There are few jobs tougher than being a minister in the Department of Health. The brief involves running one of the largest organisations on the planet and being held personally responsible when anything goes wrong anywhere. Trying to change the system usually leads to outrage. Kenneth Clarke was humiliated by a national billboard campaign. Patricia Hewitt was strangled in effigy by protesters in Sussex. A rap recently recorded about the current Secretary of State, Andrew Lansley, calling him "greedy" and a "tosser", has gone viral on the internet. As the sense of crisis grows over his proposed reforms in England, the government is backtracking. "We love the National Health Service," 10 Downing Street now says. "The NHS is our most precious national asset." If that's the case, why reform it?
The memoirs of Lord Warner, a former health minister in the Blair government, offer some answers. He is not out to prove anything. Instead, he is careful to build a picture of the system that is patchier than most politicians like to paint: the NHS, he writes, is "a popular, civilising influence in our liberal democracy", yet it "needs to change to survive".
For quality and safety, the NHS is no longer the envy of the world, he argues; nor is it really the envy of the world's finance ministers. Worse, from the point of view of social justice, it provides "lousy services" in poorer areas. The "self-absorbed" and monopolistic culture of the NHS is "a major problem". The model needs to be turned upside down. Hospitals are so rooted in the public and political psyche that we allow them to keep taking on more services, whether or not they are solvent or safe. Instead, we need to shift care out, looking after older people in nursing homes and enabling people with chronic conditions to self-manage at home. Some hospitals will need to close.
Labour was right to grasp the nettle of reform. While those in the blue corner will sneer at Warner's claim that Labour "saved" the NHS, those in the red corner will bristle at the litany of mistakes. He records the messy reorganisations that brought about change but not progress; the failure to make commissioning by primary care trusts effective; the expanded, bureaucratic workforce; and the stuttering approach to choice and competition.
On the safety and quality record, he reminds us that, in 2008/2009, only 41 per cent of hospital trusts complied with NHS standards. The productivity story is unhappy, too, given that a 60 per cent increase in input over ten years produced a 4 per cent reduction in output. Yet it is the money that angers Warner most. "No one else in the world would be running an £80bn or £100bn business," he writes, "based on the kind of appalling financial management we have in the NHS." After splashing the cash during the fat years, the NHS was warned repeatedly that as it moved from feast to famine there would be a funding shortfall; it "has only itself to blame for not preparing better for a period of more meagre rations", Warner argues.
Broadly speaking, this means that the government is right to pick up where Tony Blair left off, though Warner wants bolder plans. He recommends much more competition - including competition on prices - and an end to national pay bargaining. Financial management needs to improve vastly in hospitals and general practices. He is sceptical about handing power and money to clinicians. He cites, for instance, an exchange at the Royal College of Surgeons in 2005. After listening to him expound the virtues of choice and competition, an angry orthopaedic surgeon burst out: "Lord Warner, my patients don't need choice, they know I am the best."
Some passages here will interest only policy wonks and health-care professionals, but A Suitable Case for Treatment is often compelling and offers some lovely and lively portraits and turns of phrase. "Bringing about NHS change," it concludes, "becomes like a First World War battle, capturing a few yards at a time - often with casualties - and then along comes a new general who beats a retreat. As the coalition government tries to take the Blair reforms to their logical conclusion, history suggests they may have the same experience." In fact, the retreat is already becoming a rout. l
Nick Seddon is deputy director of the think tank Reform
A Suitable Case for Treatment: the NHS and Reform
Grosvenor House, 368pp, £16