New Labour and the NHSBMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7191.1092 (Published 24 April 1999) Cite this as: BMJ 1999;318:1092
Politicians should pay more attention to building capacity in the NHS
A prime ministerial speech on the NHS is rare. So when Tony Blair addressed an audience in Birmingham on 13 April it provided an opportunity to take stock of New Labour's approach to health policy and assess what the government has achieved in its first two years.
Appropriately for a prime ministerial address, the speech concentrated on the big picture, setting out the government's vision for health and health services. This vision centres on five strands: quick and convenient treatment, high quality care throughout the NHS, a positive experience for patients, better health as well as health care, and a partnership between the NHS and each individual in achieving better health. The last of these strands runs through much of New Labour's thinking about health and welfare and distances the government from Old Labour by emphasising personal responsibility alongside the state's responsibility.
In an audience containing many of the leaders of the newly established primary care groups, the prime minister highlighted the opportunities available to these groups to build on the achievements of general practice over the past 50 years. These opportunities stem from the control over resources available to primary care groups and the option of taking on responsibility for managing community services and community hospitals as primary care trusts. The possibility this creates is of “one stop shops” in which general practitioners will work alongside a wide range of other professionals to provide a single point of entry for patients.
More controversially, the prime minister reiterated the government's commitment to supplement established forms of general practice by extending the coverage of NHS Direct, a nurse led telephone helpline, and by setting up 20 walk in centres. The importance of these announcements was in underlining the priority attached to quick and convenient treatment, a priority also reflected in the move to replace waiting lists for hospital treatment with booked admissions. The emergence of private primary care centres has probably also galvanised the government into finding ways of making NHS services more accessible.
Whether walk in centres are the appropriate response to the desire to improve access to services is debatable. It is also unclear what the relationship will be between these centres and the personal medical services pilots that have been launched in different parts of the United Kingdom. A range of new approaches is being tested in the pilots, including nurse led schemes and salaried employment for general practitioners, and the announcement of yet another initiative sits uncomfortably in this context. Indeed, given the almost universal admiration of British general practice, and evidence that it is highly valued by patients, ad hoc developments like walk in centres appear to be directed as much at the spin doctors as their medical counterparts.
These quibbles should not detract from the achievements of New Labour in its first two years. Within the NHS there has been much support both for the direction of change set out for the NHS and for the allocation of additional funds to facilitate its implementation. The emphasis on cooperation rather than competition and the move to develop national standards has been welcomed across the political and professional spectrum, as has the priority attached to improving the quality of care and promoting public health.
If there is a question about government policy it concerns the ability of ministers to bring about lasting improvements in existing services and not just to launch new projects like NHS Direct. Ultimately, New Labour will be judged by its success in overcoming variations in performance in these services, and this in turn hinges on ministers finding the right levers to bring about change. With the abandonment of the market, central direction has been used to deliver the government's targets, most obviously in the drive to reduce waiting lists, alongside new forms of inspection and regulation, such as the National Institute of Clinical Excellence and the introduction of a duty of clinical governance, which mix central and local direction. The creation of primary care groups is another key element in the government's programme, designed to empower doctors and nurses to improve services.
This eclectic mix of approaches makes up the much trumpeted “third way” in healthcare reform. What is missing from the third way is recognition of the need to build capacity within the NHS to enact the policies. Capacity building includes strengthening management at all levels, investing in staff training and development, and understanding that in the long run real change comes less from headline catching initiatives than from the creation of organisations containing the people with the skills and competencies to improve services to patients. This applies as much to the drive to raise standards as to the desire to improve access and suggests that continuing professional development needs to be used alongside inspection and regulation to ensure that high quality is achieved throughout the NHS.
New Labour is a government still learning how to govern, and ministers must support their commitment to modernise the NHS by creating the capacity for sustained change. Planning for the long term may not come naturally to politicians, but the government's policies will only be implemented if ministers keep their sights trained on the horizon.