LEADING ARTICLE:Smoke clears over the NHS

During the past week we have reported skirmishes throughout the National Health Service. Blood is shed over so many issues - GP fundholding, hospital closures, rise of the manager, crisis in long-term care - that it is tempting to foresee only endless battles for this war-weary institution.

Yet, already, through the smoke, a peace settlement is beginning to take shape. All the main political parties have agreed on a long contested but fundamental principle - that those, such as hospitals, who provide healthcare should be separate from those, such as health authorities, who pay for it.

This bureaucratic principle - known as the "purchaser-provider" split - sounds obscure. What difference, you might ask, does it make to people stuck on waiting lists, patients dying on trolleys or schizophrenics refused a psychiatric bed? A great deal. Now they have a powerful potential advocate. In the past, patients enjoyed little leverage over NHS technocrats. The purchaser-provider split creates a body with spending power to wring the best deal for patients from hospitals and other healthcare bodies.

The Conservatives established a market for this deal-making. Labour, still suspicious of commerce, is pledged to abolish that market, replacing it with vaguely-defined, more bureaucratic "commissioning". But at least Labour, in its policy document to be published this week, acknowledges that the purchaser-provider divide would survive the election.

A strong voice representing consumer interests is vital. Last week we reported that only 15 per cent of NHS treatments are of proven value. This startling figure is a symptom of how healthcare, here and abroad, is shaped by those who provide it. Like other health systems worldwide, the NHS is probably offering many ineffective and unnecessary treatments. It needs sustained rationalism as much as it cannot escape rationing.

Our national poll on the NHS showed how important the service remains. Nine out of 10 say they are ready to pay 2p in the pound income tax to boost NHS revenue, an extraordinary expression of confidence from voters generally deeply resentful of new taxes. More surprising and interesting is our finding that the majority of voters - even of Labour supporters - is not bothered whether NHS-funded treatment is provided by NHS employees or by the private sector. What matters to patients is that treatment should be free at the point of delivery.

Although there is now an uneasy consensus on the division of powers within the NHS, there is still much for the political parties to play for. The Conservatives need to win the trust of NHS staff to move beyond the present stalemate. On GP fundholding, they must ensure equity and well-coordinated purchasing. They should address market failures, such as high transaction costs and inadequate levels of training and research. But we should also acknowledge this: the Tories have improved the NHS's capacity for overdue modernisation. The successful and courageous implementation of the British health reforms compares favourably with the collapse of Bill Clinton's efforts in the US.

Labour - and to a lesser extent the Liberal Democrats - has a huge advantage in enjoying the confidence of NHS staff and patients. But this trust can be a double-edged sword. There is a danger that the unions and professional vested interests would again take control under Labour's watch. When Tony Blair speaks of re-nationalising the NHS, we understandably fear his real wish is to turn the clock back.

Voters doubt that the NHS is "safe" in the hands of any political party. In so saying, they recognise that change is inevitable: a higher demand for healthcare is likely, for example, to generate more privately- as well as publicly-funded and delivered care. The way is open for a political party that can both secure trust and build on the imaginative changes of the past four years.