BLAIR’S BRITAIN, 1997–2007
Page 62
very frustrating for a person impatient for change.
Blair’s ten years as Prime Minister have certainly had a considerable
impact on schools, but whether for good or ill history will decide. On the
plus side, I would put embedding the national curriculum, tests, Ofsted
and financial delegation inherited from the Conservatives; the literacy
and numeracy strategies in primary schools; the improvement of individual schools, particularly some poorly performing ones; the extra
funding for schools, both for buildings and recurrent expenditure; and
keeping A-levels. On school staffing I am ambivalent, since the overall
figures mask acute shortages in challenging schools and some subjects.
Moreover, the workload reforms were botched to some extent by not
43 BBC News, ‘Behaviour Lessons for Teenagers’, 30 April 2007, http://news.bbc.co.uk/
1/hi/education/6607333.stm.
44 Chartered Institute of Personnel Development, ‘Employers Are Prioritising School
Leavers’ “Soft Skills” Says Survey’, 25 August 2006, www.trainingreference.co.uk/news/
gn060825.htm.
45 United Nations Children’s Fund Innocenti Research Centre, Report Card 7, An Overview
of Child Well-Being in Rich Countries (Florence: UNICEF, 2007).
46 Jeff Searle and Peter Tymms, ‘The Impact of Headteachers on the Performance and
Attributes of Pupils’, in James O’Shaughnessy (ed.), The Leadership Effect: Can Headteachers
Make a Difference? (London: Policy Exchange, 2007), pp. 18–19.
funding the extra teachers needed to implement them. And the jury is
still out on much else. I would particularly question the pursuit of diversity of schools as an end in itself. A system of compulsory education
surely needs a coherent shape serving all children, rather than a free-forall among different school types. At the end of the first Blair government,
I thought that Blair had wanted to make too many changes at once; at the
end of the second I doubted the substance was there. Looking back over
the whole thirteen years we can see that flaws in two of the cardinal
ideas – pressure from the centre through target-setting and diversity of
schools – stand out as major reasons for the achievements being less than
might have been hoped.
18
The health and welfare legacy
The state of UK health services in 1997 was characterised as one of crisis.
Famously its future leader and the nation lived through ‘twenty-four
hours to save the NHS’. In 1997 the crisis was seen mainly in terms of long
waiting times. Later came assessment in terms of under-funding, low
levels of spending in relation to the European average, and poor outcomes in terms of key disease areas such as cancer and heart disease. Later
still came a different assessment in terms of poor value for money and
lack of incentive. Thus within the Blair premiership there were three
different policy phases which we will note as Blair (1997) Blair (2000) and
Blair (2003).
These policy changes were heading into a health environment which
was showing much more rapid change across all developed countries than
in the previous four decades. A new wave of high-benefit programmes
was bringing benefits to patients but stretching funding in all systems.
There were moves worldwide towards a greater focus on prevention and
away from hospital treatment. Survival was improving but bringing a new
challenge of reducing disability and improving quality of life.
Blair (1997) was mainly set by the priority for containment of public
spending. The decision was taken to stick with the previous government’s
plans for public expenditure, both for the total and for detailed allocations. However, within this constraint some initiatives were taken. There
were the National Service Frameworks starting with that for coronary
heart disease.1 Promising but short-lived were the Health Action Zones
(HAZ) with special stress on lifestyle change in deprived areas. In addition there were targets for reducing waiting times for elective treatment
and a stronger emphasis on public health with the appointment of
a Minister for Public Health and a particular emphasis on reducing
11 Department of Health, National Service Framework for Coronary Heart Disease (London:
DoH, 2000).
smoking. These policies were mainly developed from within the
Department of Health led by Health Secretary Frank Dobson, who was
not a member of the Blair inner circle. There appears to have been little
direct involvement in them by the Prime Minister.
Paradoxically these policies were beginning to show quite positive
results. Much of the gain from the National Service Framework for
Coronary Heart Disease came before the large increase in funding which
marked out the Blair (2000) approach: and the HAZ were beginning to
secure strong involvement from local communities. The public health
focus was showing success in changing public attitudes to smoking in
public places even though levels of smoking fell rather slowly. More questionable, however, was the decision to omit the target for reducing
obesity which had appeared in the previous government’s Health of the
Nation report.2 This period also saw the foundation of the National
Institute for Health and Clinical Excellence (NICE) and the start of an
independent regulator to review standards through the health service.
Both NICE and the principle of independent regulation were to endure.
The key steps to the Blair (2000) approach included a winter crisis in
1999 over admissions, a personal letter from Frank Dobson spelling out
the absolute requirement for more funding for the NHS, and a series of
meetings with clinicians and health professionals which raised the issues
of under-funding and poor outcomes. Among them was a meeting with
key clinicians in cancer services reporting on poor outcomes and lack of
availability of drug therapies particularly in breast cancer treatment. The
experience of a patient – Mavis Skeet – whose operations in Leeds were
cancelled several times, was also influential in terms of raising the political temperature. The trigger for action was a personal intervention by
Lord Winston, a leading expert on reproductive medicine and a Labour
peer. His interview in the New Statesman in January 2000 seemed to have
been motivated partly by concerns about the care for his elderly mother.
He expressed very wide concerns about the funding of the NHS:
It is not good enough to say we’re going to spend £20 billion over 35 years
or whatever. Do we want a health service that is steadily going to deteriorate and be more and more rationed and will be inferior on vital areas such
as heart disease and cancer, compared to our less well-off neighbours?3
12 Department of Health, Seventeenth Report: Health of the Nation, A Progress Report
Together with the Proceedings of the Committee Relating to the Report and the Minutes of
Evidence, and Appendices (London: DoH, 1997).
13 Mary Riddell, ‘The New Statesman Interview – Robert Winston’, New S
tatesman, 14
January 2000.
The personal influence of the Prime Minister was great in the two later
policy periods concerned with funding and reform. His involvement in
the period before 2000 was mainly concerned with waiting lists and their
public presentation. The next two phases were very much the personal
initiatives of the Prime Minister. In early 2000 there was a new commitment to reach European levels of funding. To this the Department of
Health added The NHS Plan for using the funding which was driven by
the Health Secretary Alan Milburn and which set out a ten-year programme of investment in training more doctors in new medical schools,
building new hospitals and introducing IT around the theme of NHS
modernisation.4
The key direction was that of building capacity. The NHS Plan did
begin with some discussion of whether the NHS was capable of delivering
change: but at this stage these doubts and reservations did not affect the
main policy theme of adding to capacity. These changes were accompanied by a series of targets which were monitored in detail by a delivery
unit based in No. 10 and headed by Professor Michael Barber. This unit
produced data which gave the Prime Minister a much closer contact with
service performance in a more detailed way than had been the case with
any previous administration. The relentless message of these targets for
the health service was that activity and improvement were taking place
very slowly. By 2001 there were beginning to be unfavourable reviews of
productivity change in the NHS and by the start of 2002 it became clear
that the first stages of increased funding had not increased activity or
reduced waiting times at all.
The targets, together with the influence of No. 10 policy advisers, led to
the second key Tony Blair conversion which was to the role of competition. This began from the summer of 2001, helped by difficult contacts
with patients in Birmingham during the election campaign. The patient
day in Birmingham was also the scene of a major argument between
Prime Minister and Chancellor over a passage in the manifesto that was
permissive of independent Treatment Centres.
It was after the 2001 election that the Prime Minister began to describe
the NHS as a 1948-style institution which had to change. It was also after
the election that a series of incidents convinced ministers that it would be
much better if local managers had more freedom to manage. One clinching incident here was when there were parliamentary questions to the
14 Department of Health, The NHS Plan: A Plan for Investment, a Plan for Reform, Cm. 4818
(London: HMSO, 2000).
Secretary of State about the problems of the mortuary in Bedford
Hospital.
Out of this changing direction came some new policies: patient choice,
money following the patients (payment by results), the Foundation
Trusts and Independent Sector Treatment Centres (ISTCs). Foundation
Trusts were a hybrid between the German not-for-profit hospital and the
Scandinavian community board. They may also have been influenced by
a visit which Alan Milburn made to Spain in the summer of 2002 where a
press release mentioned the rather different Spanish concept of foundation hospitals.
The reform agenda picked up speed from 2002 to 2005, helped along
by a powerful team of advisers within Downing Street. It was accepted
that the NHS was affected by triple nationalisation: in funding, resource
allocation and in provision. Policies were developed for more pluralism
and some competition on the supply side, thus beginning to modify one
kind of nationalisation.5
The aim was set for a programme by independent Treatment Centres
which would account for 15% of procedures, thus creating a longer-term
market which would sustain investment and innovation. The Foundation
Trust Bill was passed through parliament, even if only by two votes in the
Commons, and Foundation Trusts began to show distinctly better performance in financial management and quality of care. The financial
problems of the Bradford Trust were resolved by the regulator and local
management without involving central government. A new paper also
restyled The NHS Plan as an NHS improvement plan and set out a coherent programme for the redesign of the service to give more patients choice
and to improve care for patients with long-term medical conditions.6
This promising reform programme was, however, slowed by the emergence of immediate and pressing problems with financial deficits. The
NHS found itself faced with large amounts of new funding – cash
increases of 8–9% a year on average and 12–15% for some deprived areas.
A vast amount of funding and new staffing was poured into a system
which had a very weak capacity to manage or to use new funds in an
effective way. Even if there had been strong management capacity it
would have faced a very serious problem in the shortage of specialised
resources and staffing available for purchase in the short term. The extra
15 Nick Bosanquet, A Successful National Health Service (London: Adam Smith Institute,
1999).
16 Department of Health, The NHS Improvement Plan: Putting People at the Heart of Public
Services (London: DoH, 2004).
funding was not synchronised with the new hospitals and the additional
doctors. In the event the funding was mainly spent on new employment
contracts and on increased staffing, which was criticised by the House of
Commons Health Select Committee as having been excessive and haphazard.7 This was one more sign of the lack of synchronisation between
the plans at the centre and the actual decisions taken locally.
The policy changes also led to management overload for all and great
resistance for some. The most bitterly contested were those for ISTCs
where the Prime Minister’s key policy was faced with delaying actions at
all levels – from the Treasury concerned about the possible effects on PFI
schemes, from the Department of Health, and from local health managers concerned about destabilisation of local hospitals.
The introduction of these new policies was further shaken by the unexpected new crisis over deficits which came to be the key policy issue for two
years. There were a number of reviews of why this had come about, of
which the most comprehensive was by the department’s Chief Economist.8
This showed that the main reason for the deficits was the uncontrolled
expansion in staffing numbers of 120,000 beyond the targets set in The
NHS Plan. In the background was the low priority given to financial
control before the problem of deficits was realised. To many it seemed
hard to explain how a service where spending in cash terms had tripled
from £30 billion in 1997 to £90 billion in 2007 could be in a situation
where many organisations were in financial deficit with about 10% of
Trusts near administration or insolvency by any normal standards.
By 2007 the ten Blair y
ears in the health service were widely assessed
but with an extraordinary degree of variation between different groups.
Opinion surveys of voters and surveys of NHS staff were generally negative. Opinions by recent patients were positive, as were those by health
service researchers and opinion-formers. An editorial in the Health
Service Journal summed up this consensus view that ‘Blair had saved the
NHS’.9 Yet a reformed NHS with patient choice, immediate access and a
pluralism of providers seemed a long way off. If Blair had saved the NHS
it was hardly the NHS envisaged in the most creative phase of 2001–5.
The achievements of the Blair years were seen in terms of improved
outcomes, lower waiting times, improved funding and better staffing.
17 House of Commons Health Committee, NHS Deficits, First Report of Session 2006–07, vol.
I, HC 73 (London: HMSO, 2006).
18 Department of Health, Explaining NHS Deficits, 2003/04 – 2005/06 (London: DoH, 2007).
19 ‘It Was a Difficult Journey, but under Blair the NHS was Saved’, Health Service Journal, 3
May 2007.
Improved outcomes: The claims here were particularly strong for heart
disease and cancer that the specific decisions had saved thousands of
lives. Certainly there was significant progress but it was difficult to
attribute specific causation. The improvements in outcomes for heart
disease and cancer were part of an international trend which began in the
early 1990s. The rate of change in outcomes showed little increase over
the Blair period, nor was there anything very distinctive about the UK
record compared to that achieved in other systems, including those with
lower proportions of government funding. The conclusion of an independent review by the OECD was that ‘on some outcomes, the effect of
higher spending is less clear: premature cancer deaths and heart/circulatory diseases have continued to decline, but not faster than during the
1990s’.10
Waiting times. There was certainly success in reducing the numbers
waiting from over 1 million to 700,000 but this was waiting on a highly
particular basis at the point of entry into the health system. There were
still long waits for those needing further treatment or those with recurrent disease. Many of these patients with very serious problems would