Jeremy Laurance: Can the NHS learn to treat patients as customers?

'Money is not the problem - and this explains Treasury jitters - it is capacity'
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The Independent Online

"I believe," Alan Milburn said yesterday, "the best days of the NHS are ahead of us not behind us".

These are the words of a man who knows his pockets are about to be stuffed with gold. The Secretary of State for Health was speaking to an NHS leadership conference and it is hard to remember a time when any minister awaited a Budget announcement with such confidence.

But is he right? While it is a racing certainty that the Chancellor Gordon Brown will put a smile on the faces of the NHS's finance directors next week, it is less certain that his billions can transform Britain's biggest service industry. The health service employs 1.2 million people and treated more than 31 million people in hospital last year – not including the legions who consulted GPs and nurses.

Downing Street claimed this week that "the tanker has been turned" after the health department published an NHS progress report showing the longest waiting lists down to 15 months for in-patients and six months for out-patients (hardly a cause for celebration, but at least the direction of travel is right), quicker ambulances, shorter waits in accident and emergency, fewer delayed discharges.

All this is good news, and ministers were, for once, generous with their praise for the NHS staff who made it possible. But we are still only in the foothills of NHS reform. The mountain is yet to come.

There are two principal areas where the NHS has still to prove itself if it is to deliver the world-class service to which Tony Blair has personally committed himself. The first and simplest – though it is not simple – is on quantity. The NHS must accelerate the rate at which it is treating patients.

There are just over one million people waiting for hospital in-patient treatment but for much of last year people were being added to the list by GPs as fast as they were being taken off it into hospital. Hence the disappointing progress towards cutting waiting times – down by just three days from an average 18 weeks to 17 and a half.

No one needs telling that the length of time people wait for treatment is critical to how the NHS is perceived. But boosting activity further is going to be extremely difficult. The hospitals are already full and the doctors and nurses are fully stretched. Money is not the problem – and this explains Treasury jitters about whether extra billions for the NHS will be well spent – it is capacity. Buying in extra capacity from the private sector is useful but will help only at the margins.

The second area where the NHS has to prove itself is on quality. Much has been achieved here too. We have, thanks largely to the Bristol heart surgery scandal, one of the best regulated health systems in the world, with regular checks on the performance of doctors and nurses and continuous monitoring of hospitals. France, often held up as the model to which we should aspire, has nothing of this kind.

But the aspect on which the NHS is weakest is in reproducing in a state-run service the customer relationship that exists in paid-for services. When money changes hands, the patient enters into a contract with the treating physician which acts as a lever to ensure good, considerate, thoughtful care.

Much treatment in the NHS is good and some is bad. But for most patients who pass through the system, their treatment is not all good or all bad, it is a mixture of the two. A key pre-occupation of ministers is how to build in incentives and targets that encourage the delivery of good care in the absence of financial exchange. How to balance the rhetoric of choice in a context of limited resources.

It is this Achilles heel that Liam Fox, the shadow Health Spokesman, sought to exploit when he tolda Tory meeting in Harrogate that the public had to be convinced the NHS was not working and could not be made to work. "We've got a problem where the NHS and healthcare has been synonymous. We're here to break that," Dr Fox said.

His comments were leapt on by Labour who claimed they demonstrated that the Tories were bent on destroying the NHS. Gordon Brown told the Commons that Dr Fox was proposing to make people "pay for being sick". But unless ministers can get the incentives in the NHS right so that the service is truly patient-led, the Tories won't need to destroy the NHS. The public, growing ever more affluent and demanding with constantly rising expectations, may do it for them.

There is another worry. In their anxiety to protect the NHS, the jewel in Labour's welfare crown, ministers have so hedged it about with targets, star rating systems and earmarked funds they are in danger of crushing the life out of it. The Kings Fund reported yesterday that the NHS had been overwhelmed by a torrent of well-meaning initiatives.

Meanwhile, doctors whose specialties have not been singled out for special support under one of the national service frameworks are losing heart. One senior consultant, in an area not designated a priority, told me yesterday: "Wherever the Chancellor's billions have gone, they are not reaching the front line. I find despair among many of my colleagues over this. I don't trust the politicians at all."

However big the plum Gordon Brown pulls out of his budget briefcase for the NHS next week, it will not alone solve its problems. It will take imagination, innovation and flair to do that.