The response to the Coalition's health reforms summons to mind the parable of the blind men and the elephant: opinions as to what we are grappling with are hopelessly conflicting. Some have presented the health bill, introduced to Parliament yesterday, as a revolution; a big bang which will transform the National Health Service out of all recognition.
Others describe it as an evolutionary change; a natural continuation of structural reforms that have been running, at various speeds, for two decades. David Cameron himself seems unsure of how to describe what the Health Secretary, Andrew Lansley, has come up with. At times the Prime Minister has presented it as a once-in-a-generation overhaul. At others, he has tried to reassure patients and health workers that their lives will be little changed.
But just as the blind men in the parable were unwittingly describing different parts of the same animal – a trunk here, an ear there, a tail at the back – it is possible that both perspectives on NHS reform will turn out to have an element of truth in them. It is true that devolving healthcare commissioning responsibilities to family doctors, the central thrust of the bill, is not new. GP fundholding was established by John Major's government in the 1990s. And Labour introduced practice-based commissioning and encouraged GPs to work in partnership with neighbouring practices. The previous government also tried to increase the role of private health care providers in the system, something the Coalition wants to push further. And when Primary Care Trusts have been abolished, it is perfectly possible that managers will end up being re-hired by GPs consortia, doing very similar sorts of care commissioning jobs. So far, so organic.
Yet though it might be less of a structural shift than some imagine, the impact on incentives in the system could still be radical. Family doctors would have a financial incentive to perform more elective surgery in local clinics, rather than sending patients off for expensive stays in hospital. Putting more control in the hands of doctors and patients, rather than managers, should drive efficiency in all sorts of areas. And if the role of private health providers expands considerably, that really would amount to a revolution.
The truth is that this bill represents an experiment. There is a large amount of waste in the NHS's £104bn budget at the moment. And Mr Lansley says this reform will help the health service deliver the £20bn of savings it needs to make by 2014. But this seems naïve. The likelihood is that, as the House of Commons Health Select Committee argued this week, the inevitable disruption of the restructuring will impede the search for those savings.
And it is impossible to know whether the new safeguard regime for patient care will be effective. Stripping the National Institute for Health and Clinical Excellence of its role in evaluating the cost-effectiveness of new drugs is a gamble. The Department of Health will, in effect, be relying on GPs to ration medicines. And we cannot tell whether GPs, who are to be handed responsibility for £80bn of health spending, will prove to be competent managers. It remains unclear as to what would happen if a consortium of GPs overspent and went bust.
Mr Lansley has inaugurated a pilot scheme. But the legislative juggernaut is on the move before the results are in. Primary Care Trusts have been told that they will be abolished by April 2013 come what may. Doctors are going to have these new responsibilities thrust upon them whether they are ready for them or not. Whatever the merits of reform, this is a reckless way to go about implementing it.