On the critical list

Blair and Brown's billions are not enough. Here health service expert Julia Neuberger argues that the NHS needs a radical change of culture.

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When Gordon Brown announced his funding boost for the NHS last week, his pledge made one thing above all quite clear: the health service is going to continue to be paid for through direct taxation. While he promised an extra £1bn for the NHS next year, there will be no revolution, no rejection of the financial system devised by Aneurin Bevan and set up under Labour's post-war government. And today, in this newspaper, the Prime Minister, has made plain his commitment to general taxation as the way to pay for increased NHS investment as well.

But however welcome these pledges are, the people who work in the NHS know it takes more than a fatter cheque book to improve the service. Extra cash will not in itself get extra operations done, GP surgeries built or mental health services provided.

The Government began increasing spending on health in 1999, yet two years of above-inflation funding rises have led to few visible improvements in the care of patients. Instead, ministers and managers tried to tackle staffing problems. Shortages had become acute, and the new money was used to keep as many staff as possible. They were offered pay rises, better career opportunities and flexible working conditions.

But to really improve the service, more staff were needed as well – and extra professionals take years to train.

Reforms of the NHS made in the last four years have tackled other important issues: greater responsiveness to patients, closer co-operation between health and social services – especially in dealing with the elderly and the mentally ill – and more coherent professional regulation. They have recognised inequalities in society that have such an important effect on how healthy people are likely to be, and put some extra resources into the most deprived areas.

What has not been happening, though, is a slackening of the central reins of power. Ministers have talked about devolution and local control of budgets, but the transfer of power has been largely illusory. A recent study carried out by the King's Fund showed that the average health authority in England has control over only one-fifth of the new money being allocated to it. All the rest is absorbed either by inflation or by work the Government has told them they must do, like reducing waiting lists or speeding up cancer care.

The Government knows that neither individuals nor organisations improve performance by being criticised, contained and threatened. Yet every NHS manager in the country now faces a welter of targets and priorities, ranging from the establishment of new organisations (for example, primary care trusts) to new quality-control procedures for doctors, and from targets to improve the health of the local population to exhortations to involve it more in planning serives. The result? They are exhausted, cannot prioritise, and cannot spend the time they should listening to local communities.

All of the blame for this should not be laid at the Government's door. The NHS has always been controlled as much by the professions who work in it (doctors, especially hospital consultants, predominant among them) as by the Government. The NHS has always been centred around hospitals, with GPs at the margins. The views and wishes of patients and carers have, traditionally, been of less concern to many professionals than their own judgments about a person's clinical needs.

Could this be the moment, when unprecedented sums of money are coming into the NHS, to change the medical culture? The NHS is operating in a very different environment from Bevan's optimistic time. The population is ageing. In the first three decades of this century, the number of people over 65 is projected to rise by 50 per cent to 15 million.

The NHS will also have to deal with the challenge of consumerism. The generations born since the Second World War are less willing to accept the word of professionals far more assertive as consumers than those born before 1945. Patients today demand more choice in treatments and more alternatives to Western medicine. If those challenges are to be met, politicians will have to think seriously about the way the NHS works, boosting primary and community care services over hospitals.

The NHS would also benefit, perversely, from investment outside it. If at least £700m extra were given each year to social services to help them to look after vulnerable older people, it would keep them out of hospital and speed up their recovery after illness or injury.

Then there is the constant interference from Whitehall. The NHS needs to exist more at arm's length from government. It has also been at the beck and call of doctors, while the people who have really been left out in the cold are the public. But the public is less pliant than it was, and ministers are waking up to how important it is to listen to them and meet their demands. That is the real test coming up for the NHS.

Julia Neuberger is chief executive of the King's Fund, a health think-tank