Personal views: Virtual politics in the new NHS
Authors: Brian Salter
Journal: BMJ (1998)

Neither the white paper for England, The New NHS: modern, dependable, nor its subsequent guidance has done anything to address the real political problem of the health service: the apparently irreconcilable collision between the ever growing demand for health care and the finite resources available. What it has done, and herein lies its considerable political skill, is to transport us into another dimension of virtual politics. It was indeed “a triumph of style over content,” as Rudolf Klein and Alan Maynard have observed, but that, after all, was its ambition and not merely the unfortunate consequence of incompetent drafting.

The purpose of virtual politics is to create a parallel world where belief in the difficult reality of change in a particular policy arena is suspended and all becomes possible. In virtual politics, it is the immediate symbolism of the policy illusions which is of paramount importance, rather than the practicality of the content. If successful, a pressing political problem is obscured, or public attention is diverted, or both.

It is not a new idea, but an interesting development of an old one where politics is regarded as literally a creative art. Given the intense political heat generated by the demand and supply mismatch in health care (as manifest, for example, in rising waiting lists, increasing emergency admissions, and overspent health authorities) something significant has to be seen to be done in order to hold the line. Thus does the process of policy formation become an end in itself, rather than the means to an end.

There are several criteria to be met if the exercise in virtual politics is to be successful and the illusion believable. Firstly, it must at least placate, and if possible engage, the dominant power groups.


This The New NHS has done by giving the medical and (less predictably and less significantly) the nursing professions the lead role in the primary care groups and confirming the pariah status of managers. Secondly, the illusion must gain the support of the army of analysts, advocates, and apologists who research, report, and construct opinion on the NHS. Without their energetic maintenance of the policy dream machine its ability to sustain the illusion that its world has meaning is drastically reduced. Thirdly, it must capture the public’s sympathy through imaginative innovations with media appeal. Hence The New NHS gave us NHS Direct and specialist appointments within two weeks for everyone with suspected cancer classified as urgent by their GP: excellent copy. 


There must be no challenge to the medical profession



Given that these criteria were met, the virtual NHS was off to a flying start. But how long could the illusion be sustained in the face of the reality of the constraints on change in the health service: the inflexibility of the existing demand for services, the marginal room for manoeuvre in most health authority budgets for any redistribution of activity, and the weak or non-existent lines of accountability between health authorities and the independent—that is, private—general practitioners?

Initially, the answer seemed to depend on the pace at which the reforms were to be introduced. The slower the rate of change and the more they were introduced on an experimental or cosmetic basis, the greater the chance that the traditional reliance on the medical profession (in one form or another) to deal with the manifold demands of the British patient could continue undisturbed until a real solution to the demand and supply mismatch in health care could be found.

But there is now a major difficulty with this scenario. If the virtual world of the proposed reforms is to be maintained there must be no challenge to the medical profession on whose cooperation the existence of the virtual edifice depends. Yet partly in response to public pressure surrounding the case of the Bristol consultants and partly as a result of its emerging drive for quality the government has now embarked on a clinical governance policy which does precisely that. State intervention is proposed in territory which has historically been part of the sacrosanct sphere of medicine’s system of self regulation. 

If the medical profession interprets these proposals as a surreal product of the policy dream machine then all will be well. But if it views them as a challenge to medical autonomy then the heat and light generated by the reality of power and conflict in the NHS will rapidly subdue the virtual images of harmony and goodwill which the government has so far sought to project.

Grim reality will re-emerge where a make believe £21bn increase in the NHS budget is really £9bn, the promised 7000 new doctors cannot be cloned into existence, and the new bureaucratic tier of primary care groups will mean more managers.