24 Hours to Save the NHS: the Chief Executive's Account of Reform (2000-2006)
Oxford University Press, 248pp, £14.99
In 1948, Aneurin Bevan predicted that "we shall never have all we need", and for more than 60 years the National Health Service has been proving him right. The line on the graph keeps on soaring. In 1948 we spent 3 per cent of our gross domestic product on health care. We now spend 10 per cent, and by some estimates if we don't bend the cost curve we will be spending over 50 per cent of GDP on the health-care system by the end of this century.
Labour doubled spending on the NHS over the past decade, but now the country has lurched back into financial crisis. The coalition's approach has been to freeze spending, which means the NHS will have to do more with less in order to make the resources stretch to meet the predicted need.
The title of this sleek and highly accessible account comes from Tony Blair's rallying cry in the 1997 general election that there was "24 hours to save the NHS" from the Tories. Though Lord Crisp, who was permanent secretary in the Department of Health and chief executive of the NHS for six years, accepts this was political rhetoric and not economic reality, his central claim is that when Labour came to power, the NHS was on its knees, but by 2010 reform and investment had secured its survival.
Crisp navigates clearly through the policy and the politics, and in its structure (the main points are boxed at the end of each chapter) and style, this resembles a textbook. The resulting weakness is that it imposes order where none exists. The book emphasises continuity over the past three decades, which is fine when that period is viewed with a wide-angle lens (the evolution of the "internal market" and the purchaser-provider split, the development of payment incentives and the introduction of business processes and IT). But wind down the microscope, and we see tergiversations and U-turns. In some cases New Labour came in, reversed Conservative policies, reinstated them and then undid them again, giving the impression of constant redisorganisation.
The scorecard is messy, as Crisp acknowledges. The assault on waiting times worked, although the blizzard of central targets led to gaming - hitting the target but missing the point. Star ratings exposed some rotten hospitals but not enough was done about them. Some clinical outcomes improved, such as those for cancer. Patient satisfaction rose.
However, productivity fell, and unexplained and unacceptable variations in outcome continue to dog the service. In 2007, almost a quarter of UK hospital staff said they wouldn't want to be treated in their own institution.
Any sense that the NHS had been "saved" is today in tatters. Reform was always an "uphill struggle", but the coalition government's incompetence has been exploited by vested interests such as the British Medical Association, a "self-centred" lobby. From this toxic mixture of politics and medicine, policymakers have fashioned structures such as commissioning groups that have been torn down and cobbled together again so hastily that they look like organisational shanty towns. Choice and competition, which Crisp championed, have been ditched. The plans "have been so watered down that they . . . are simply inadequate to deal with the problems", making the NHS "set for years of managing decline" (though some of us would say the plans were so flawed to begin with that they wouldn't have worked anyway).
Only "radical reform" can save the NHS for the future, Crisp argues, and he calls for a redefinition of what the system is for, shaped around integrated services. He joins a lengthening list of experts who have identified hospital "reconfigurations" as crucial for improving quality and saving money; that demands focusing specialist care in centres of clinical excellence, closing down underperforming units, investing in preventative strategies and caring for elderly or chronically ill patients in the community, using remote monitoring and outreach services.
If the present government does indeed care about health care - and wants to avoid a series of budget-busting hospital bailouts - its commitment should be to services, not facilities.
It cannot afford to ignore Crisp's advice, and there is no time to lose.
Nick Seddon is deputy director of the think tank Reform