54 TheEconomistFebruary 13th 2021
1O
nce upona time, an ambitious young
Tory mpcould write columns mocking
bien-pensantpieties about the health ser-
vice—dinner-party attendees who thought
“how maahvellous it was that the duke and
dustman were treated alike in our glorious
New Jerusalem, watching the same tv, eat-
ing the same spotted dick, attended by the
same starch-bosomed nurses.” When that
was written, in 2004, Tories liked to flirt
with the idea of adopting the social-insur-
ance systems seen in much of Europe. At
the very least, they would argue, the health
service’s internal market ought to be sharp-
ened to raise standards and cut costs.
Now that mpis the prime minister, he
treats the nhswith rather more reverence.
The health service is, Boris Johnson says,
“the beating heart of this country...It is
powered by love.” His government’s pre-
scriptions for it also differ. A white paper,
due to be published as The Economistwent
to press but leaked beforehand, sets out
plans for the first major nhslegislation in adecade. They would put the final nail in the
coffin of the internal market—competition
will no longer be the “organising principle”
of the health service—and would give min-
isters more direct control over the nhs.
The country’s current rulers believe
they express the will of the British people,
and are therefore justified in grabbing
power from any institution that gets in
their way, whether the eu, the courts or bu-
reaucrats in the civil or health service. But
politicians mess with the nhsat their peril.
Although health outcomes are below par
for the rich world, Britons love the health
service with a deep and abiding passion.
This gives medics enormous power.
The fate of the last politician to try to re-
form the health service serves as a warning.
In 2011 Andrew Lansley, health secretary in
the Tory-Lib Dem coalition, set out to abol-
ish almost all national and regional man-
agement by extending the use of market
mechanisms, and to take oversight of the
system out of political hands. Although thelegislation he promoted eventually passed,
it met strong opposition. Mr Lansley was
sacked, and the officials put in charge of
the nhslargely ignored the changes his
legislation sought to introduce.
The Conservative party has taken a
more cautious approach to the health ser-
vice of late. At the general election in 2019,
Mr Johnson promised the nhs lots of mon-
ey to build hospitals and hire nurses. There
was no mention of traditional Tory cost-
cutting demands. The reforms in the new
white paper are happening partly in re-
sponse to the requests of nhsbosses.
Although the internal market helped
cut waiting times, there is not much evi-
dence it improved the quality of care. And
the split between purchasers (mostly gps)
and providers (mostly hospitals) makes the
health service unwieldy. As the population
ages, fewer patients go to hospital for a sin-
gle operation, and more need care for a
complex set of problems. The hope is that
integrated care, of the sort pioneered in
Singapore and by Kaiser Permanente in
America, will serve them better than the
fragmention of an internal market.
Integrated care’s introduction to the
nhshas been driven by Sir Simon Stevens,
the health service’s boss, who has brought
purchasers and providers together to plan
care for areas covering 1m-3m people. The
white paper suggests sweeping away re-
maining barriers, such as procurementNational Health ServiceHands on
The first major reform of the health service in a decade seeks to reduce
competition and give politicians more control over itBritain
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