The missed opportunity for NHS reform
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
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 commissioning envisaged.
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 debate
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
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 foundation trusts.
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 trust ebbs
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 exposed
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 those risks.
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
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 serious mistakes.
Pickles’ council bashing stirs Tory revolt
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
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 fiasco
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
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 the public.
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.
April to June 2011
Public Policy Media