Dear Prime Minister,
You once said that your political priorities could be summed up in three letters: NHS. In last year's election campaign, you signalled your commitment to the health service with two promises. First, there would be no "top-down reorganisations". Second, its budget would rise every year. You must now realise that those pledges cannot be met.
The claim that NHS funds would be "ring-fenced" was always tenuous. The imposition of £20bn of "efficiency savings" on the health department guarantees that front-line services will have fewer resources. No one denies that there is waste in the system but no modern health service has ever implemented the kind of austerity drive you demand, let alone in such a short period. You might not call it "cutting" but that is how it feels. Inflation will stretch budgets further. "Real-terms" spending increases are a fantasy.
As the NHS struggles to cope with this harsh economic climate, you also want it to implement the biggest organisational change in its history -
a reform that rips up established structures for managing resources and fundamentally changes the service's founding ethos. You must realise that this is a huge error.
The Health and Social Care Bill was originally styled as a liberalising reform. The theory, developed by your Health Secretary, Andrew Lansley, is that family doctors should buy care on behalf of their patients, shopping in a marketplace in which private providers compete with state care. Primary care trusts (PCTs), which currently manage a limited "internal market" process, would be scrapped.
There is a case for reforming NHS commissioning, with more GP involvement, and for slimming down PCTs. That could have been done without legislation. The real purpose of this reform is to transform the NHS from a system where care is mostly provided by the state to one where it is largely provided by private companies. You say that this is not the “privatisation" of the health service. There is no better word.
Perhaps you can make the case for such a reform and persuade people to go along with it but you have not done so. Instead, you and Mr Lansley have hidden behind long-term budget pressures. Since NHS costs rise inexorably, the argument goes, the private sector must plug the gap. It is true that the 1940s model of monolithic, centralised state care was unresponsive to patients' needs and disinclined to innovate. It is also true that partnership with the private sector can be an effective spur to change. The kind of free-for-all that Mr Lansley envisages would not share best practice or increase efficiency, however. It would sow mistrust and confusion. It would undermine the collaborative process that is vital for the treatment of chronic conditions. It would turn ill-health into a commodity, with some problems more lucrative to solve than others. Cataract operations might thrive in the free market; long-term treatment of mental health disorders would be forgotten.
The vision is flawed. Meanwhile, the bill has been mangled by amendments. The essence of Mr Lansley's plan survives but with ad hoc layers of bureaucratic complexity thrown in by anxious Lib Dems. It is a mess that no one loves and no one can sincerely defend. There is no advantage to you in proceeding with this fiasco. The only reason for doing so would be stubbornness and fear of derision for exercising such a U-turn. The cost of that pride would be paid by every person in Britain who relies on the NHS. Eventually, it would be paid also in lost votes for the Conservative Party. You have shown in the past that you can be flexible, abandoning policies that are unpopular or plain bad. This one is both. You claim to love the NHS. We implore you, then, to think again.