Donald Macintyre: If only politicians could keep their hands off the NHS

'What has come clear is that the NHS is no longer sacred territory, its future no longer taken as read'
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The Independent Online

If you stand back for a moment, one of the most remarkable aspects of the Evening Standard's report this week about Rose Addis, the 94-year-old woman allegedly abandoned in an A &E department for three days in the Whittington Hospital in London, is that Alan Milburn became involved in it at all.

Leaving aside the increasingly vexed question of whether it was accurate, it isn't rational to expect the Secretary of State for Health to be responsible for micro-managing throughput in casualty at the Whittington. Once routinely described as the biggest employer in the world after the Red Army, the National Health Service remains the largest single organisation in Europe. It treats about a million people a day.

The idea that Mr Milburn can exercise finger-tip control from his office in Whitehall is about as barmy as they come. Yet it was he who, almost routinely, and certainly willingly, became embroiled, and by yesterday had embroiled Tony Blair, in an increasingly furious and high-profile war of words with the newspaper and Iain Duncan Smith over whether the incident happened.

Which serves to illustrate a central point in the King's Fund report published today – the extent of what it calls, at first sight a little innocently, the "over-politicisation" of the NHS. To put it mildly, ministers are far from blameless for this state of affairs, a point of which the King's Fund is well aware and which we'll come to in a moment. But first we shouldn't underestimate the agenda which drives many of the screaming headlines currently fuelling the widespread view that the NHS is in a terminal state of collapse.

I don't know whether there's anything in the – on the face of it extraordinary – charge levelled by Peter Mandelson in a recent newspaper article that the more virulent press attacks on the Government's handling of the public services are an attempt to make the Government too unpopular to risk a euro referendum. It is certainly quite a widespread view at the centre of Government. But something else is clear. It isn't just that the doomsday view is quite sharply at variance with the recent statistics from the NHS modernisation board – which includes leading clinicians and is reporting some genuine progress now that investment is at last flowing through the health service. Or the tediously complicated fact that while there are some horrendous failures in the health service, most honest users of it would admit to much more varied experiences – both good and bad – of how it functions.

It is that the NHS is no longer sacred territory, its future no longer taken as read. Mr Blair was broadly right in the Commons yesterday about the Tories' intentions, but wrong that they have pursued them since the NHS was launched. Indeed this is the first time since the NHS's formation that the Conservatives now look likely (boldly going where even Margaret Thatcher feared to tread) to enter an election proposing to unravel some of its central principles, particularly in relation to funding. The conclusions drawn from the current spate of horror stories are nourished by that new political climate, and in turn help to create it.

In that sense, therefore, the King's Fund looks hopelessly unrealistic in suggesting that the NHS can be depoliticised, let alone in its desire to see the debate over its funding dead and buried. But in another sense it isn't being unrealistic at all. For it has some fairly practical proposals – which would certainly require fresh legislation – for prising the NHS from the tightly clenched fist of direct political control.

First, it wants to see the NHS made a free-standing public corporation "at arm's length" from the Government – not wholly unlike the BBC – responsible for allocating funds across the NHS, regulating and setting standards for health care.

Secondly, it wants health care providers – starting with hospitals – to be run as individual not-for-profit operations, freed of direct Government control and acquiring their own assets from the Government and with them the ability to raise capital from the money markets. The priorities would be set as much to meet local needs as to fulfil centrally set Government norms.

Finally it would (rightly) like to see the gradual opening up of much more patient choice – of hospital as well as of GP – within a publicly funded service.

On the first proposal the Health Department is likely to be very wary, (though the Treasury might be rather less so) not least because it has just set up a new structure. On the second, it would argue that the King's Fund is already going with the grain of Government proposals to award foundation status, and with it more autonomy, to the best performing hospitals.

There is something in this. Certainly Mr Milburn has rightly seen beyond the statism which he believes the left, still stuck with the socialism of 1945, clings too rigidly. In some ways, after all, the idea of a not-for-profit trust, or even a mutual, co-operative or friendly society model, harks back to an earlier era when the left didn't automatically assume that only the state could centrally provide public services.

It's also striking that in several European countries, where the left's relationship with the state has been rather different, there are fewer hang-ups among socialists about different structures. Mr Milburn would argue that he too wants to see much more independence, but that his first job is to set national standards.

There are two caveats here, however. The first is that the Government's plans differ from the King's Fund in that the latter would spread this independence to all hospitals – while reserving the right of the state to intervene to save failing hospitals, or more likely, failing hospital departments. The hospitals would still compete for patients, and for resources, but the presumption would be that they would be assumed innocent until they were proved guilty. Thus they would enjoy autonomy unless proved not to deserve it, rather than the other way round.

The second is whether Mr Milburn's heart – and that of Tony Blair – are deep down as ready to abandon political control as their heads. Primary care groups and hospitals complain with good reason of how little – sometimes less than 20 per cent – of the new money is up to them to allocate, given the plethora of centrally decreed initiatives and directives. Similarly Mr Milburn is serious when he says he wants to see hospitals looking outward to patients and not upwards to Whitehall. But there is something distinctly dirigiste about the way he has replaced Community Health Councils with a complex and unproven network of bodies supposedly representing patient interests.

But these issues matter. In the end the answer to one of the more telling criticisms of the NHS by its right-wing opponents – that it is a fundamentally bureaucratic "Stalinist" institution – is to construct a model which isn't, but is still a tax-funded public service. Hungry to take the credit for success, and imbued with a belief that they know best, all ministers in all governments are reluctant to lose direct control. But by doing so they may in the long run usher in a service which both improves the NHS's responsiveness to patients and gives local staff – clinical and otherwise – more responsibility and fulfilment. The King's Fund ideas are an important contribution to that process.