The Coalition agreement promised no top down reorganisation of the NHS and the White Paper had lots of nice sounding stuff about patients at the centre, doctors in charge and less bureaucracy. After lots of consultation making everyone feel important, the Bill was published and signed off by the LibDem leadership. “Labour attacks Tories on NHS changes” was not a story of any interest.
In the Commons the Bill sailed through on coalition votes without any LibDem disquiet and no great outcry from anyone in the professions – just Labour and the Trade Unions in opposition – so again no story.
In the Commons Bills are examined line by line through a Bill committee of 20 odd MPs with a built in Coalition majority, not on the floor of the House. Over long weeks the Labour MPs on the Committee mauled the Bill to bits; they forced over a hundred votes on key issues and lost every single one. But the true nature of the Bill as opposed to the rhetoric and disinformation was exposed. It was made clear that the Bill was actually about changing the nature of the NHS; fundamentally removing the key role of the accountable secretary of state. About introducing changes through the driving force of price competition with politics free utility style regulation replacing any idea of a managed system. The remainder of the Bill was dealing with the consequences of the main thrust.
Because the coalition could not openly admit they were carrying out the biggest redisorganisation in the history of the NHS all kinds of diversionary nonsense was made up. As an example the move of public health to local authorities was described as if it were a thought out policy in itself when in fact it was an afterthought necessary as a consequence of axing PCTs – a market system does not need publicly accountable commissioners.
As almost every commentator pointed out it was now clear that there was no compelling narrative for the changes; no explanation as to why the massive shake up was necessary made worse by the SoS himself admitting 90% of the Bill was unnecessary! Attempts to show the NHS was rubbish and so had to be reformed were debunked by evidence that actually the NHS was as good as any system in the world and had the highest ever levels of patient satisfaction.
Meanwhile, slowly but surely, various players actually read the Bill and maybe even read the critiques being provided for them. Lid Dem activists saw through it; Peers took cross party active interest and began having seminars with expert input. Crucially in the real world the NHS began to understand and even to start implementation of the huge reorganisation the Bill required. Light bulb moments all over the place. In the Commons Committee the incoherent nature of parts of the Bill became obvious even to the government (who withdrew large chunks of the Bill and rewrote them).
The combination of fear of the Lords, coalition tensions caused by LibDem activists, grumbling from the NHS itself and the genuine discovery that the Bill was badly drafted and incoherent led to the famous pause. The pause was not due to pressure from professional bodies but they were starting to show disquiet.
So pause, Future Forum, promises and assurances and a few mostly cosmetic changes to the Bill as a result. The core of the Bill (Part 3 about Regulation and Competition) was changed because the original version was incoherent, but it was still the heart of the Bill. A few token sessions back in Committee and again the coalition votes allowed the revised Bill to sail through the Commons with just two Lib Dems in opposition. Over to the Lords.
Now the Lords were well prepared. They had read what was in the Bill and had made great efforts to be briefed and informed. On first go over 100 Peers spoke in the debate and interest was as high as for any Bill ever. Now things really started to go downhill for the coalition. In the Lords (unlike the Commons) Bills are discussed in detail on the floor of the House, everyone can join in and a great number did as hundreds of amendments were put down and examined. The quality of the debates sowed a wealth of knowledge and experience which the government struggled to cope with.
Once again the government blustered and stalled and made encouraging noises and won the actual votes – but crucially votes were carefully avoided on many key issues as the Minister agreed to go away and have a think.
Now external pressure is really beginning to build as the Lords were bombarded with an unprecedented storm of advice, analysis, briefings and rants from outside bodies of all shapes sizes and persuasions – although by a ratio of about 100 to 1 the representations were wholly or partly hostile. So where exactly was the support for the Bill?
By now lots of people had read what was actually in the Bill and chosen to ignore the misleading comments and commentary from the government. They had even compared what was promised to the Future Forum and compared this with what actually changed in the Bill.
As was famously said at the time – the more that people read the Bill the less they liked it.
So the noble lords from all sides gave thought to dozens of key issues around competition, regulation the role of the secretary of state, private patients, regulation of healthcare workers, positioning of public health, patient and public involvement, independence for oversight and scrutiny, role for local authorities – all of which had been mauled in Commons committee and they were again ripped apart. It is obvious to all that there is no compelling coalition narrative which supports why they are making the changes through this huge reorganisation.
And then the Risk Register issue came along – which is a whole story in its own right.
So the Bill once more went into a kind of moving pause as the NHS got on with implementing it whilst the Lords tried to find compromises on the key issues like the role of the SoS. Fortunately the outburst from the actual SoS that nothing needed to change and that opponents did not understand helped the cause enormously.
Now enter the professional bodies; challenged by Andy Burnham to make their position clear. Many had at various times expressed support for and opposition to various different bits of the Bill. The great and the good from the professions had been in and out of the corridors of power throughout the journey, but now their often ignored membership began to have a voice. They were mostly against but not against enough to come out and tell the Minister they wanted the Bill withdrawn. Andy managed to get the main players together in one room and asked them to think about opposition to the Bill and to work out a common position as to how the changes that everyone agreed were necessary could be progressed without the Bill and the massive risks and disruption it was causing in the real NHS. They sort of agreed to try.
It almost worked – it was almost a coalition of the unwilling and everyone (except maybe the surgeons who knew how little the Bill would affect them) at least privately agreed that the NHS would be a better place if the Bill was stopped and a collective effort was made at stabilisation. They could also have dealt once and for all with the constant misrepresentation, as seen with Cameron at PMQs, claiming that in fact the Bill had widespread support from clinicians – (especially in Doncaster).
Nearly but not quite. If the combined Royal Colleges, all 20 of them, had joined the BMA and the Trade Unions in a common statement as simple as just – we do not support the legislation – then maybe just possibly that would have caused enough pressure to force at least a further pause and then who knows what.
It was close. Desperate arm twisting, promises, blandishments and no doubt hints of trouble or of future honours broke the consensus. Key bodies, without bothering to consult the people they represented, backed off.
So here we are. Tens of government amendments will make relatively minor changes and everyone will claim that was the result of listening and constructive engagement! Labour will force votes on the rally key issues and lose. The core of the Bill will survive its final mauling in the Lords, then go back to the Commons for an orchestrated block vote by the coalition – no chance that the LibDems will revolt – they have tasted power and they like it.
It has always been true that the only way the Bill can be defeated is if the coalition withdraw it – because they fear the political damage of continuing is worse than the damage of withdrawing a flagship reform firmly supported throughout by Cameron and Cleggy. They had the chance last year and decided to appoint the Future Forum to give them enough cover to bluff it out.
Now again they can bluster on – they have just enough fig leaf cover through various assurances to important Presidents of Colleges (and others who should also know better) to get by both Lords and Commons. They will make another raft of changes to show they have listened (again) – making this third time lucky for listening. But Part 3 and the change to a regulated market is still there – Monitor and the Courts are poised to take over and run our NHS for us.
It will now take longer and be a little harder to get to the full regulated market that LaLa always wanted ed but then this was always a plan for two terms. LaLa survives for another year – implementation rolls on – thousands of NHS staff loose their jobs – instability and uncertainty reign for a couple more year. Waiting lists and times edge up but quality and patient experience remain at high levels as basically our NHS is as good as any system in the world.
By the time the true impact of this Bill is realised and the market starts to take hold it will be too late.
So we had a chance at least for a while and we blew it – when the worst happens and we start to look back at 2010 as the high point of our NHS – do not forget who betrayed the interest of patients in the interests of their professional standing.
Health and Social Care Act 2012