When Andrew Lansley's over-ambitious health and social care bill first saw the light of day early last year I was among those scornful of such a distraction at a time when the NHS was under Labour-initiated pressure to produce £20bn of efficiency savings – ie higher output for the same money – over a brisk five years.
Like most people I depend on the NHS and unlike most people I'm reaching an age where I'm starting to get my taxes back from the service. Most of the time it treats me, my friends and family pretty well – and we're grateful.
But as the bill progressed and attacks on it became ever-more hysterical, the contrarian in me obliged me to stand up for bits of it. The wretched thing won't be either as good or as bad as the warring camps say.
Whatever the politicians say now, every health secretary for the past 30 years – except Old Labour's gallant Frank Dobson – has been pushing the NHS in the same direction as the hapless Lansley, towards greater patient choice and faster, more responsive treatments in a more competitive, less monolithic environment than has existed since the great Nye Bevan's bold nationalisation in 1946-8.
Even Dobbo once admitted in my hearing: "If all my hospitals were as good as my best ones we wouldn't have a problem." That says it all really. Dobson thought the issue was all about money and capacity constraints, but it wasn't and it still isn't.
I don't subscribe to the Tories' pre-election claims that the Brown-Blair billions saw NHS productivity plummet – there is plenty of evidence to the contrary available now in terms of better cancer and heart outcomes and much else.
But we still heard too much about careless and callous behaviour, the result of poor attitudes by individual staff and systems towards patients and the taxpayer.
As for co-operation, allegedly threatened by the insertion of a highly regulated quasi-market, steady on, chaps. Co-operation between primary and hospital care, between health and social care, or mental care – they've hardly been a triumph these past 60 years.
So we may learn something from greater private and voluntary sector involvement, just as they will learn something from the values and virtues of the dear old NHS. Thus, those much-abused independent sector treatment centres (ISTCs), another Labour initiative, had a miraculous effect on the slothful performance of some NHS hospitals in the cataract, hip and knee business. I have heard NHS consultants admit it.
So I can't get as excited as the TUC-funded False Economy research group is, as reported by the Guardian on Wednesday, though I understand their concerns and am glad they are holding what is now the H&SC Act – the Queen signed off on it this week – to account. We all benefit from openness, though it's hard work.
Society's getting older, treatments (brilliant ones too) cost more, lifestyle choices wreck lives in countless avoidable ways. All advanced healthcare systems the world over (no one actually copied ours) face similar problems. There's no time to lose. Here's a smart, sceptical health website I always enjoy.
Of course, some GPs with an eye to the main financial chance, are going to take shares in private health care firms sniffing around the NHS or running out-of-hours services. They are the entrepreneurial types of medic who will always be at the fore of chances to expand their take-home pay. Plenty of doctors aren't like that, the NHS ethos is different, so that many of the cash-motivated types will long since have gone to the private sector or to fleece the old in Arizona.
It creates fresh opportunities for financial conflicts of interests, which the clinical commissioning groups (CCGs) set to handle £60bn of NHS taxpayers' cash – yours and mine – and Monitor, the economic regulator, will have to watch carefully.
The Guardian, the Sunday Times and Private Eye will all have a field day with whatever rogue-ish practice emerges from the new system, much as they did with Bevan's model.
I'll let you into a secret: GPs and hospital docs have always had a conflict of interest of this kind. Part of Bevan's compromise with the BMA (usually wrong in these battles) in the 1946-8 negotiations was to allow the GPs to remain self-employed private professionals rather than NHS state-employed staff. Hospital consultants were allowed to retain the right to do private practice on the side – using NHS hospitals, kit and even staff, if memory serves.
"I stuffed their mouths with gold," the great man explained.
There has always been tension as a result of Bevan's deal, it's been a shifting frontier, but as long as we assume that most doctors are decent people – as most of the rest of us are – then we will muddle through. There will be scandals involving those private sector sharks who are circling the NHS pool and smell blood. Some are already at it and we all hope they get blown out of the water.
But the scandal at Mid-Staffs hospital, patients neglected unto death, whistleblowers silenced and the rest, all took place in an NHS context. So do the fraudulent "ghost patient" rackets that occasionally get GPs jailed and the Harold Shipman mass murder in Hyde. That's life, it happens and the Guardian's energetic health team and live blog forum will be following it tenaciously.
Contrary to routine assertions, I have never met a British politician, however rightwing, who wants us to go down the route to the US healthcare model, though plenty think we can learn from the French, Swedes, Kiwis, Bruces and others. Lansley himself says "if there's one thing worse than a public monopoly, it's private monopoly" – not a phrase you'd catch on Rupert Murdoch's lips.
So let's not panic and say the NHS is finished. No government hoping to be re-elected could ever sanction its destruction. But times change and those elderly and sick people who staggered into the new NHS's hospitals and clinics carrying their hernias and other neglected ailments would be astonished at what we expect from the service in 2012, pampered as we are.
I leave you with a thought I picked up from Dr Donald Berwick, a champion of US public healthcare and of Obama healthcare – whose very constitutionality is being challenged in the US supreme court this week.
The American "fee-for-service" model of paying doctors for what they specifically do has almost wrecked the system. But long service and study had taught him – he sounded saintly and wise as I heard him praise the NHS – that the future lies not in salaried doctors either, but in "gain-sharing" for patient and medical staff. Here's one explanation of the concept (pdf).
It's not a panacea, nothing is, though Berwick says transparency is "almost" one. But change is unavoidable. I think that's what clunky Lansley is trying to say, he just can't get the words in the right order. The Guardian
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