Health service: The change remains the same

Nigel Lawson grumbled that the National Health Service was the closest thing the English have to a religion. Its hold over the political class has strengthened since his 1980s heyday, with all three parties now proclaiming their devotion, not least the Cameronite Conservatives, who offer their piety as proof that they have changed. But what was once a unified church has splintered into a faith of many sects. A generation of ceaseless, breathless and often pointless revolution has produced dissent about what is truly sacred. Some venerate the doctors and others the state-owned hospitals. Others again say the only commandment that counts is that care is free at the point of use, and that the market can, perfectly happily, take care of the rest. The new health secretary, Andrew Lansley, yesterday set out his own particular doctrine, in the form of a white paper . It was clearer about the sort of health service he is against than the sort of health service he is for. Out goes what remains of Aneurin Bevan's nationalised vision, and out too is New Labour's one-time belief in a regime of targets and terror. Forget the emerging academic evidence that targetry worked wonders on waiting times – for both good and bad reasons, doctors resented them. Always more trusted by voters than ministers, the medics who had already persuaded the last government to cut the number and iron out the undoubted perversities in many targets, have now won a more thorough victory. There were other points, too, on which Mr Lansley's opposition strategy of hugging the British Medical Association close appeared to have been carried into government. Separating service purchasers from service providers is the orthodoxy in public sector reform, but this is being turned on its head by the plan to hand family doctors control of the NHS purse strings. Even if many GPs do not seek this control, it is striking that the very part of the profession that Labour threw most money at is about to become more powerful again. The Conservatives have also effectively crushed Liberal Democrat proposals to strengthen the voters' voice in the service, through elections to primary care trusts. Instead, PCTs will be abolished, and the junior coalition partner has settled for a new co-ordinating role for town halls in health, a mere face-saving gesture towards democratisation. The Lansley doctrine, however, is about more than doctor worship. The supremacy of the medics will be challenged, and perhaps outdone, by that of market forces. Buried in yesterday's small print was a proposal to turn Monitor , the body that currently superintends the foundation trusts, into a full-blown economic regulator to oversee a healthcare market in the same way that Ofcom and Ofgem oversee the markets in communications and energy. Crucially, it will be required to go out of its way to attract corporate challengers to the NHS. Once the shift to a market system is made, European law may make it irreversible. Family doctors may, perhaps, be gaining enough power to shelter themselves from the full gales of competition, but the hospital sector will feel its force as never before. Mr Lansley's decision to remove the cap on foundation hospitals' private work will only aggravate fears about where all this is leading. The biggest risk of all, however, is that the service will not survive the shock. With the baby boomers moving into their 60s, the near-freezing of health expenditure – which is all the health service's much-vaunted protection affords it – will feel like a deep cut. That makes this a dangerous time to go through yet another great upheaval, which – for all their ambiguities – is the one thing that the Lansley plans will certainly produce. In opposition, the Tories rightly damned Labour for reorganising the service too often. Now that they are in office, its weary staff must worry that the only thing that never changes in the political theology of the NHS is the demand for change itself.