Tuesday, 14 February 2012

NHS Reform: Oh what a mess

Once again, it appears that health service 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 Conservative-led coalition government has ended up between a rock and a hard place as a consequence of the troubles it is having with its health and social care bill.

To understand this problem there are two key issues to understand. Firstly, there is no doubt that the NHS is in desperate need of reform. 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, for the longer term. Some of us believe that a tax-funded NHS, free at the point of consumption is unsustainable in the longer term. However, 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 deemed to be “protected” from the brunt of the cuts it is still charged with finding £20 billion of “efficiency” savings over the next four year in order to meet the growing demands of an ageing population and new medical developments. Achievement of this level of savings is a pipedream. The NHS has always, since its inception, had annual growth in resources and not too long ago it was having annual real terms growth in excess of 7% per annum. In other words, the NHS is adept at consuming huge increases in funding each year and it is na├»ve to think that it can suddenly switch into a mode where it can deliver such huge efficiency savings.

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. Firstly we have 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. Secondly, the general public prompted by the media, opposition political parties (of all types) and the health professions are virtually always suspicious to 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.

Into this world stepped Andrew Lansley the new Secretary of State for Health. Many people were taken aback by his reform proposals incorporated in the health and social care bill. There are many changes included in the bill but the most publicised and contentious issue was the proposal to transfer responsibility for the commissioning of hospital and community services from the Primary Care Trusts (which were to be abolished) and to general practitioners working together in commissioning consortia. 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 (in the view of those of us who have worked in this field for 30 years and seen many attempts at GP involvement in commissioning) they didn’t have a cat in hells 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 funding etc. 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 which are important and need to be enacted. However, the main content of the bill regarding commissioning and competition are 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 it is difficult to believe that there won’t be a new Secretary of State soon. However, the tragedy of all this is that (as noted earlier) the NHS is still in need of urgent reform but this fiasco has probably closed- off any chance of radical reform for the remainder of this parliament. What happens when the NHS doesn’t deliver the £20 billion savings?

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, risks etc. This chimes true with one of the authors who was a Labour health adviser in the 1980s but still 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 in our view 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) and employ more doctors and nurses. It is time they started thinking about what doctors and nurses actually do not how many of them they are. Surely the Mid-Staffs health scandal taught us that.