
It's the 75th birthday of the NHS, so what better time for another rare intervention from Tony Blair. This morning his institute published a paper about the future of the NHS. In line with current Labour thinking that what public services need is reform, not funds (which, in turn, are informed by Tony Blair Thought of two decades ago), the report offers a number of technical and seemingly technical fixes to improve the health service. But the overall thrust is clear: bureaucratic centralisation is the chief opponent of efficient delivery, not lack of cash.
It shouldn't need saying that this corner of the internet rarely receives Blair's missives with open arms, but it would be churlish to file the report in the desktop recycling bin just because of its provenance. The report, authored by a health policy wonk and an academic, does make some good points. Yes, there does need to be an injection of capital so the NHS can fully utilise new technologies. Who would be against that? The report says this can be utilised to cut waste and introduce less labour intensive treatment. There should be local autonomy for what are termed 'integrated care systems' to treat and improve health outcomes in their areas, backed by the stability of multi-year budgets and incentives to innovate - which include keeping and reinvesting any savings made. A digitised 'Personal Health Account' - a souped-up NHS app enabling access to services and putting patients in charge of their own health data, which can be linked to secondary apps and wearable technology, would revolutionise and personalise our relationship to the NHS. Rolling health services out from GP surgeries and hospitals, which would reduce demand on those services through an expansion of provision is another floated suggestion. And making more use of personal-use genomic medicines, making sequencing available on a mass scale and integrating genetic susceptibilities it into one's personal data is another ambitious goal. If we absent social relationships for a moment, this is what a 21st century health service should look like.
But social relations aren't about to go away, and how the report frames this technologically enabled vision raises a lot of political questions. Firstly, the report says it wants to move the NHS away from a patch-them-up-and-let-them-go model of treatment to one more reflective of complex health needs. This is nothing new. In fact, the first NHS reorganisation in the mid-1970s was premised exactly on these terms. Of moving from treating disease to addressing the long-term health problems of a population that was living longer. Indeed, that is the main business of the NHS today. Therefore, the report's argument that we "must move from a health-care model set up to treat episodic sickness to one that prioritises continuously improving individual and population health" is an extension of what the NHS already does in part to the whole. A useful straw man if you want to exaggerate the case for reform though.
Then there are the rocket boosters these proposals have put under the so-called patient choice agenda. This is not an innocent idea of simply allowing patients more choice in their treatment, but was under Thatcher, Major, and Blair designed to introduce and bed down marketised relationships between different parts of the NHS. In the New Labour years, the idea was to allow patients complete choice of where they were treated. NHS organisations would compete with each other for patients, allegedly driving up standards and increasing efficiency. This was swept away by the Tories in 2012 for thoroughgoing marketisation, semi-privatisation, and outright scamming in which "any willing provider" was in with a shout of scooping up NHS money. What happened over Covid procurement and the missing billions was this writ large. The Blair Institute are proposing is something a bit more subtle. Through the use of personal health technologies, they want to bed down principles of individual responsibility for health - which can be monitored via the app. This builds on the individualist (and individuating) thrust of public health strategies in the Blair years, and one that attempts to evacuate politics from health altogether. I.e. You have the power to choose healthy outcomes informed by constantly updated metrics, and therefore what happens to you is (largely) in your hands. It's consistent with the modes of governance Blair enforced across the public sector, and one that proved (politically) effective quite recently. If you get ill, it's going to either be a case of 'pathogenic life factors' or bad luck. Never air quality, food quality, environmental despoliation, unhealthy work practices.
And then we have the private provider argument, because of course we do. There's the useless argument about "spare capacity" in private health that gets mentioned every five minutes by Wes Streeting. As an aside, Streeting often defends this saying he wants the NHS to get to the place where it can out-compete the private sector. Yeah, right. I'm sure the private health interests funding his operation do so because they want to be put out of business. The Blair Institute goes there, but they flag up more opportunities for private sector involvement. Remember the localised integrated care systems? "Freedom" of ICS chiefs would inevitably mean contracting in for-profit providers to meet targets, just as they did 20 years ago. Indeed, these organisations should "empower" patients to make "informed choices" about choosing between GPs and "secondary providers". On the dispersal of health services, the report is explicit that "high-volume, low complexity" services should routinely be hived off to "multiple providers". Again, it's all about patient choice. The patient data revolution the report envisages allows for more public private partnerships, and larger market for data add-ons to the key NHS app as well as "innovation". Undoubtedly encouraged by a generous system of state grants and inducements.
This, again, carries on where Blair left off in 2007. While there were plenty of New Labour true believers in marketised policies as drivers of best outcomes (the Tories, despite their well earned 'stupid party' monicker, are never daft enough to really believe this twaddle), the politics of this made sense because NHS outsourcing, PPPs, and Private Finance Initiatives tied - at least for a while - sections of British capital to what you might call the Blair Rich Project. By pouring state money into private pockets, this was one means by which New Labour was able to cultivate patronage and crony networks that helped ensure, for a brief window, that it was the favoured party of (most of) capital. It's entirely a matter of coincidence that ex-health ministers and certain MPs later enjoyed handsome consultancies and board positions advising private health and outsourcing giants. It didn't last, and when Labour was dumped out of office the Tories ramped up the openings through the total marketisation of the NHS. Here, the Blair Institute's programme for change is more than just about the future of the NHS. It is directly advising the incoming Labour government about how to use NHS reform to win over a section of British business, with the obvious consequence of diluting the popular pressures that will bear down on the party after such a long period of Tory rule.
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