A health service in search of a vision

As Virginia Bottomley fights for her job, Chris Ham examines the Government's failure to provide a perspective for the NHS

Virginia Bottomley's problems over the future of London's health services are symptomatic of the lack of strategic direction guiding the NHS. The paradox is that the Government has a large number of priorities encompassing the patient's charter, the health of the nation, care in the community and the development of primary care. The difficulty is that while many of these priorities are laudable in their own right, taken together they are not always consistent and fail to provide the direction needed to take the NHS into the next century.

To borrow a phrase from a different context, tactics have come to dominate strategy and even on the tactical questions the judgement of ministers and their advisers has been found wanting. As the leaked Maples memo indicated, the Government's main priority is damage limitation and keeping the NHS out of the headlines. It is therefore hardly surprising that health ministers have resisted the temptation to open up a great debate on the future of healthcare. The flaws in this approach are now clear for all to see as short termism is exposed and the absence of underlying direction becomes evident.

The task of politicians is to lead, to educate and to inform. If they are to do this effectively, they require a strong sense of direction and a clear view of what the future holds. In the case of health services, the reforms introduced in 1991 were based on a strategy that was only half thought through and where the end point was not specified. As a result, the detail has been added during the process of implementation and ministers have been making it up as they have been going along.

The consequences have not been all bad. The absence of a national blueprint has unleashed an unprecedented period of innovation within the NHS in which policy has been driven from the bottom up not the top down. This has turned traditional relationships on their head. The real knowledge and understanding of how the new NHS operates rests with doctors and managers at a local level, and civil servants and ministers have been trailing in their wake.

The power given to doctors and managers to shape the implementation of the reforms has resulted in demonstrable improvements in health and healthcare in many places. Equally, the changes which have occurred have given rise to difficult and controversial decisions. In a national health service, the ultimate responsibility for taking these decisions rests with the Health Secretary. It is for this reason that Mrs Bottomley has been in the spotlight this week, announcing decisions on the future of London's health service which have resulted from a lengthy process of debate and analysis.

The weakness of the Government's approach to the health service is that the innovations occurring at a local level do not fit into an overall framework. This applies not only to London, where arguably there is more of a strategy than elsewhere, but also to the implementation of the NHS reforms as a whole. The kind of health service that will emerge over the coming years has never been spelt out and there is a policy vacuum at the heart of the NHS. To use a clich, the vision thing is missing and politicians have appeared more concerned at times with the fine detail than the big picture.

To be fair to Mrs Bottomley, she inherited a series of time-bombs when she was appointed to her post, and in many respects has handled these skilfully. The fact that one has now exploded is not unexpected and has resulted as much from the failings of her predecessors as from her own shortcomings. In this respect, John Redwood has been more skilful in his exercise of the politician's craft by recognising public concerns over the future of hospitals and by taking a quite different approach to these issues in Wales than that pursued in England. This may smack of opportunism but in the run-up to an election this is hardly surprising.

The more important point is that on matters such as hospital closures, the public needs to be informed and educated about the reasons for change and this is a task that can only be performed by politicians. In the case of London, there has been a lively debate but more often than not this has been dominated by the Government's opponents, and the arguments for change have not been well articulated. This is a pity because there are undoubtedly benefits likely to accrue from a concentration of services in specialised centres. There are also advantages in delivering more care outside hospital. Yet so far this debate has been confined largely to the experts and it is essential that the public is more fully involved in future. Only in this way will it be possible to promote the health literacy that the Health Secretary has long and quite rightly argued for.

The need for a strategic approach applies with even greater force to the question of priority setting in the NHS. This was illustrated by the case of child B and the decision of the Cambridge Health Authority not to fund a second bone marrow transplant in this case. It arises even more pointedly in relation to continuing care for elderly and disabled people where the NHS is finding it difficult to meet all the needs that exist. There are also gaps in the availability of NHS dental services as more patients have to resort to private treatment.

There is now mounting evidence that the commitment to a cradle to the grave NHS will be impossible to sustain. In this area, above all, there is a need for a national debate to raise awareness of the issue and to explore solutions. All countries face this dilemma and in several of them politicians have taken the lead to explore future priorities for healthcare. As with hospital closures, the issues are inherently complex and there are more votes to be lost than won. But unless they are debated directly, they will be that much more difficult to deal with in the longer term.

The same applies to the future of the NHS itself. The 1991 reforms have transformed a monolithic, bureaucratic organisation into a more pluralistic healthcare system in which there is a much stronger capacity to increase efficiency and deal with longstanding weaknesses. So far, this has been achieved while maintaining a commitment to the principles on which the NHS was founded. It is much more questionable whether it will be possible to sustain this commitment, particularly as the Treasury's private finance initiative leads to the progressive privatisation of health service provision.

The likelihood is that a further period of Conservative government will transform the NHS into a national insurance organisation with a mixed economy of service provision. This may not matter so long as patients still have access to necessary medical care without having to pay for treatment. Again, the consequences need to be fully debated and explained if the Government is to avoid the charge that it is privatising the NHS through the back door. The public remains deeply suspicious of the Government's long-term plans for the NHS and these plans must be clarified and explained to overcome fears that a hidden agenda is guiding the NHS reforms.

The need for a strategy to guide health services into the future applies to politicians of all parties. As the Labour Party firms up on its health policy, it is essential that Margaret Beckett and her colleagues spell out a plausible and convincing vision of the future. This needs to explain how a Labour government would deal with the dilemmas facing the NHS in a situation in which the level of funding made available is unlikely to change dramatically. If this entails a more cautious approach to hospital closures than that currently pursued, then the consequences for other areas of expenditure have to be worked through. The public has learned to distrust politicians who promise all pleasure and no pain, and the test of honesty and openness applies across the political spectrum, not just to the current holders of power. Labour may be winning the health debate by default but it urgently needs to explain how it would handle the agenda currently occupying Mrs Bottomley's attention.

Professor Chris Ham is the director of the Health Service Management Centre at the University of Birmingham.