Reform is urgently needed in the NHS, but Andrew Lansley’s Health and Social Care Bill is not the way to do it. The health secretary failed to undertake a robust analysis of the proposed legislation’s feasibility, prospects of success or risks
Following the election of the coalition government in 2010, the new Secretary of State for Health, Andrew Lansley, lost no time in setting out his proposals for NHS reform. Many were taken aback by his plans, the most publicised and contentious issue of which was the proposal to transfer responsibility for the commissioning of hospital and community services from primary care trusts (which were to be abolished) to general practitioners working together in commissioning consortia.
The current state of the Health and Social Care Bill going through Parliament suggests that this policy will come back to haunt the Tories. After years of trying to de-toxify the Tory brand in relation to the health, and to assure the general public that the NHS is ‘safe in their hands’, the government has ended up between a rock and a hard place. Reform is desperately needed, but Lansley’s plans have few supporters. Things are pretty serious when the Conservative Home website can suggest that at least three Cabinet ministers believe the bill should be dropped.
There are two key issues to understand. Firstly, in spite of all the various changes that have taken place over the last decade or so, the reality is that large parts of the NHS are unsustainable in their present form. A tax-funded NHS, free at the point of consumption may not be able to survive.
The situation has been exacerbated by the dire state of the UK’s public finances and the impact of public expenditure reductions. Although the NHS is ‘protected’, it is working towards an unachievable target of £20bn in efficiency savings following shortly after periods of huge real-terms growth.
Secondly, the NHS is hugely resistant to change. Nigel Lawson once said that the NHS is the established religion of the British people and politicians have to tread warily when proposing change. There are the internal constraints represented by the trade unions and more importantly the various health professions (especially the medical profession) who see change as a threat to their established positions.
But also there’s the general public, prompted by the media, opposition political parties (of all types) and the health professions who are virtually always suspicious of change in the NHS and oppose it strongly. Even the closure of the most decrepit, outmoded and ineffective hospital will prompt campaigns to ‘save our hospital’ and fill MPs' postbags with protest letters.
Now, whereas some health reform proposals might generate public opposition it is worth fighting for them because they are likely to work and be beneficial in the longer term. An example here might be the creation of foundation trusts.
However, the problem with Lansley’s proposals regarding commissioning were that they were likely to promote huge opposition (which they did) and they didn’t have a cat in hell’s chance of working and being effective. Most GPs are simple souls who have trained as doctors and like spending their time with patients not sitting in meetings discussing commissioning, strategies, contracts or funding. There are exceptions to this but they are exceptions.
So where does this leave Lansley’s proposals and the Secretary of State himself? Well it seems inconceivable that the bill will not pass through Parliament and become law. There are several less publicised clauses that are important and need to be enacted. However, the main content of the bill regarding commissioning and competition is likely to have been so emasculated as to become virtually useless. Pity the NHS managers and civil servants who have to implement this half-a-Bill.
This will be hugely embarrassing for the government and some commentators suggest that Lansley won’t be secretary of state much longer. On the other hand, the prime minister seems determined to press on. However, the time and effort that has gone into this bill makes it unlikely that there will be any further radical reform of the NHS for the remainder of this parliament. This still leaves the NHS with the problems of poor productivity, patchy service quality and wrongly configured hospitals that the present bill will do nothing to remedy. Thus the NHS will still be in need of urgent reform.
What lessons can be learned from this? Well it is alleged that the Lansley plan was cooked-up at Conservative Central Office in opposition, and served up as a finished white paper just two months after the election, without any robust analysis of its feasibility, prospects of success or risks. This chimes true with my own experiences as a Labour health adviser in the 1980s where I subsequently observed the newly elected Labour Government thrashing around in the late 1990s for a workable health service policy after 18 years in opposition.
What is it about opposition parties that even after more than a decade in opposition they still come to government with half-baked policies? It is lack of resources or a lack of focus? Too often, opposition parties, of all colours, fight shy of developing workable policies, while in opposition, and prefer to focus on slogans, the main ones of which are to reduce administrators, spend more of our money (which is now in short supply) on health and employ more doctors and nurses.
It is time they started thinking about what doctors and nurses actually do, not how many of them there are. Surely, the Mid-Staffs health scandal taught us that.
