Julian Tudor Hart

WHY ARE DOCTORS UNHAPPY, AND WHAT CAN BE DONE ABOUT IT?

BMJ 2001

GPs are squeezed between patients� expectations for instant remedies without risk or error, and government pressures to speed the conveyor and tighten quality control. Extending the strategy initiated by the Conservatives in 1990, New Labour's Alan Milburn is developing an industrialised, consumer-led NHS. Meanwhile bureaucracy marches on: as a proportion of spending on healthcare, administrative costs have doubled from about 6% before the 1990 "reform" to about 12% now. This is still behind USA at about 25%, but the modernisers are on course to reach that target.

The driving force behind this strategy is perception of the NHS as an industry producing clinical interventions as discrete commodities, episodically consumed by patients. In the programme espoused by New Labour, innovation will come from State-assisted corporate investors, for whom public service will be subordinated to pursuit of profit. Motives for this electorally unpopular(1) strategy were explained by Richard Smith in 1996(2) and Allyson Pollock in 1999(3). New Labour�s devotion to creeping privatisation of the NHS starts from its conversion to classical economics, the World Trade Organisation, the World Bank, and its commitments to the General Agreement on Tarrifs, Trade and Services to open all public service to global competition and investment. None of these has any mandate from the Party membership or the electorate.

To prepare for this, all NHS activities are so far as possible being parcelled into commodity units, suited to profitable provision by traders in public service. But how far is possible, without impeding effective and efficient care? Conservative governments tried and failed to create market competition between hospitals and between GPs. New Labour tries and will fail to get private investors to build new hospitals and develop new primary care where there is greatest need for improved care, not where these investments would be most profitable. As with other privatised national services, investors will make the profits (mainly by reducing the number, pay and security of staff), while the NHS and its patients keep the risks.

Things would be easier if New Labour could proceed directly to North American solutions. If the NHS didn�t have to provide the most difficult services for the most difficult people, but just let them pile up in hospital Emergency Rooms, we could concentrate on high quality care for easy people, and heroic salvage for the rest. But in the UK, according to opinion polls, a substantial majority even of conservative voters continues to believe in a socialised NHS, based on neighbourhoods and devils they know, not on shopping around between competing providers(