Bitter Medicine

A recent issue of the British Medical Journal posed a simple question by way of making a cynical joke: “What do you call a government that embarks on the biggest upheaval of the NHS [National Health Service] in its 63 year history, at breakneck speed, while simultaneously trying to make unprecedented financial savings?”

So went the punch line: “The politically correct answer has got to be: mad.” As it so often does, this satire had a serious intention: namely, to warn Prime Minister David Cameron that any reforms to the NHS will be met with fierce resistance. The journal was not alone in drawing this line in the sand. Opposition politicians and labor unions also rallied to the flag of resisting reform. One union leader warned that the government’s plans invited a “Titanic-sized” disaster.

The NHS is the unrivaled third rail of British political life: Britain’s National Health Service, free for all at the point of use, is more than just another public good. It’s hailed as the crowning glory of the post-1945 peace dividend, and even though its health outcomes are mixed at best, heaven help any British politician who dares suggest it might not be as fundamentally sound, and morally praiseworthy, as Britons like to think it is.

In seizing the issue, Cameron has made a convincing show of boldness, but might have also set the terms by which his political fate will eventually be determined. However severely the prime minister has slashed other sectors of government spending and however inauspicious the country’s latest growth figures — GDP shrunk 0.5 percent in the final quarter of 2010 — it’s the NHS reforms that are seen as the most controversial. The government needs a plan for economic growth, but it also needs to show that, despite what the Labour Party argues, the NHS is “safe in Conservative hands,” as Cameron puts it.

Health care has long been a problem area for the Conservatives. That’s why Cameron very concertedly excluded the NHS from the platform of government spending cuts, including reductions in welfare payments for the unemployed, and large layoffs in most government departments. His plan instead centers on introducing mechanisms for greater competition — including, crucially, on price — for the treatments offered by the NHS while also introducing market incentives to health-care providers. The idea is that consortiums of general practitioners will soon be able to choose from a variety of health-care treatments when “purchasing” treatments for their patients. In that way, hospitals will have to compete with one another for business.

Although the NHS will remain paid for by general taxation and free at the point of use, the aim is to build a more flexible service more responsive to patient needs that’s less bureaucratic and better able to adapt to changing market demands. The downside might be that an already complex service will become still more complicated and susceptible. Critics note that Cameron’s plan will spark a “race to the bottom,” in the words of NHS Partners Network, a prominent health-care provider interest group, in which price, not quality, determines the availability of health care.

For all the furor that the thought of cutting the NHS inspires, the truth is that the British health system is thoroughly mediocre. It produces, by international standards, moderate outcomes for a moderate outlay. Cancer death rates, for example, are around 6 percent higher than the European average. Most Britons will admit that every good experience in the labyrinthine system that employs more than 1.4 million people is matched by an equally miserable or frustrating encounter. Waiting times for treatment — once the most-publicized failing — have fallen, but for many the system remains too slow, too unresponsive, and too inefficient. Moreover, there’s little transparency. Patients frequently have little access to public information about how good their local hospitals really are. So it’s fair to say that complaints about plans to change the NHS are as common as complaints about the NHS itself.

But as bureaucratized as the NHS is, it is also heavily politicized. For the Labour Party, the NHS has become an object of religious devotion. Only Labour, the party tells its followers, can be trusted to guard the health service’s flame.

The modesty of Cameron’s proposed changes is a tacit tribute to Labour’s scaremongering about Tory intentions. Indeed, in defending their proposed program, Conservatives cite what might seem an unlikely source: Tony Blair. The former Labour leader, who once complained about the “scars on his back” inflicted by vested interests hostile to his own domestic reforms, remains an object of fascination and inspiration for senior Conservatives. It’s no coincidence that there’s some resemblance between Cameron’s NHS proposals and those enacted by Blair when he was elected prime minister in 1997. Even Blair’s former health-care advisor, Julian Le Grand, has felt compelled to defend the current plans, saying that they are “a logical, sensible extension of those put in place by Tony Blair, which in turn developed the internal market set up by [Blair’s predecessor] John Major.”

The cynics on the government benches argue there’s no point in trying to assuage health-care interest groups as to the necessity of making changes to the NHS — they will invariably oppose almost all government-led reforms. Indeed, Blair has admitted that his greatest domestic mistake as leader was in succumbing to procedural inertia in making reforms in health care and education, failing to push harder and earlier for change. His Tory successors are keen to avoid that error, even at the risk of trying too much, too soon, too fast.

But Cameron’s government has not yet found a way of packaging its message. From the safety of the opposition benches, Labour has mounted an effective guerrilla campaign that, according to the latest opinion polls, would defeat the Conservatives by as many as 10 points if a general election were held today.

Ultimately, Cameron’s government is tasked with solving a political paradox: How can it marry boldness with reassurance? On the one hand, it stresses the fierce urgency of reform; on the other it seeks to calm voters’ fears by stressing how aspects of its plans for education and health-care reform build on foundations laid down by Blair. In other words, they are both radical but not quite as radical as you might think.

Steve Hilton, Cameron’s chief strategist and the man credited with helping “detoxify” the Tory brand, is fond of saying, “Everything must have changed by 2015. Everything.” But the problem for Cameron’s coalition with the Liberal Democrats is that even if its sweeping reforms for education, health care, and welfare prove wise, they are unlikely to show real results before the 2015 general election. Changing the culture at the NHS to make it more efficient and responsive to consumer needs will probably require both patience in the long term and money in the short term, neither of which are readily available as the government seeks to reduce public spending by 40 percent in some government departments.

Without demonstrable successes, the case for a second term of Cameronism will be that much weaker and almost wholly dependent on robust economic recovery and stable and sustainable public finances. But with inflation creeping toward 4 percent and the latest economic figures disappointing, Cameron’s government now faces its most difficult moments yet. In an age of modern politics that demands instant results, his decision to try to change the country’s most immobile bureaucratic monolith is admirably brave, but it might also be politically fatal.