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Changing the way the health service operates is essential, argues former minister Lord Warner in a new book At a time when Labour may think it has the government on the ropes over its planned NHS shakeup, the party’s leadership is unlikely to welcome a book being launched next week by Lord Warner, the former health minister under Tony Blair, on why the health service should embrace market-based reform. But Warner has never been one to hold back on speaking his mind. In 2009, when Gordon Brown was pushing through policy of free personal care at home, Warner branded it a “cruel deception”. Last month, as a member of the Dilnot commission on long-term care funding, he appeared to jump the gun on the commission’s conclusions by declaring that any compulsory form of care insurance would not “fit the public mood music”. Now the former civil servant, social services director and Youth Justice Board chair is returning to the NHS debate with some typically trenchant reflections on what he thinks should be done to secure the service for the future. While the government could succeed where Labour lost its nerve on reform, he thinks, the plans before parliament need some serious underpinning to work. “Simply increasing the influence of clinicians without changing the way the NHS does its business will not deliver desired change,” Warner concludes in the book, A Suitable Case for Treatment – the NHS and Reform. “Without a more robust financial, economic and performance architecture, greater devolution and clinician power could produce financial meltdown …” It is clear from the book that Warner was frustrated by much of his ministerial experience, from 2003 to 2006, particularly after becoming minister of state in 2005 and taking responsibility for NHS delivery and subsequently reform. He acknowledges that Labour “saved” the service, but laments the “serious mistakes” he believes it made in failing to achieve effective commissioning of healthcare, allowing an excessive expansion of the workforce, thus worsening productivity, and ducking the challenge of replacing seriously underperforming and unsustainable hospitals and other care providers. It is the latter that he regards as the acid test of the coalition’s plans, much of which he admits he supports. “Having given people a reasonable chance to remedy their defects,” he says, “you have to be able then to remove them and let some new players come in. Whether they are from the NHS, social enterprise or the private sector, I don’t think I care. “But one of the things I do care about, which is one of the reasons for writing the book, is just allowing failure to carry on, taking taxpayers’ money and giving lousy services to the public. And many of those lousy services are in the poorer areas: the sharp-elbowed middle classes usually find some way to cope with the problem.” He wants to see evidence that the coalition is serious about penalising failure. He wants also a tougher financial management regime for the new-look NHS and intends to table an amendment to the reform legislation in the Lords, proposing a financial management standards board sitting within the NHS commissioning board and drawing on outside expertise. Appalling management “No one else in the world would be running an £80bn or £100bn business based on the kind of appalling financial management we have in the NHS,” he says. “It’s a very curious state of affairs to be expending that amount of public money on something where, on the whole, we don’t know the costs of goods and services and we certainly don’t know the different costs between different providers. “I find it difficult to see how you can have any kind of market of proper competition if you don’t have, in the public arena, a financial management system which delivers more and better information about the costs of goods and services.” Warner thinks the jury is out on whether GP-led commissioning will work as the coalition hopes. To do so, he says, it will need far better data collection and analysis than primary care trusts ever had and, above all, a willingness and capacity to “reign in” the acute hospital sector and switch resources into community health services and social care. The acute sector, he argues, is clinging to a model of care that is wholly outdated for the ageing population. “Stacking significant numbers of 85- to 90-year-olds, largely women, in the medical wards of acute hospitals doesn’t seem to me an appropriate clinical business response for this day and age,” he says. Urging a big shift towards more care of older people in nursing homes, which is far cheaper and away from the threat of hospital-acquired infections, he adds: “Many more could be in single rooms in nursing homes, being nursed and managed more safely than on bayed wards in hospitals.” Among other items on the Warner wish-list are a fresh and strategic approach to managing the NHS estate, making far better use of its land, buildings and facilities, and an end to national pay bargaining to allow flexibility in local labour markets. Such ideas, he accepts, clash with what he sees as the innately introspective nature of the NHS – “a major problem” – and an unwillingness among much of its leadership to approach it as a business. He likens the NHS mindset to that of local government leaders in the 1970s and early 1980s. “They were forced, brutally, by Thatcher to start looking outside for some of the solutions to their problems. It’s not about handing stuff over lock, stock and barrel to the private sector; it’s actually getting on your bike and going to look at how other businesses do their business.” As a minister, he recalls, he was repeatedly told that things he was suggesting were “not the NHS way”. “Well,” he says, “it’s about time they were.” But Warner is not confident. “Bringing about NHS change,” he reflects in the conclusion to his book, “becomes like a first world war battle, capturing a few yards at a time – often with casualties – and then along comes a new general who beats a retreat. As the coalition government tries to take the Blair reforms to their logical conclusion, history suggests they may have the same experience.” • A Suitable Case for Treatment, by Lord [Norman] Warner, is published by Grosvenor House at £16. NHS Health Doctors Nursing David Brindle guardian.co.uk