For eight years the NHS has been engaged in an unprecedented construction programme, building super-hospitals with the aim of housing all specialists under one roof in regional centres of excellence. These shining monuments to Labour’s new relationship with business have been built under the private finance initiative, where capital is raised by a private sector consortium that leases it back to the health trust over 25 to 30 years.
It looks like the honeymoon with PFI is over. The schemes have proved far more expensive than ministers expected, and fears are growing that several trusts will not be able to make the payments on their leases. Last month, the Secretary of State for Health, Patricia Hewitt, announced a review of a £1.5bn scheme to rebuild St Bartholomew’s (Barts), the oldest hospital in the country, and its near neighbour the Royal London. That scheme may now be scrapped. Schemes involving hospitals in Plymouth, Hillingdon in west London, and University Hospital Birmingham are also under threat. Although 78 PFI hospitals have been built or are under construction, new projects worth an estimated £7-£9bn are in jeopardy.
It is perhaps no coincidence that Hewitt has engineered a spectacular change of direction. The medical pro-fession is now told it should reinvent the cottage hospital by thinking locally. As her department struggles to deal with a budget deficit predicted to reach £250m by the end of this financial year, rising to £620m by April 2007, the medical profession could be forgiven for thinking that ministers have better things to do with their time than reinvent the wheel.
To be fair, many of the recommendations in Hewitt’s white paper, Our Health, Our Care, Our Say, have been welcomed by the profession, among them a system of preventative health MOTs, an emphasis on treating people closer to home and an increase in patient choice over access to GPs and specialists. Eyebrows have been raised, however, at moves to increase private sector involvement in the newly decentralised system, especially when the company that stands to gain most from private GP practices is the American medical giant United Health Group, run in Britain by a former Downing Street adviser, Simon Stevens. As Lucy Chapman’s chilling account from the front line of a PFI hospital demonstrates, many of those working within the NHS already believe that patients are being put second to profit in the brave new world of private-public partnership. There is little to reassure them in the new white paper.
So what is driving these reforms? When so few of the new measures demand primary legislation, where is the need for another white paper? The answer lies with a certain Diana Church or, more precisely, the Prime Minister’s response to Mrs Church during a Question Time programme at the height of last year’s election campaign. Tony Blair admitted he was “astonished” by the revelation that some GP surgeries were refusing to make appointments more than two days in advance. They were doing this to ensure they hit government targets, but the Prime Minister was completely unsighted on the issue. It was a minor piece of administrative insanity that affected just 2 per cent of surgeries. The Department of Health had been aware of the problem and was taking action to deal with it. But the encounter had been deeply embarrassing to Blair, so immediately after the election No 10’s policy storm troopers were unleashed to “sort out primary care”.
John Appleby, chief economist at the King’s Fund think-tank, describes this as “year zero” policy-making, with ministers failing to identify the problem before searching for the solution. “This is driven by Downing Street, not by Health or the Treasury,” he says. “It looks like Blair wanted change for change’s sake. Where is the genuine reform? What’s the problem you are trying to fix? It is difficult to get an appointment to see your GP – you would hope there was more to it than that.”
Dr Richard Taylor, the independent MP for Wyre Forest, first elected in 2001 following a campaign to save Kidderminster’s local hospital, shares his medical colleagues’ bafflement at the proposals. “I applaud the focus on community hospitals and mental well-being, but shifting consultants out of hospitals will remove consistency of care. What most people want is a good local accident and emergency department, but this will reduce the number of skilled doctors available for A&E.” Taylor identifies a further problem in his area, replicated across the country: “The local PFI project in Worcester is too small for our purposes now, but it will probably be too large in 20 years’ time.” This is the government’s nightmare scenario: a vastly expensive generation of giant PFI hospitals lying half-empty as patients opt for treatment at local GP-run medical centres and cottage hospitals.
Hewitt describes her reforms as truly radical, as they combine an emphasis on prevention with intervention at a local level and renewed links with social services and mental health care. “You could argue that we should have done this before, that this is where we should have started, but we are where we are,” one Hewitt aide told me. With a rejuvenated opposition, the pressure is on to show that the years of largesse have not gone to waste. Hewitt’s advisers insist that the “cottage hospital” philosophy does not negate the previous enthusiasm for super-hospitals. Horses for courses, they say. In the new market-driven world of health funding, however, if an individual patient “chooses” to be treated by a GP specialist or locally based consultant, the hospital loses out by failing to attract that customer. Much as it would like to, the government can’t have it both ways.
It might be conspiratorial to suggest that the latest reforms are designed as a Get Out of Jail card for the government on PFI. It is too late for that. But it is no more of a sea change in healthcare than 14 months ago, when Hewitt’s predecessor, John Reid, announced his version of the revolution.
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