NHS: Cultural unease about doctors, power and cash
On the windswept celtic edge of Britain there is a small GP practice that I know well. I bump into the guys when I'm on holiday, often in the pub, or on the beach. We talk about rugby, they pass judgements on the latest minor politician to get the job of health secretary.
Occasionally, being inveterate medics, they slip sneaky questions into the conversation designed to find out about my health. And occasionally I tell them about my own GP in London, which makes them go pale and order another pint.
I'm registered with a busy London GP surgery that has decided to be a kind of primary health factory. You can walk in and get seen quickly; there are numerous clinic-style services; the receptionists are friendly and efficient. But in two years I have never seen the same doctor twice.
Most of my encounters have followed a pattern: I describe, as clearly as possible and using medical terminology, what my long term conditions are; they scan the notes on the computer to check this is true; they make a brief binary choice: is the problem simple enough to be resolved by tablets or complex enough to send off into the hospital system?
It works. In fact it works better than trying to be a village GP in a city.
However, and this is no judgement on the various individual doctors, I feel my mates on the beach will know their patients better; be more accountable if things go wrong etc.
So why is this relevant to the NHS Bill fiasco we've just seen played out in parliament?
Well my mates on the beach want, primarily, to be doctors; but increasing numbers of big-clinic health factory style GPs have expressed the desire to be "commissioners". And this has touched a nagging nerve among the English middle classes (I say English because the main thrust of the Bill does not apply to the rest of the UK).
What the NHS Bill has run into is various forms of lingering unease among the public about private involvement, unequal treatment and the pecuniary motives of doctors. It is as much cultural as about economics or health.
Most people now realise that individual GPs are earning a heck of a lot of money. For that, many people would prefer some modicum of continuity and holism in their primary healthcare - but some, like me, will swap it for quick, no-nonsense treatment, above all, swift triage into the specialist/hospital system when necessary
As people began to realise the new system would reward those very GPs who had begun to form mini health factories, and give them ultimate power - and heard stories of health bureaucrats eagerly quitting their jobs on PCTs to form "commissioning support" companies - there arose a cultural worry that I think lies behind all the technical and economic objections to the Bill.
Because everybody who's been to hospital knows that hospitals are full of specialists who know a lot about a specific subject, and full of hi-tech equipment. Meanwhile GP surgeries are full of harassed docs who know a little bit about everything, and inhabit the world of coughing grannies and sick children. The concern arose as to whether these GP clinics could effectively spend £60bn on the health needs and "choices" of people they only really know from a computer file.
As long as the NHS looked like a big, complex, half-market/half-state monolith all these fears about "doctors on the make", health fatcats leaving the NHS to become management consultants the next day on twice the money - which were always there - remained submerged.
But once the NHS internal market is perfected, and transparent, even if it only exists as yet on paper, these worries about money, accountability and power bubble to the surface.
It was these worries that the Health Select Committee tried to address in its Fifth Report, published today. They grilled Andrew Lansley and various health officials about the potential conflict of interest between a GP holding money and making a decision whether to spend it with either a hospital or their own clinic.
This is what they found:
"79. The Committee finds that the evidence provided by the Secretary of State and officials runs counter to the direction of policy. If integration of primary and secondary care commissioning is important, then separating them in order to support the proposed system architecture may cause significant harm to the commissioning system as a whole, and should be reconsidered."
The detail can be found in the report, here. But the political problem lies in the fact that sections of the electorate had already begun to doubt the new system could protect them from two sets of rival health elites - GPs verus hospital consultants, backed by their respective managements - simply gaming the system to extract a surplus derived from the supposed achievement of performance standards set by themselves.
This, after all, was what made civil servants in the Treasury originally try to delay Mr Lansley's White Paper. An unnamed civil servant told the Guardian at the time:
"The white paper got bounced back because there was no way the Treasury could sign up to a proposal which handed £80bn of public money to 35,000 GPs who are basically unaccountable private businesses."
All the other stuff - mutualisation, the switch from recording inputs (number of ops) to outputs (better health), the bonfire of targets etc - even the effective de-nationalisation of the NHS and arms' length accountability of the Secretary of State - seems to have been eclipsed at the level of grassroots of politics by this nagging concern.
Because the policy pause is not only driven Liberal Democrat opposition to the Bill or the popularity of the Andrew Lansley Rap (parental advisory!).
The most perfect machine on earth for transmitting the anxieties of the English middle class is the Conservative Party - and, through voices as diverse as Norman Tebbit, Stephen Dorrell, Sarah Wollaston and Nadine Dorries (not to mention legion Tory doctors in the BMA) that's what it has done.
If you read the subtext of Ed Miliband's speech yesterday, there is a big signal contained within of the opposition's willingness to go on experimenting with a pubic/private mix of provision; an implicit self-criticism over targets etc. It was not a defence of the NHS as it existed on 5 May 2010.
So, weirdly and by accident, we may now have arrived at a moment many politicians have shied away from: a real, strategic level debate about what we want from the healthcare system.
Such a debate would have to honestly address the productivity failures of the NHS; the problems of inequity that have dogged attempts to emulate the best of the American health management and promotion systems; the reality of drug and treatment rationing. Plus the problem of where private money fits in a public system - whether it's the 60 quid I pay for private physio, the growing demand to be able to co-pay for drugs nixed by NICE, or the issue that dare not speak its name: social insurance.
It would have to frontally address our cultural unease about doctors - what do we want them to do, how powerful do we want them to be, and how enmeshed in the financial management of a system that pays them?
So with this flurry of interventions - from Mr Lansley, Ed Miliband and the Select Committee - it looks like the public debate has finally begun.
It's only a pity it has begun halfway into the parliamentary process.