The missed opportunity for NHS
18 June 2011
Reflecting on the outcome of the NHS reforms leaves a feeling
not just that an opportunity has been missed, but that the
cause of NHS reform has been put back.
On the positive side, the connection between local
commissioning groups and local government opens up two
chances for progress. The first and most likely to succeed is
integration of health and social care. The second, and far
harder to achieve, is for commissioning groups to work with
councils to open up the debate about what a good healthcare
system looks like, and to begin the long and painful process of
prising the electorate away from their obsession with hospitals
as the best form of care (polyclinics anyone?).
But the rewriting of Andrew Lansley's flawed and politically
inept plan has undermined progress in two crucial respects.
First, by overstating the case for competition he gave
ammunition to its opponents to equate competition with
privatisation. The outcome is that the cause of competition has
been put back by years – restricting it to the minority of
services covered by the "tariff" NHS price list. This deprives the
NHS of efficiencies and innovations which would help improve
quality, cut the length of hospital stays and save money.
Nick Clegg did himself no credit on this. Determined to position
his party as the saviour of the NHS he whipped up public
anxiety over competition – crudely exploiting incomplete
understanding of the issue – and thereby inflicted long term
harm on the service he professes to love.
Second, Lansley’s botched attempt to devolve decision-making
has ended up strengthening the hand of the centre. Having
failed to win over even the GPs to whom he wanted to devolve
commissioning, he has now heaped power into the hands of
the National Commissioning Board.
For example, it is going to hang on to the budgets of the
commissioning groups which are not ready, meaning it will
soon have a network of local staff and decision-making power –
centralised control that is the antithesis of the localisation of
Perhaps the most useful recent contribution to the health policy
debate has come from RCN chief executive Peter Carter, who
has called on the government to merge or shut poorly
performing hospitals, notwithstanding the fact that it would cost
his members jobs. Closing failing hospitals and moving care
into the community is the issue that has to be grasped.
Labour is irrelevant to health
24 May 2011
In the turmoil of the debate over the Health Bill, one
organisation has proved itself all but irrelevant – Labour.
The party's failure to make an impact on health epitomises its
policy paralysis in opposition. The row over choice and
competition is just one example. While Nick Clegg has been
taking what he claims to be the moral high ground by opposing
competition in the NHS (which sounds a lot better than
opposing choice, even though it is often the same thing)
Labour has failed to adopt a clear position.
This failure has two root causes – under Ed Miliband’s
leadership the party is unsure where it has been with NHS
reform and it does not know where it is going. Health shadow
John Healey has made half-hearted criticism of Labour's use of
private sector treatment centres to wipe out waiting lists in the
hundreds of thousands, saying "we may have pursued
competition for its own sake", but that hardly amounts to a
coherent analysis of the role of choice and competition in a
modern health service.
Just in case this is not a high enough dithering quotient, in the
same Guardian interview last week Healey describes himself
as "relatively agnostic" about whether all trusts should become
In the absence of anything approaching a policy Labour has
tried to land some opportunistic punches. But attacking the
government for creating a "competitive free-for-all" – which is
not what is being proposed – is exactly the sort of simplistic
scaremongering which helps the producer interests of the BMA
and Royal College of Nursing create a climate where changes
to help patients and taxpayers founder. With the Coalition in
chaos Labour could be playing a major role in the health
debate, providing some evidence it might soon be ready to
govern again. Instead it languishes in the margins.
Cameron sidelines Lansley as
3 May 2011
The revelation by Health Service Journal that David Cameron’s
office has set up a private advisory panel of NHS good and
great is a belated admission by Downing Street that it has
failed to get a grip on a crucial policy area.
The roots of this error can be traced back to the respect
Cameron developed for Andrew Lansley in opposition for
neutralising the NHS as a problem for the Tories. Believing that
his health shadow had developed a Midas touch for an issue
that had often proved toxic for his party, Cameron left him alone
to develop his ideas, with misplaced confidence Lansley knew
what he was doing. By the time the prime minister dispatched
Oliver Letwin last November to find out what was going on,
Lansley’s reforms were already off the rails and public
confidence in them was collapsing.
The establishment of the Downing Street panel – featuring
such luminaries as KPMG’s Mark Britnell, Jennifer Dixon of the
Nuffield Trust and, less credibly, former NHS chief executive
Nigel Crisp – adds more confusion to the chaos that is
Coalition health policy. Last summer Lansley was an all-
powerful health secretary. Now he is undermined in three
directions. He has had to accept NHS chief executive Sir David
Nicholson as chair of the new commissioning board, the health
bill is being rewritten by the likes of third sector champion Sir
Stephen Bubb via the hastily arranged NHS Future Forum, and
now the prime minister is bypassing his health secretary to talk
directly to leading figures in the health world.
Lansley's position looks increasingly untenable. I almost felt
sorry for him when he told a group of nurses last month that his
only political ambition was to be health secretary. But dumping
him in a reshuffle has risks for Cameron. Sections of his party
feel Lansley is being unfairly blamed for Cameron's failure to
know what his own government was doing, an error which
highlights the prime minister's growing reputation for poor
attention to detail.
Lansley’s failure to manage risk
27 April 2011
The report published by the Commons' Public Accounts
Committee is yet another cross-party kicking for Andrew
Lansley's beleaguered health reforms.
Three weeks ago the health select committee highlighted the
risks. Now the accounts committee's "landscape review" has
rounded on the failure to put in place robust plans to deal with
It rams home the point that the Coalition has being trying to
pass a Bill which does not explain what will happen if either a
trust or a GP consortium runs out of cash.
With consortia, this would be a bad enough problem if there
was a clear line of accountability between Parliament and the
commissioning body. But the committee has woken up to the
fact that the governance around these small business people
cum doctors is, at best, tenuous. Even the all seeing eye of
NHS commissioning board chair Sir David Nicholson will not be
able to keep every consortium from the rocks as they
experiment with their new powers.
The Lib Dem response has been to push for more democratic
accountability through council-led health and wellbeing boards.
But, as the committee stresses, the role and importance of
these bodies is far from clear. Bearing in mind many GPs
resent the power of primary care trusts, they are hardly going to
warm to the idea of some grubby local politico questioning their
As the bill stands the commissioning consortia will be formally
accountable to regional offices of the NHS commissioning
board, not the local health and wellbeing board. That might
change at the end of Lansley's pregnant pause, but it will still
not solve the multiple weaknesses in governance the public
accounts committee has laid bare.
Within all this confusion, little attention is being devoted to the
real issue facing general practice – the unacceptable service
which too many GPs provide. For example, the committee
highlights the eight-fold variation in the extent to which GPs
refer their patients to cancer specialists. The King's Fund told
the MPs that GPs' new role under the reforms could "help to
reduce such variations, through more effective peer
engagement". Presumably that's a euphemism for doctors
spotting that some of their colleagues are repeatedly making
Pickles’ council bashing stirs
18 April 2011
Local government minister Bob Neill is under attack from an
unexpected quarter about the abuse he and Eric Pickles are
heaping on councils – his local party.
According to the Telegraph, activists in his Bromley and
Chislehurst constituency are threatening him with deselection
for the repeated, indiscriminate attacks on alleged council
waste. Tory controlled Bromley complains it shouldn't be
lumped in with Labour councils.
Pickles are Neill are now fighting on at least three fronts within
their own circle. The Tory led Local Government Association is
furious at the way ministers have caricatured local government
as profligate, badly managed and inflicting avoidable cuts. One
Tory councillor said they felt "betrayed" by the ministers. And
within government, cabinet secretary Gus O'Donnell formally
asked David Cameron to rein in special advisers after the
smearing of former Audit Commission member Jenny Watson
in the Times, almost certainly by an adviser to Pickles.
So far Pickles has been remarkably effective in deflecting
responsibility for council cuts away from the government, and
his rumbustious style appeals to some Tory backbenchers
weary of esoteric concepts such as the Big Society. But his
aggressive, and often highly personalised, attacks are building
up a formidable list of people who would like to see him come
to grief. Neill is now caught in the backlash.
In practice Tory constituency parties virtually never rebel
against sitting MPs. But this development nonetheless adds to
the impression that Pickles and Neill are high risk, and may not
help their prospects for advancement come the first reshuffle.
Hidden cost of Lansley’s reform
14 April 2011
The tragedy of the meltdown of Andrew Lansley's health
service changes is that he risks wrecking the case for reform of
any sort, not just his flawed restructuring.
The understandable anger reflected in the RCN vote of no
confidence in him is nonetheless symptomatic of the crude
sloganising which has made this policy mess impenetrable to
Good services are becoming defined as protecting jobs and
keeping out the private sector. Labour, once the vanguard of
NHS reform, has filled the void where its policy should be with
its own crude scaremongering. It has described the plans to
transform Monitor into an economic regulator as "creating a
monster", and now leader Ed Miliband is aiming low punches
with talk of hospitals becoming insolvent – a complex and
important issue which he is wilfully taking out of context – and
GPs charging for services.
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