 Andrew Vallance-Owen 175 Clive Smee 92 Sir Duncan Nichol 96 Sir Graham Hart 100 Sir Alan Langlands 103 Simon Stevens 107 Lord Nigel Crisp 111 Paul Corrigan 114 David Colin-Thomé 116 Matthew Taylor 119 FOREWORD It has been a great pleasure to put this book together. Nick gamely put off his sabbatical, climbing peaks in Scotland, to do it. The contributors entered into the spirit by giving us rich contributions at short notice, many giving generously with their time to be interviewed, and others putting finger to laptop during impossibly busy schedules. The result, I hope you will agree, is a set of thoughtful reflections, by no means uncritical, which provide a good historical marker of the NHS at 60 years old, and pause for thought. We were particularly interested in reflections from those who had been in a national position to shape the health service; in particular former secretaries of state, permanent secretaries, and chief executives of the NHS, as well as a more eclectic selection of significant others. Set out in part chronologically, there are two reform the NHS, including its financing: “There startling patterns to the contributions. First, the is no constituency for change.” As Sir Kenneth extent of consensus not only about financing, but put it: “End of message.” Public support for the also on many matters of organisation. Given the underlying principles of the NHS remains as strong experience and quality of thought apparent, it is today, principles rooted in the fact of general difficult not to yearn for a non-partisan ‘fantasy taxation being the main source of financing. ministerial team’ to be at the helm, at least for Funding from this source is probably a short period. Second is the importance of the main reason why the NHS is envied abroad ‘journey’, with events unfolding as opportunities – the ability to control costs effectively, perhaps and constraints at the time allow, and of the need too effectively. Public support and effective cost to learn from this to shape the next phase. It will control are unlikely friends in health systems across be important to learn from the experience of the the globe, but the NHS continues to keep them NHS in Scotland, Wales and Northern Ireland, on good terms. It would be political suicide for a which have pursued different paths. Most of the party to turn its back on that, even if attractive contributions in the book are focused on the alternatives were available, which they appear English NHS, in part due to the unusual and more not to be. controversial set of reforms implemented there. However, collective financial parsimony relative to One of the most memorable sentences in individual changing expectations is the challenge. the book, reported in Sir Kenneth Stowe’s How much spending is enough? Healthcare is to contribution, was the one famously uttered by an extent a discretionary good, as pointed out in Margaret Thatcher after hearing radical plans to Henke’s contribution the richer a country is, the Aneurin Bevan at a recruitment drive for nurses at County Hall, London, 21 January 1946 Aneurin Bevan at a recruitment Getty Images © Hulton Archive, Photo: William Vanderson 5 REJUVENATE OR RETIRE? VIEWS OF THE NHS AT 60 hitherto undreamt of efficiencies. Others are more pessimistic. There is more consensus that public funding will continue as the basic main model. “What has changed is the balance Alan Milburn used almost the same words as between the collective and the Stephen Dorrell, who said: individual in society... and that is a What has changed is the balance between challenge for the health service. the collective and the individual in society... and that is a challenge for the health service. To recognise that is not to walk To recognise that is not to walk away from its away from its collective aspiration collective aspiration which... is overwhelmingly which... is overwhelmingly right.” right. Rt Hon. Stephen Dorrell It may not just be right, but pragmatic too. In the meantime the hunt is on, at home and abroad, for value for money in a way that does more it spends on healthcare (publicly or privately). not jeopardise equity access or public satisfaction. Given current trends, at some point this century The chess board and objective are the same, (probably just after midway) the percentage share but the pieces are in different positions in each of gross domestic product (GDP) devoted through country owing to history, values and context. In public funds must plateau. Demand for healthcare a recent, highly insightful analysis of reforms of beyond that limit would have to be financed healthcare across 11 developed countries, Bob through other means. Evans wryly notes the overall lack of progress in tackling one major area – modifying provider This has been a story told for at least a decade. and clinical behaviour – because of the power Many have noted the obvious self-interest of some of the professions to contest needed change of the soothsayers in suggesting the erosion of “in the struggle for the hearts and minds of the tax funding, and alternative sources to top it up. population”. However, as he challenges, “cost The contributors of this book are divided as to control involves modifying physicians’ behaviour as whether the evil day will occur at all. Some believe much as, if not more than, limiting their incomes”. the day will be saved by new technologies forcing If cost-containment leads to “head-on” conflict 6 FOREWORD over “professional organisation and autonomy” he that promote ongoing internalised behaviour warns, “reforming governments do not generally modification at the grass roots through some receive broad public support”. It is not surprising combination of clinicians taking responsibility for to find, as Alan Maynard noted in a similar review, a local budget, information advances allowing that across Europe in the last decade, reforms of more self- and peer-scrutiny of performance, and healthcare across have focused on the demand- competition on outcomes. William Waldegrave side (for example, increasing co-payments) rather must be right when he says in the book, “we’ve than supply-side – yet the latter is surely where somehow trapped people in a structure which profound gains are to be made. isn’t working”– something which applies as much to politicians as doctors. The challenge will be to The innate, profound and consistent conservatism design reforms to ‘untrap’ without warfare with of the medical profession to change, as the medical profession. Thus the journey is likely demonstrated historically by many of its leaders, to be steady advance than big bang. Without it, comes across loudly in a number of contributions the collective model will be eroded. to this book. To cite Sir Kenneth Stowe again, reflecting on the slow progress to improve quality The Nuffield Trust is hugely indebted to Nick and failure to implement the recommendations Timmins for many late night hours of work putting of the Griffiths Inquiry, “It says it all. There is a the book together (on top of a day job) and for failure of medical leadership. It could have been unfailing good humour. Matthew Batchelor was theirs but it wasn’t.” Why are so many doctors the thoroughly conscientious project manager blinkered when it comes to improving services who also worked long hours with patience and rather than just the treatments of the individuals care. Many thanks also to Angelique Buhagiar, in front of them? The talent is there, and there Catrin Rees Ferreira and Kate Uvelli Howe at are encouraging signs, but unless the sleeping The Nuffield Trust for support on practical giant can be roused there cannot be much hope matters.