A Bitter Pill for Private Health

Today there is a great political tournament. The battleground is a fine stretch of political turf called "choice". The weapons are two territory-marking speeches as Michael Howard and Tony Blair go head-to-head on the NHS. The result should be a flow of clear red water between them for all to see. It should be an outright Labour victory, with Conservatives rudely reminded that public services will always be enemy terrain.

That's how it should be. Unless, of course, Tony Blair chooses to muddy the water with third way, ideologically confusing language designed to infuriate his own side and stir them into rebellion. Blair and Alan Milburn, his former health secretary, always liked to insult the NHS in Tory language as a monolithic relic of 1948 in dire need of radical surgery.

The truth is that it has been radically reformed roughly every eight years of its life for purely political reasons. Its problem has been lack of cash and too many clever new plans. No wonder "choice" sounds to some like yet another threat.

However, John Reid, the current health secretary, talks NHS language. He has turned the "choice" agenda from a vaguely threatening Blair/Milburn idea into solid proposals that could deliver the final proof that the NHS works best well funded.

Here's the battleground. Reid's version of "choice" means that by the end of 2005 all patients will get the right to choose between four or five hospitals. At present, a GP refers a patient to a hospital neither knowing its quality or waiting times; and the patient waits for an appointment of the hospital's choosing. But soon a GP at the computer will access all the local waiting times and ratings: then and there, they will book a time and place to suit the patient.

This is the end of patients waiting patiently. Remember that in 1997 the official maximum waiting time was over 18 months. But the Tories under Virginia Bottomley had only counted waiting time from the consultant putting a name on the operating list to the day the patient got a bed. It was always a bit of a fiddle that left out long waits for the first outpatient appointment and waits for tests, scans and results. By 2008 all those hidden delays will be counted into a new maximum of 18 weeks right from GP to operation. The average wait will be half as long.

If the NHS can really deliver what will be a near-zero wait for most patients, then it will have exceeded the expectations of its founders. To be sure, there will still be some rationing over what operations and drugs are available, but the main instrument of NHS rationing was always the waiting list, and soon that will be gone.

So what is Conservative "choice"? Patients can take 50% of the cost out of their local NHS budget and pay the rest themselves. They give the cost as £1.2bn from NHS funds just to cover the subsidy for those who already go private, before adding in the cost of others who take up the offer. The idea is to free up NHS capacity while getting people off waiting lists for only half the cost of treating them.

So here is clear red water. The Tories offer choice for those who can afford to pay a top-up, leaving shrinking choice for those left behind. It could reduce the NHS to a last resort for the helpless, treating only complex, expensive illnesses and the poor. The more money was taken out, the worse the NHS would get. Middle-class flight would become mass exodus for all who could scrape up enough savings to escape.

Are there also risks in Labour's "choice"? Some fear the middle classes will yet again get the most out of it. But this overt, obligatory choice should offer the non-assertive a better chance to copy the middle classes and navigate the NHS better than they do now.

What of the creeping use of the private sector? In the dash to cut waiting lists the private sector is doing more NHS work. Mobile cataract units are already scything through the lists. New treatment centres are coming onstream, churning out hips and knees. For all Reid's assurances that in his lifetime the NHS will never commission more than 15% from the private sector, there is a suspicion that more will eventually be outsourced. Blair floats the idea that the NHS might become more purchaser than provider, and as all hospitals become foundations, the divide between public and private providers will be blurred. Unions will need better assurances of equal treatment for all staff whichever sector they are in. However, the private sector's capacity is minuscule beside the NHS giant.

What really matters is that the NHS will have won the titanic ideological battle between private and public healthcare. Bevan and Castle fought tooth and nail to stop private practice damaging the NHS, but they will have the last laugh as the NHS is now beginning to devour private practice.

Look what's happening: private healthcare companies are struggling. Bupa and Capio are selling off hospitals. Nuffield has decided to devote itself to working for the NHS. The cost of private operations is falling sharply to match NHS rates, competing for NHS work. Consultants and anaesthetists, whose new contract makes them give their first four hours of overtime to the NHS, are seeing their private fees cut under competition from lower fees paid in the new treatment centres.

Although the same 12% of the population still has private health insurance - mostly provided by employers - the number of self-pay operations settled in cash by the uninsured is falling fast, as people find NHS waiting times too short to waste their savings on queue-jumping.

William Laing, a private-sector analyst, says: "The private sector is now awaiting the thunderstorm. They are hurrying to streamline, offer lower prices and sell off capacity. The NHS market is their main future now the Blair/Reid plan is about to deliver choice, capacity and low waiting times. They have to adapt." Or hope the Tories get in to throw them a life-line with their "choice" plan.

True, the NHS doesn't offer carpets and private rooms yet. Real-life NHS experience still offers too many anecdotes of dirty wards and unkind, under-supervised nursing. But Reid, having had a close relative in hospital recently, is now targeting the "culture" of NHS treatment of its patients for his next attack.

Choice can mean anything. In education it can sound ominous, but in health the two parties' interpretations offer a crystal-clear ideological divide as deep as in 1948, when the Tories opposed the NHS from the start.

If waiting lists keep falling, then the Tories are again on a damaging loser that will infect all their other policies. For the NHS is loved and voters will choose equal "choice" for all, since Tory "choice" for the few to be treated in Harley Street smacks too much of that old "freedom" to dine at the Ritz.