Disruption ahead

Ara Darzi says attacking managers is good politics, but not good policy.

The National Health Service was founded to take away the fear that getting sick meant going broke and that growing old meant getting poor. Aneurin Bevan's assertion that no society could call itself civilised if it denied access to health care because of poverty has become an essential tenet of Britain's civic code. Despite the more hysterical claims of the present government's critics, no party seriously contests the founding principles of the service.

The NHS remains this country's most cherished institution; every individual and family contributes to it and benefits from it (it should not be forgotten that private health care is provided by NHS-trained staff). Some have concluded that, because our NHS is so precious, it should be sheltered from change. I disagree.

Indeed, to believe in the NHS is to believe in reform of the NHS. For the NHS to prosper, it must embrace change, even in these uncertain economic times.

It is precisely because of the continuous nature of changes in clinical practice that reform is a constant in health systems. Health care exists at the edge of science - there are new drugs and treatments, innovations in what we do and how we deliver care. People rightly expect the latest treatments in the most modern settings. That's why to stand still is to fall back.

Yet just because doing nothing is not an option, that does not mean that doing something is always better. We need thoughtful reform, responding to the needs of patients and the aspirations of front-line staff and tackling head-on the huge quality and productivity challenges that we face. The present reform bill is based on three hypotheses that demand closer examination.

The first hypothesis is that higher performance from health-care providers is best achieved by giving a stronger role to the market. I have always believed that the right competition for the right reasons can drive us to achieve more, to work harder, to strive higher, to stretch out our hands and reach for excellence. It can spark creativity and light the fire of innovation.

Competition and choice are two sides of the same coin, arrived at from very different starting points. Motives matter. Competition starts with the ideology of faith in free markets and the responsiveness of corporations to competitors thirsting for profit. Choice starts with faith in people and their capacity to make good choices for themselves, supported and empowered by professionals.

When I was a minister, we introduced free choice - public or private - for all patients. Competition was a consequence, not an end in itself. With prices fixed and patients empowered, professionals could compete on who could provide the highest-quality care. There has always been choice in the NHS - but for the few, not the many. Those in the know have always known where to go and how to get there. Reforms of recent years have been about extending choice to the many.

When patient choice was first introduced by the Labour government in 2006, it was hugely controversial, and yet, by 2010, the debate had ceased and it had become an accepted part of how the NHS operated. The health service - clinicians and managers - had come to accept it and stopped resisting against it. If anything, the health service was beginning to get off the back foot and becoming more confident about the great depth of clinical talent it possessed.

I remain perplexed why the present government decided to pick a fight that had already been won. It seems obvious to me, given the rising tide of chronic disease, that our most pressing challenges lie in solving the integration of care, not in creating an ever more perfect market. I look forward to seeing how a regulator will simultaneously promote collaboration, integration and competition.

The second hypothesis is that commissioning is the greatest problem and the "silver bullet" - it has been the primary focus of the government's reform efforts. Yet, by its very nature, commissioning can only ever be a means to an end rather than an end in itself. When I was a minister, my review of the NHS set out our purpose clearly: High-Quality Care for All. I avoided a top-down reorganisation of the NHS because I was not convinced it would lead to the improvements in quality of care that patients require. It is precisely because the government chose to set out a vision of the means and not the ends that it found itself in such difficulty. And the means it identified - empowering GPs - seemed to reinforce fragmentation of the service rather than overcome it.

If clinical commissioning is about giving clinicians the power to reshape and reform services to improve quality of care for patients, then it has my support. But I fear that what we have before us is a U-turn, wrapped in a compromise, cloaked in the language of consensus. It seems that the language has changed but the substance isn't much different.

In the House of Lords, I recently said that I would not know where to begin in the commissioning of community podiatry (though the Society of Podiatrists kindly contacted me after the debate to offer me a crash course). I would contend that my GP colleagues would find it equally challenging to commission the highly specialised cancer services that my team provides at St Mary's in London. I hope that the reforms to NHS commissioning prove to be worth the disruption they have caused.

The final hypothesis is that management is part of the problem and not part of the solution. This is where the government has been plain daft. If the newly appointed chief executive of a FTSE-100 company came into office and announced that he was firing half his company's management, shareholders would rightly revolt. Attacking NHS management may be good politics, but it is bad policy, and in the long run it is self-defeating. Health care is the most complex part of the economy; we should be investing in better management, not less.

Raising the quality of care for patients is what has inspired me throughout my career as a surgeon and a minister - and it is an ambition that
I share with colleagues across the NHS. It is our collective purpose, our common endeavour.

Today, the NHS is the patient on the operating table. It has been put to sleep, spending the best part of 18 months worrying more about new commissioning structures than raising quality and productivity. The incision has been made, and the old structures swept away. The medical team can't agree - this bill has had a jumpier journey than most.

By any measure, right now, our NHS is in urgent need of higher-quality care.

Lord Darzi is a professor of surgery at Imperial College London and served as a health minister in Gordon Brown's government

This article first appeared in the 14 November 2011 issue of the New Statesman, The NHS 1948-2011, so what comes next?