It will take more than a few targets to make the NHS fitter

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Eric Garcia

Washington Bureau Chief

THE ITALIANS satirist Salvemini found a gentle but cutting way of poking fun at the sweeping centralisation of Mussolini's Italy. "Under the leadership of Il Duce, the production of kisses has risen by a thousand per cent," he exclaimed. "Meanwhile, the projections for expressions of affection have been exceeded, particularly in the South."

Salvemini would have found New Britain an irresistible subject. League tables and performance targets have become the equivalent of the four- year plans: purveyors of false reassurance and illusory simplicities, arithmetical comfort blankets in an uncertain age. The BBC's annual report reassures us that the corporation's diligent executives made 53 promises and met 45 of them. Never mind the quality, feel the width. All I want is one big one - that the BBC will deliver core quality broadcasting, rather than continuing its present ungainly digression into a miasma of half-baked, unwatched channels and commercial ventures funded by an increasingly reluctant licence-payer.

Managerialism was an outgrowth of late Thatcherism's obsession with applying the model of business to the public services - remember the prattle about unconscious patients being "health-care consumers"? As it turned out, however, the rise of management theory exerted far greater influence on embryonic New Labour, than on the Tories.

The prospect of an approach to policy that promised measurable efficiency, while evading awkward ideological questions, was irresistible.

Not all target-setting is foolish. New Labour was right to drop the left's knee-jerk disapproval of any attempt to examine the quality of public services. School league tables told us only part of the story about the state of schools. But their presence established the right of parents to information about schools. It shone a small beam of light into the darker recesses of teaching and the incompetence of some local authorities,

In dealing with underperformance in the NHS, however, targets threaten to generate much reassuring noise, with no prospect of any real reforming heat. The Government's public health White Paper, Saving Lives, published yesterday, is awash with good intentions. Heart disease and strokes are to be reduced by a third within ten years; cancer, suicides and accidents by a fifth. So if we stop dying, falling over and topping ourselves by 2010, Whitehall can pat itself on the back. If not ... well, let's be honest, there never really is an if-not.

The test of targets is what the consequences would be, and for whom, if they were missed. Would anyone be fired? Would the responsible ministers be named and shamed and the culpable departments be privatised, like failing local education authorities?

As if. We have experience of these things. Governments used to routinely over-shoot the public sector borrowing requirements. They did not parade before us, covered in shame, when over-spending occurred: they merely developed a raft of reasons why it was all the fault of the global economy. In the world of the target setters, there is no Day of Judgement, only the Day of Postponement, then the Day of Excuses.

This White Paper confidently presumes that, in the natural order of things, New Labour will still be in office in 2010 to take the rap if the nation should prove resiliently unhealthy. I don't wish to intrude on dreams of eternal power - to which all politicians are prone - but what is a promise worth if the giver may not be around to deliver it?

Saving Lives builds on the Public Services Agreement which threatened Government departments with financial penalties imposed by the Treasury if they fail to meet their own targets. If the death rate in the target groups should not fall by the requisite amount, are we to assume that the Department of Health will have chunks of its budget removed by the Chancellor as a punishment, thus reducing even further the money spent on health? "Certainly not," said an official. So if they fail to meet the targets, nothing will happen? "The target really acts as a guideline, concentrating minds on the areas where we know we are falling behind similarly wealthy countries in ensuring public health."

Thank God: something like the truth at last. What the Government really means is as follows: too many preventable deaths occur in Britain, and occur with very high frequency among the lowest income groups. We have frittered away too many years and too many lives in a pointless argument.

Right-wingers maintained that life-style was wholly a matter of individual choice, made by free men and women and that poverty was not a cause of illness. The left which concentrated solely on factors like employment, housing and income in determining how healthy we are, refused to acknowledge that individuals must bear responsibility for their own behaviour.

This Government acknowledges that the true picture lies between the two caricatures of what determines the nation's health. Of course poverty affects health.

Being poor is a stressful and demeaning business. It lowers expectations and creates cycles of poor diet and abuse of alcohol and tobacco, to say nothing of illegal drugs. Some 70 per cent of the difference in mortality rates between the upper and lower socio-economic groups is accounted for by smoking. So the policy of giving free nicotine patches to low earners and eradicating the promotion of cigarettes is an an obvious path to take. Small preventative steps can make life or death differences.

The really tough question from which the White Paper averts its optimistic gaze is what should happen to people who continue to resist the encouragement of the state to live more healthily, and then require expensive treatments. It has not yet the courage of its own logic - namely that there will have to be some form of conditionality attached to care.

With two White Papers on health provision and public health under its belt since taking office - surely it would have been better to have merged them into a coherent whole - Government is still fleeing the issue of what kind of NHS is sustainable. One thing is certain: the health service has great gaps and shortcomings, and is developing more by the year.

It is a premise admitted in a pamphlet, A Good Enough Service, published this week for the Institute for Public Policy Research by Bill New, a health policy analyst.

Mr New will never make a spin doctor. "The NHS," he writes, "could be encouraged to strive for `good failure' rather than unachievable success."

He is right. Until we alter our expectations of what it can deliver, face up the inevitability of health care rationing, and work out the fairest, most effective way to fund it, the morale of the NHS will continue to sink. That is unfair to the people who work in it and those who need to use it, whatever false reassurance the target-setters of Whitehall dispense.