Hastening slowly: Mr Dobson plays a waiting game

BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7114.966 (Published 18 October 1997) Cite this as: BMJ 1997;315:966

A task that cannot wait is to lower expectations in the short run

  1. Rudolf Klein, Professorial fellowa
  1. a King's Fund Policy Institute, London W1M 0AN

    Britain's new government is at present engaged in a curious policy striptease, with more tease than strip. Hardly a day passes without the unveiling of some new initiative or the announcement of yet another working party to review specific aspects of the NHS. But we are still left waiting for the promised series of green and white papers translating the government's general aspirations into specific proposals for the NHS and public health. In this respect, the speech by Frank Dobson, the Secretary of State for Health, at the recent Labour party conference proved unrevealing.1 There was a dribble of specifics. But the government's overall strategy remains veiled. Nor is this surprising.

    Ministers face a dilemma. The frustrating reality of a financially constrained NHS struggling to cope with competing expectations has somehow to be reconciled with the rhetoric of transformation that swept ministers into office. In these circumstances the best that can be hoped for is incremental change, which, over the years, will move the NHS in the desired direction. The last thing the NHS needs is policy drama, and perhaps the most welcome aspect of Mr Dobson's speech was his emphasis on experimenting with change and testing out what works best.

    The conflict between aspirations and reality is already apparent. The NHS Executive's guidance to health authorities and trusts on priorities for 1998-92 makes it clear that dealing with emergency admissions may make it impossible to achieve shorter waiting times. Indeed, the waiting list issue may prove as much of an incubus for the Labour administration as it did for its Conservative predecessor. Perhaps Mr Dobson should have started by asking the royal colleges to develop national criteria, on the New Zealand model, for classifying those on waiting lists by their degree of urgency. For, in the absence of such national criteria, it is impossible to know what degree of priority should be attached to devoting resources to reducing waiting lists and whether local variations in waiting times reflect variations in the local propensity to put patients on the list or genuine differences in the capacity to meet need.

    The general direction of change is also becoming apparent. The new government will be able to “end” the internal market because, to a large extent, it is already dead on its feet. The substitution of long term agreements for annual contracts between purchasers and providers, the switch of emphasis from competition to cooperation, represents the endorsement of a trend that has been evident for some time.3 There remains the problem of fundholding. Here government strategy seems to be to edge it towards voluntary euthanasia. On the one hand, fundholders will be encouraged to take part in experiments in local commissioning, so giving them a voice in the way resources are used (although it remains unclear how strong a voice it will be without control over money). On the other hand, fundholding budgets are likely to be more stringent.

    Even if fundholding is gradually marginalised, however, this may not allow the government to achieve its major aim of reducing bureaucratic costs. Fundholding is expensive to administer. But locality commissioning also imposes administrative costs and it is not self evident that it will generate any compensatory efficiency gains. In any case, cutting bureaucracy is not a magic formula for giving infinite elasticity to the NHS's budget; at best it can produce one off savings and provide some temporary relief.

    Long term relief will depend on decisions about total funding for the NHS. But here too ministers face tough choices. The £300 million announced earlier this week (p 971) and the £1.2 billion promised for the next financial year are designed to avert unfavourable headlines rather than promote a more effective service. For the future the government needs to develop a coherent strategy for using any extra funds that become available, as distinct from using them for fire fighting. If morale is to be raised, should priority be given to increasing the pay of NHS staff or to relieving the pressure on them by employing more staff? Answering such questions will take time. And perhaps the most urgent task ministers have is to lower expectations about what they can sensibly be expected to deliver in the short run.

    Much of what they have done is welcome: for example, the abolition of gagging clauses in contracts. Other initiatives, such as the introduction of health action zones, represent interesting experiments, although past attempts to promote collaboration across administrative boundaries suggest the need for scepticism.4 Inevitably, action has not matched rhetoric. Nor, in the time available, could it. But the new rhetoric—with its emphasis on promoting public health and on addressing inequalities—is itself important. It provides the benchmarks for assessing the government's performance over the next five years.


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