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 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 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 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 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 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 expert judgment. 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 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 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 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 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. __________________________________________________