Milburn's vision of a new NHSBMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7294.1078 (Published 05 May 2001) Cite this as: BMJ 2001;322:1078
Adopting the missionary position
News p 1083
Having established a reputation as the most centralising secretary of state for health in the history of the British National Health Service, Alan Milburn now seems determined to recast himself as the man who shifted the “centre of gravity within the health service from Whitehall to the NHS frontline.” This, he emphasised in a much advertised speech last week,1 is to be the theme of Labour's second term in office.
Power and resources are increasingly to be transferred to primary care trusts, which are expected to control 75% of the NHS's budget by 2004. Clinicians are to be more involved in the design of services at all levels, starting with the Department of Health itself, as well as being given more control over budgets. NHS trusts, including primary care trusts, “will have greater operational freedom.” And to promote this “new decentralised approach,” the structure of bureaucratic control is to be simplified: responsibility for “performance managing the local health care system” will be devolved to 30 new strategic health authorities. Summing up his new vision, Mr Milburn proclaimed, “the time has come to liberate the NHS frontline.” Amen, say all of us.
The first reaction to Mr Milburn's speech is, however, likely to be one of cynicism. At one time or other all secretaries of state for health—Conservative as well as Labour—have rhetorically embraced the notion of devolving power. But this has not stopped a seemingly unstoppable trend towards ever greater centralisation, culminating with the present government. However, it is worth giving Mr Milburn the benefit of the doubt on two counts. Firstly, his speech marks public recognition of the fact that government policies depend on engaging the enthusiasm of those working in the NHS and that there is a danger that staff may feel “disempowered or disillusioned” as well as overloaded. Not before time, it might be said, but at least the sinner shows signs of repentance. Secondly, his speech represents an attempt to show why the new vision should be seen not as a retreat from the previous emphasis on centralisation but as evidence that the government's command and control strategy has worked. This contention is not self evidently convincing but is worth exploring.
Mr Milburn's argument runs as follows. Given that the aim of the government's strategy is “to make the best practice in one part of the health service the norm in all of its parts”—or, as Aneurin Bevan, the politician responsible for establishing the NHS in 1948, put it, to universalise the best—then it follows that a strong machinery of control has to be established. National standards have to be set. National service frameworks have to be promulgated. There has to be a system of inspection. Otherwise anarchy rules: variation would continue to be the norm in the NHS as it has been for the past half century. But once the corset of control has been created, then it becomes possible to allow more freedom within it in the knowledge that liberty is not a licence for poor standards or inadequate performance. The emphasis can switch from hierarchical managerial control to adopting a missionary, developmental style of promoting best practice through the new Modernisation Agency.
The logic is persuasive. But there are problems. Not only is “universalising the best” an oxymoron. The phrase also assumes that the “best” can be determined by central government rather than being defined variously and experimentally in the light of local circumstances: not for nothing was the NHS, as created by Bevan, a monument to paternalistic technocracy. Narrowing the range of quality and performance is unquestionably desirable. So is prodding poor performers towards achieving what the best do already. But it is far from clear from Mr Milburn's pronouncement how much discretion trusts and others will have to diverge from national norms or to experiment. Freedom for them will lie in the knowledge of necessity: if they deliver the government's goals, they will be allowed a degree of (unspecified) discretion. Clearly therefore there is a need for much more debate about what are, or are not, acceptable variations, as well as for a cull of the ever proliferating range of targets and goals set by the government.
If scepticism is the inevitable first reaction to Mr Milburn's vision, a more considered verdict might therefore be to welcome it as providing the criteria against which the record of a second term Labour government can be assessed. And given this government's dedication to setting targets, perhaps the next step would be for the secretary of state to announce a set of devolution performance indicators. The National Plan committed itself to a reduction in the number of circulars produced by the centre. Other indicators might be the number of telephone calls from the secretary of state's private office to NHS managers and the volume of reports demanded by and flowing into the Department of Health. No doubt many others could be devised. The challenge to Mr Milburn—or his successor—will be to demonstrate that reality can match rhetoric.