Politics is a thankless task. Patricia Hewitt's white paper on health in the community was so widely welcomed that even the Tory press found nothing much wrong with it. (The Mail was reduced to mocking her voice.) At last this policy does what Labour should have done from day one - dragging the cash and attention from the Green Wing glamour of hospitals towards communities and surgeries where the old, the frail, the depressed and those with never-ending chronic conditions use most NHS care - often indifferently delivered.
After a huge public consultation, surgeries will open at hours to suit working people; GPs will be urged to specialise; and consultants will hold community clinics. To pay for all this, £4bn will be moved from hospitals into the community. Private firms and cooperatives of NHS staff can bid for community contracts in deprived areas, while community hospitals (some, not all) will be saved to become local polyclinics. This new emphasis on "community, not hospital" is what every expert in the NHS has always called for.
However, community medicine is dull stuff. After one day of mid-bulletin reporting, this decent policy sank like a drowned cat. Yet this is the kind of policy-making that works: unheroic, not macho, waving no big placards. The value of a policy is often in inverse relation to the amount of noise it makes. But no wonder prime ministers prefer something "eye-catching" and ideological.
That was what got the NHS into the needless trouble it is now in, as the Blair/Milburn/Reid pigeons come home to roost. Politicians love hospitals - and "cold surgery" waiting lists in particular. The ideological fun is all in high-concept tinkering with markets over the mere 20% of work that is planned admissions. True, debate focuses on waiting lists, and Labour has been phenomenally successful in cutting waiting lists to the bone by driving tough targets; though, alas, the public doesn't believe it.
The idea of a market driven by payment-by-results was designed five years ago to spur on those targets. The irony now, says Dr Chris Ham, a top NHS official recently returned to academe, is that just as those targets are reached, the market system finally goes live that will drive all the incentives to do precisely the opposite of everything this week's excellent white paper proposes.
The government created the market the wrong way round. The primary care trust (PCT) commissioners should have been the mighty force built up first, to buy in the best for the local community - keeping the purse strings, the power and the big brains in NHS management. Instead the PCTs are still weaklings whose money will be mugged out of their pockets by the might of the man-eating hospitals, whose current debts make them all the hungrier. Ever since Frank Dobson promised to save Barts, despite no local need for it, in the heat of the 1997 election, Labour has made a fetish of hospitals. Now the market goes live with the boot on the wrong foot.
In April the nuclear button is pressed: payment by results, where the cash follows each patient, will apply not just to waiting-list surgery as at present but to the other 80% of hospital admissions that are unplanned emergencies. The risk is high that many hospitals will spin into financial mayhem, with no spare cash to ease the way.
Of those in debt, some are high performers who rushed ahead and did too many operations, cutting some waiting lists virtually to zero. The rationing brakes were forgotten before the election, and targets not due until 2008 have been hit before the money's there. The NHS forgot its rationing laws in the dash for results. Badly managed hospitals were also allowed to slide into the red rather than miss targets.
Hospitals will be eager to recoup losses when payment by results begins; their clever managers may bamboozle many weak PCT commissioners. There is a tariff set for each operation. Watch as patients are diagnosed as in need of more hospital days and more treatments, to attract the higher tariffs. Can PCTs really judge each case? The Treasury, seeing the danger, has just issued emergency regulations to make sure that anyone taken into A&E isn't whisked into a bed, attracting a higher tariff. Jokes abound about prowling ambulances chasing patients.
PCTs are not yet ready, as many amalgamate to become stronger and attract top managers. It will take another year for chief executives to finish fighting over new posts and settle new staff and new letterheads into local relationships. Plucking a sum out of the air, John Reid demanded that PCTs save £250m by rationalising. Will their larger size be worth the loss of people and energy at this dangerous moment? PCTs are still small fry negotiating with crocodiles.
While all that is going on, Hewitt is redistributing fat sums away from rich areas, such as Surrey and Sussex, to poor NHS deserts. Quite right too. Some poor areas spend 30% below average per capita, while rich counties spend 20% above. But expect the south to shriek in protest far louder than any quiet thanks from northern and inner-city winners.
So in April a real tug of war begins between the principles of this week's good community plan and the red-in-tooth-and-claw fight of hospitals to swallow up every penny, preventing much flowing out to the community. Every hospital now has a business plan that promises growth with more work, more patients, more operations - so what is left to flow into the community? Sceptical old NHS hands put their money on the muscle power of consultants, royal colleges, the BMA and every other voice demanding costly new hospital treatments at the expense of better care packages for the chronically ill.
If the market does work, bad hospital departments should fail, exposing any local oversupply and sending money back to cheaper, better community treatment. But can mere politicians withstand the cries of outrage from shroud-waving doctors claiming that patients are dying for lack of a local cardiac or renal unit? It will look like frightening chaos, even if the politicians are right and a better service eventually shakes out. Alas, the public always believes the medics.
Many are calling for delay. There is still time to slow down and try one region first. Officially, it is too late; the good hospitals would protest that they are all ready to go and sweep away their debts by treating more patients at top speed and top dollar. To delay would benefit weak performers who would need more propping up. Chris Ham is among the experienced old hands who think caution is the better part of valour.
The results are too unpredictable. This odd market may not let the good prosper and the bad fail. The tariff system will not set the right rewards for complex cases: old people with multiple problems or emergencies. Nor can it capture difficult cases in Great Ormond Street or the Royal Marsden. Other countries have found block-grant systems more efficient than this paper-chasing case by case. At least wait until all PCTs are strong enough to bear the weight. But no, it's full steam ahead.
The headlines are easy to predict: any debt is already a calamity. The sadness about all this is that the NHS is another Labour success story. Things are better, clinics and hospitals brighter, waiting lists never falling so fast. This week's community plan points in absolutely the right direction. Only yesterday's ideology drives this market on, at risk of destabilising the government itself.
