Another day, another burst of good news about the NHS. Things really are getting better. The independent modernisation board, made up of doctors, nurses and patients, yesterday announced a "significant and sustained improvement" in its annual report. Last week the NHS chief executive's annual report gave dazzlingly good figures: waiting lists fell further and faster than ever before. Waits for GPs and A&E are plummeting. Thousands more doctors and nurses are treating hundreds of thousands more patients a year (and health academics say the figures are essentially unfiddled). Heart and cancer deaths fell sharply. The great sums invested are working.
Who believes it? Every week Mori polls secretly for an anxious John Reid, revealing that more people still expect the NHS to get worse than expect it to get better. Opinion is slowly moving in the right direction, but it hasn't turned the corner yet. Ministers repeat the mantra that actual patients give glowing marks for their own treatment but asked about that abstraction, "the NHS", they believe the worst they read in newspapers.
Most voters have no contact with the NHS so take their views entirely from the press. Pick up yesterday's Daily Mail - a typical day - and a whole page tells of four people who died waiting for ambulances. Mere statistics pale beside such stories, of which there will never be a shortage.
How can Labour persuade voters that the NHS is thriving as never before? It would help if doctors and nurses, the most trusted of citizens, would talk up their own successes. But like teachers they whinge, forgetting how things were or might be again under the Conservatives. It would help if Labour politicians - including the leader - stopped threatening yet more "radical reform": it sends out a dismal signal that things must be going wrong. It would help if Tony Blair and Alan Milburn didn't keep suggesting using the private sector is always more efficient, with no evidence to support it. The prime minister should talk up his own delivery of phenomenal NHS improvement, instead of trying to trounce the Tories by pre-empting their rhetoric.
The Tories have no health policy yet. Their "patient passport" is still undefined. Will it be a subsidy for the rich to top up in the private sector, or will wiser politics prevail? They are at war over whether to stick to true blue heartland issues - immigration, Europe and crime - and abandon Labour turf over public services. But they are still good at poking a finger into Labour's sore spots. Oliver Letwin says that Labour has wasted a fortune on NHS pay rises while productivity is sinking like a stone, that the money has gone down a black hole and that bureaucrats outnumber doctors: the public sector doesn't work.
That can be hard to refute: 90% of NHS activity happens outside hospital, where the money is still barely monitored and outcomes are unmeasured. Much apparent fall in productivity is actually better treatment - extra nurses in a ward (good) mean lower productivity rates (bad). However, no one knows why surgeons are doing 20% fewer operations than they did. Their output dropped back in 1994 when more surgeons were employed, but operations didn't increase proportionately. There's still a vast variation in the number of similar operations different surgeons do. Experts suggest some operations are more complex, some doctors do more admin and too many don't get given enough operating time to work flat out.
But managing the NHS is always tough and two quite different approaches to it are taken by the experts who know and the politicians who know a lot less. NHS experts seek the answers in how things work on the GP surgery or hospital floor, finding and removing particular local obstructions to progress. The new consultants' contract pays doctors a lot more in exchange for job plans to be agreed with managers: these may help iron out bottlenecks and glitches.
But the greatest obstruction over the years has been politicians who think management solutions lie in broad sweeping reforms. Micro-managing is not their thing: they like big new systems ideologically based. The NHS has endured a major reform every five years since 1948. New Labour has been as destructive as the rest in sweeping away health authorities (HAs) that had just mastered effective purchasing and GP fundholders just beginning to grow their own clinics rather than refer minor ailments to hospital.
B ut Labour was rhetorically committed to abolishing the Tory internal market. Pretending to do so, it devised primary care trusts (PCTs) to take over purchasing from HAs, trying to combine local GP fundholding with big purchasing. So everyone working in HAs had to re-apply for their jobs in the myriad new PCTs: many of the most experienced left the NHS altogether. PCTs were never really GP-run local purchasers and soon amalgamated into 304 trusts across the country. With a few notable exceptions, most are not big enough to have the skills to cope with average purchasing budgets of £186m. A third have no finance director. Tomorrow's Health Service Journal has a survey of 50 hospital CEOs who give PCTs only an average 40% rating for their skill at commissioning; 87% of health professionals don't think PCTs have the capacity to push through the necessary changes in the NHS.
What is the political response to this? More reorganisation of course. Guess what? The government is now reinventing GP fundholding, calling it practice-based commissioning, giving GPs freedom to purchase services direct for their patients. As for PCTs, they are being encouraged to amalgamate again so they will soon look strangely familiar - not unlike the old health authorities. Meanwhile, up there in the political stratosphere, Alan Milburn and the prime minister are theorising all over again, thinking up very clever new ideas for the third-term manifesto. The NHS quivers in anticipation. What it really needs is a moratorium on big ideas with no more ideological grandstanding for electioneering purposes. PCTs will settle in, given the chance. Foundation trusts, an irrelevance, have not even begun yet. Nor have most treatment centres, which will cut waiting lists.
The good news is that the new money is working. The brilliant results are gathering pace. Yet Tony Blair is indulging in airy talk about turning the whole NHS over to various private, voluntary or independent trusts, day-dreaming in ways designed to infuriate his party. If in four years time no one is waiting over three months, private practice will be on its knees, reduced to a marginal luxury for those who want carpets. The NHS battle on the ground will be won as better managers get a better grip. Wild talk of yet more "radical reform" is entirely destructive when Labour should be talking up their good results - achieved despite, not because of, its reorganisation.
