A Radical Health Manifesto: The NHS Needs More Than Reorganisation to Change the Health of the Nation
Thornton, Stephen, New Statesman (1996)
Governments have always taken great delight in redesigning the management arrangements of the NHS. At regular intervals over the past quarter of a century (1973, 1982, 1990 and now in 1998) there have been upheavals of seismic proportions. Each set of changes has been launched amid a blaze of publicity condemning the failures of the past and extolling the virtues of the latest solution.
However, politicians - and the managers they expect to deliver such changes - delude themselves if they believe there is a causal link between the NHS's formal organisational arrangements and trends in health and healthcare.
The forces that have transformed the NHS over the past 25 years had little to do with political leadership or managerial manipulation. The first has been medical technological change, such as the advent of day surgery, which has enabled the NHS to claim dramatic improvements in productivity. The second is the growing number of dependent elderly people, which has forced the NHS increasingly to restrict itself to medical care, leaving the burden of social care to others. The third has been public expectation, fuelled by media-inspired consumer awareness which has raised quality standards, for example in maternity care.
The job of the politician is not to initiate or even to tame these social and scientific trends, but to decide how the balance of their costs and benefits should be distributed across society.
In this respect the government's NHS white paper was something of a disappointment, emphasising a false dichotomy between its own brave new world and what had gone before. It focused on the institutional solutions it wanted to ditch (fundholding and the internal market) and those it wanted to create (such as the National Institute of Clinical Excellence). There was no real attempt at an assessment of the health impact of these proposals. We were simply expected to believe all would be better.
By contrast, the government's recent green paper on public health tackled issues not institutions. Here, at last, was a radical manifesto, exploring with us in the NHS why we were here, who we were here to serve and what impact our actions might have on people's lives.
Its radicalism stems from its recognition of the fundamental importance of the structural determinants of health over matters of lifestyle - something we all knew but had waited 20 years to be able to affirm openly. This was reinforced by its emphasis on the damaging consequences of health inequalities. It makes it abundantly clear that government social policy over the past few decades has failed to halt the growing gap between rich and poor.
But can the vision of the green paper be realised? It certainly has profound implications for the NHS. It spells a shift from short to long term; from health services to health; and from universal provision to targeted action. …