Professor Alan Maynard scours the horizon for plausible post-2015 scenarios for the NHS

The Con-Dem coalition government is made of competing factions, driven by different ideologies. As in other governments, political and economic events lead to particular factions getting their hands on policy reform.

The current dominant political faction appears to have adopted some poorly-designed reforms that beg more questions than they answer. They may regret their choices.

Let’s assume that the economy stagnates for five years, NHS funding growth is fudged as positive, but is flat in nominal terms at best (and thus declining in real terms).

Assume additionally that the NHS White Paper leads to turmoil and a financial crisis of such proportions that the usual policy of sacking a few unfortunate chief executives “pour encourager les autres” proves useless.

What happens then?

Lord Lansley of Huntingdon
Whilst Andrew Lansley gets a peerage and David Nicholson tours the world advising on healthcare reform, which group of faith-based ideologues in Whitehall Village will emerge to take control?

The collectivists on the left of the Coalition will struggle to acquire control, although with the Cabinet very sensitive to civil commotion which loses votes, they may seize control.

More likely, we will see the libertarians and the right emerge , taking control of policy formation with sharp and explicit doses of marketisation and privatisation.

The marketised, privatised future NHS
Where would you start if you were one of these people? Seventy per cent of NHS expenditure finances labour costs. The contracts of employment of general practitioners, hospital consultants and all other staff might be regarded as impossibly inflexible and financially generous.

If the NHS is to be “liberated” by private sector provision of healthcare, this revolution will be inhibited by existing NHS contracts.

Therefore they have to be removed. Given the trade unions will not want erosion of their employment rights, the government will ‘starve them out’ i.e. they will reduce pay to make alternative private contracts attractive.

‘Negative pay increases’ would be accompanied by freezing incremental drift, reviewing and not renewing incentive payments such as consultant’s clinical excellence awards and altering the GP quality outcomes framework so that target achievement and payment becomes very difficult.

As the NHS is translated into a poor and unattractive employer, “innovative and industrious” private entrepreneurs would win competitive tenders controlled by European Union and Competition Commission rules.

The pace of privatisation of NHS provision could be increased. The architects of reform could take up nice directorships in private companies rather than serve as poorly paid NEDs on NHS trust boards.

All would be well in the world at the expense of NHS employees. But demand for care continues to escalate and the Daily Mail, in holy matrimony with the Daily Telegraph would be expressing horror at the failure of the NHS to provide speedy and cost ineffective care to Fanny Bloggings, aged 85 who lives in Hammersmith.

As we well know from successive governments, cases like this cause disproportionate explosions in Whitehall Village - as Fanny and her ilk are difficult to get off the airwaves.

The policy “something”
So in the best Yes Minister tradition of evidence-free policy making and what is known to the civil service as the Politicians’ Syllogism takes place:

“Step One: We must do something!”

“Step Two: This is something”

“Step Three: Therefore we must do it!”

Such swift, ‘dynamic’ and nonsensical policymaking gets the media and Fanny off the Prime Minister’s back.

What is the most likely policy “something” in this case?

The start of charging
User charges seem a likely candidate. It would be outrageous to raise taxes, as the rich would flee the country instantly! Government expenditure has already been cut by 25 per cent. You cannot ask for further cuts as, for instance, the military top brass have already given up their daily caviar and vintage port, poor dears!

So the “solution” is, let’s make folk pay for access to the NHS.

One advantage of this is that the poor, who are often ill, do not vote usually. So they will be pay and be quiet.

However, the elderly do agitate when narked, so user charges will have to be crafted using a gradualist approach which does not stir up the “grey vote”. Thus we might make pregnant women pay for prescriptions, and introduce an initially low prescription charge for the elderly and children.

Later, carefully-crafted ‘emergencies’ could be used to escalate charge levels. Charges for visits to the GP could involve some slight revenue sharing with these “shopkeepers”, and would mitigate their opposition to privatisation.

The lefties will be outraged, of course. They will scream “inequity”, “taxes on the poor”, “undermining of the sacred NHS” and “killing the ill and vulnerable”. They will be right, of course - but tough! These policies will encourage folk not to waste NHS resources and to keep fit!

Most importantly (and as civil servants know), such dynamic initiatives in the face of self-induced crises will keep us Ministers in office. And that, after all, is what policymaking is about!

The alternative scenario is that White Paper-induced chaos leads to the reversal of re-disorganisation, with the doctors and nurses frantically coping with patients’ demands as usual and unaffected by the familiar policy of changing the names of their places of work.

Whatever the outcome, expect conflict and regret a wasted opportunity to improve the care of patients and mitigate the burden on taxpayers.