Intended for healthcare professionals

Feature NHS policy

NHS: the Blair years

BMJ 2007; 334 doi: (Published 17 May 2007) Cite this as: BMJ 2007;334:1030
  1. Polly Toynbee, political and social commentator
  1. The Guardian
  1. polly.toynbee{at}

    Waiting lists have fallen and resources have grown, yet staff and the public are still unhappy with the NHS. As Tony Blair prepares to step down, Polly Toynbee analyses why his legacy has gone horribly wrong

    In what state of health has Tony Blair left the National Health Service? The story could have been one of dazzling success. If, on that May morning back in 1997 a soothsayer had told him what the results would be 10 years later, he might reasonably have expected to rank somewhere alongside Aneurin Bevan as a hero of NHS history.

    Instead doctors and nurses are united in fury while voters tell pollsters that they think the service is worse than it was and they expect it to get worse still. For the first time ever, a majority of the population think the NHS would be safer in Conservative hands. Results have never been so good, yet the public view of the NHS has never been so glum. How did this happen?

    The Labour government began well with a 10 year national strategy agreed after lengthy consultation with NHS staff led by Tony Blair himself. The Wanless report uncovered the depth of need after decades of funding that almost always fell below real NHS inflation rates. The public agreed money was needed; national insurance rates were raised to pay for it. NHS spending will have trebled by next year to £94bn (€138bn; $187bn), easily reaching the European Union average, as promised. Ever since Attlee cut back its budget before it was even launched, the NHS has been pinched for funds. It has certainly never enjoyed such a time of plenty.

    Where has the money gone? Opposition parties will keep up that chant until the next election, accusing Labour of giving poor value for the cash spent. But a fair reckoning requires some memory of what the NHS was like in previous under-funded decades. Every winter there was an NHS crisis: as the BBC's social affairs editor I used to mark it in the news diary as an expected annual event. Sometimes it was flu that had elderly patients overflowing on to trolleys in hospital corridors. But always by February and March it was money running out that caused theatre and ward closures, with surgeons left to twiddle their thumbs while waiting lists spiked up until the new financial year.

    Look back down memory lane at some of the headlines before Mr Blair came to power: “400 critically ill children turned away from intensive care units in the past three months due to a chronic shortage of beds and nurses” (Mirror, 21 January 1997). “1 in 7 operations cancelled due to cutbacks” (Mirror, 18 November 1996). “Chaos mounts as wards turn away the sick” (News of the World, 28 January 1996), ”Doctors reveal winter chaos in NHS” (Independent, 10 January 1997). Pictures of patients on trolleys abound among the old cuttings.

    Better care

    Even allowing for the usual media exaggeration, few objective NHS watchers would deny how much improvement there has been since then. In 1997, 283 866 people had waited 6 months or more for operations.1 By last March, ministers announced there were only 199. Back in 1997 few would have believed Tony Blair had he promised to cut waiting times to its present average of 6.6 weeks, (which does, of course, hide wild variations).

    In 2003 when the target was set, 75% of patients were seen within four hours in accident and emergency departments; last year it was 98.5%.2 Even allowing for statistical fiddling, nobody doubts refurbished accident and emergency departments are better. There are now 20 000 more consultants and general practitioners, 70 000 more nurses, 118 new hospitals, and 188 new general practice clinics. As ever, demand rose too: there were 3% more users a year and 75% more emergency ambulance calls.2

    All those are NHS in-puts—but what of real health outcomes? Tsars for cancer and heart disease saw deaths from both fall. Over 10 years life expectancy rose by 2 years, to 81.2 for women and 76.9 for men—but the hard truth is that the life expectancy graph has been on a similar steady gradient upwards for a long time and the rise may have happened anyway.

    Every government vows it will shift priorities towards prevention and public health. Like every other leader, Blair failed to do that significantly, although a smoking ban will help. Every government promises to redirect resources into community services where 90% of treatment happens—but like every government, Blair's failed to stop hospitals siphoning off the lion's share. Mental health had early extra money, but along with all community, maternity, and health visiting services, it suffered badly in the latest sharp spending squeeze.

    Poor decisions

    Nevertheless, the Blair record is good, so why are NHS staff and voters convinced everything is worse? This has been a decade of turmoil, with zigzag reforms dictated from the top, only to be countermanded again from the top. The history of his “reforms” hardly bears repeating. First he dismantled general practice fundholding and some aspects of the Tory internal market. He set up primary care groups, remade them into primary care trusts, and then merged them again into half the number. Demolished regional health authorities were resurrected as 28 strategic health authorities and then merged again back into the original 10 regions. The public health director for the south west region provides one graphic example of what has happened on the ground in this breathless deckchair shuffling. He has held the same job since 1994, but has had to reapply for it seven times since then because of reorganisations.

    With each turn of the screw, Tony Blair became more convinced that only a fiercely competitive market could jolt the NHS into better productivity. He castigated Bevan's “monolithic” state driven model and trusted the magic of Adam Smith's “hidden hand” to drive greater efficiency. But he made a fundamental error by putting the power in the hands of the providers and not the purchasers. He built up mighty foundation hospitals and independent treatment centres first, neglecting weak and feeble primary care trusts without the managerial clout to power his great market machine. Instead, the hospitals sucked money out of the pockets of the primary care trusts' inexperienced finance directors.

    Making a market caused rows with his own party, but all this organisational stuff was of zero interest to patients. They woke up to the change only when the market began to bite in painful ways. The market demanded no deficits, no more collaborative loans between hospitals that were now supposed to compete, so in one breakneck year long-standing debt had to be tortured out of the system. This the public did suddenly notice.

    How can there be deficits with so much money sloshing around the NHS? The debt squeeze accelerated “reconfigurations” that meant some 60 local hospitals would close or lose their accident and emergency or maternity services. Many of these closures had been due for years and this was just the inefficiency the market was designed to throttle, but here was the gift a resurgent Conservative opposition needed. Save Our Hospital campaigns sprang up everywhere, even sometimes where there was no threat.

    Just as the deficit squeeze started to freeze posts and even to cut some jobs, news of the accidental overpayment of consultants and general practitioners reached public ears. True, there had been a shortage of doctors in 1997 and they needed a good increase, but the bungled contracts looked like money out of control. Add in the saga of the mighty Connecting for Health information technology system, which over-ran in cost and time and failed to deliver in ways that were well-predicted by all the experts. Add that to the growing outbreaks of methicillin resistant Staphylococcus aureus and Clostridium difficile, and the public decided the NHS was in meltdown.

    However often Tony Blair and his health ministers recite their litany of successes and improvements, public opinion heads downwards. Voters asked about the NHS said it was a disaster, although when asked about their personal experience they reported that their local services were indeed better.3 But they just presumed they were lucky and chose to believe increasingly lurid anecdotes in the press rather than their own experience. Few can remember a decade ago to make useful comparisons: no one waiting three months for a hip operation now will remember waiting 18 months back then. Voters don't do gratitude.

    The press, as ever 75% right wing, sense an issue to put the wind in the Tories' sails. Bad NHS stories are a staple diet of the media second only to crime—but bad hospital stories are now multiplying exponentially. With 1.3 million NHS staff each grumbling to scores of family and friends, alienating them is politically lethal too. David Cameron may have won the hearts and minds of NHS staff with his promise of no more reorganisations—if they believe any new health minister can ever resist the temptation to disorganise everything all over again.

    Blair came to power famously promising to save the NHS. He feared public support would vanish without reform. In a sense, he succeeded, as it is David Cameron who has finally had to force his party to accept a free tax funded NHS with no flirtations with top-up payments or private insurance.

    Tony Blair leaves with the NHS as his Iraq on the home front. But history may be kinder if in a couple of years the new system has been allowed to bed down. The internal market may work and good results may speed up. If so, Blair's NHS legacy may be rewritten more favourably, but his successor will have serious problems.


    • Competing interests: None declared.


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