The National Health Service (NHS) is heading towards its biggest restructuring since it was founded in 1948. Stand by for nervous pre-emptive strikes by medics, managers and ministers. The past few days have produced a flood of health-related stories. Time for some context. The NHS was described by one American academic as "the finest bit of social legislation since Magna Carta". The trouble has always been how to fund it. Its tax-based system has proved the cheapest and fairest way of funding health care, but it has suffered from one persistent and serious defect: the politicians had to be persuaded to find the cash. Now they have done just that. Labour has promised to increase spending on the service by a third over the next five years from £50bn to £69bn. Annual spending increases will rise to 6% in real terms, double the historic trend. But as a quid pro quo, ministers have insisted the service must be modernised. A 10-year plan is to be published later this month.
Traditionalists believe the NHS has continued to provide clinical treatment as good as anywhere in the world, but concede that the continuous financial squeeze has left us in some areas with conditions which would cause a riot if experienced on a package holiday: shabby rooms, peeling paint, grim grey corridors. Two recent reports have questioned even the standard of health care. The World Health Organisation's league table of health systems, published two weeks ago, placed the UK 18th out of the 191 member nations - below France, Italy, Greece, Spain, Japan, Norway and Portugal, though ahead of the US, Germany, Denmark, and Sweden. The nation which topped the league, France, carries out 30% more hip-replacement operations and 42% more heart bypasses. One reason, as the health secretary has conceded, is that they have more doctors. Yet it is not that simple. Germany, with twice as many doctors as the UK, came 25th.
A more disturbing report was last Friday's study on lung cancer in the Clinical Oncology journal, which found the disease had become untreatable in more than one in five sufferers because of the time they had waited for treatment. Although the study involved only 29 patients, the government's cancer tsar conceded it was highlighting "unacceptable problems that we know exist and are determined to tackle in our cancer services". Fast-growing tumours are not restricted to lung cancer, but affect head, neck and cervical cancer too.
Changes in the pipeline are not restricted to the national plan. Last week's row at the British Medical Association conference, when the General Medical Council was censured for the first time, was driven by the GMC's proposals for a medical MOT, under which all doctors will have to have their licences to practise revalidated every five years. Labour's Commission for Health Improvement has begun its inspections, which will monitor all units and services in the system. Hospital and health authorities are drawing up annual appraisal systems. A traditionally independent profession is having to come to terms with being made accountable.
Gross though recent medical abuses have been - incompetent operations on children, arrogant removal of organs from dead babies, inappropriate operations on women - doctors point to the numbers treated by the NHS: 1m patients each day. What they ignore is the chief medical officer's report which suggested that one in three hospital consultants and one in five GPs suffered from some performance problem. His aim was not to find scapegoats but to move away from the present blame culture to a system which would identify underperformance early and provide the medics involved with more support. That serves the interests of both patients and doctors. Making the health service more patient-oriented will have that double benefit too. The government is right to ignore BMA grumbles against the new NHS helpline, walk-in clinics and online health care. Medics as well as patients will gain if ministers succeed in breaking down the rigid professional demarcation barriers which prevent doctors, nurses and allied professionals from working more flexibly. A more responsive service can give the professionals more cause for pride and greater job satisfaction.
On one issue both medics and managers are united: their suspicion of central controls. In its 1997 manifesto, Labour insisted that "there can be no return to top-down management"; yet top- down management has returned. But this may have been necessary to generate the energy for reform. The test is whether ministers will be ready to let go of the levers once their framework is in place. The health secretary has spoken of "earned autonomy", which managers have welcomed: successfully run units will be left alone. A modernising blitz is justified. But it must not ignore the old unsolved challenges facing the NHS: chronic care and health inequalities.
