Two Bills

Clive Efford’s Bill being voted through hopefully marks the beginning of the end of the era of market experimentation with our NHS. The end of the failed decades long experiment with purchasing as commissioning.   Even the architects of the hated Health & Social Care Act with its aim of bringing about a full regulated market for our healthcare did not turn up to defend what their colleagues now regard as an embarrassing fiasco.

No Bill passed now will stop a future Tory administration, with or without a UKIP prop, from completing their mission to privatise our NHS.  No Bill passed now can prevent a future Tory administration from opening our NHS to US companies or from making rules and regulations which favour private interests.

But this Bill could be passed now.  It showed how enforced competition with its inevitable slide into privatisation can be removed from the NHS; without any reorganisation and without transition costs.  It showed how to make good on the many promises (or lies depending on your viewpoint) made by Ministers about how commissioners are actually not constrained in any way by domestic or EU law, about how we still have proper political accountability and that TTIP poses no threat.  The Bill makes such promises consistent with legislation.

The Bill is not designed to end the purchaser provider split; or to block any further competition of any kind; or to block private companies from playing some role; or to remove the private sector from the NHS.  Even if that was the policy and a way to carry out such a policy had been agreed it would still require far more legislation.

Whether or not the Bill becomes law (and it is highly unlikely that it will) the commitment by Labour to repeal the H&SC Act remains; that is a far bigger and far more complex task.  How this will be done and over what time scale is a major ongoing piece of work.

In the background is the almost visceral opposition within the NHS to yet another major top down rearrangement of the deck chairs.  That is why the Labour policy is clear about working with existing structures and about evolving change over a ten year period with most changes being resolved locally within a national framework.  Clive Efford’s Bill shows how a major policy change – to remove competition – can be achieved without massive structural changes, redundancies on a huge scale and huge fees to lawyers and management consultants.

We should also be aware that most of the evidence shows these structural changes do not work anyway.  In Scotland and Wales we have different structures but outcomes are much the same.  There are higher costs in multi payer multi provider systems as international comparisons show but the potential savings to be made in England are wildly exaggerated.  Even the worthwhile but more modest savings would not be easy to unlock quickly without disruption and unintended consequences.

The major issues that our care system has to address are around:-

  • Who pays for care and how (especially personal social care)
  • How do we reduce unnecessary variation
  • How do we improve outcomes and the patients’ experience of care
  • How do we make care person centred (or wrap care around the person)
  • How can the care system do more to address the determinants of poor health
  • How can the care system fit properly into the wider public sector – housing, education etc.

What we probably need is legislation to remove the barriers that prevent us addressing these key issues and to enable those with solutions to implement them.

Against this background we can look at the NHS Reinstatement Bill.

This is not really a Bill in that most of it is still to be worked out.  It is useful as it helps frame the ongoing and lively discussions about what structures might be the eventual result of replacing the H&SC Act and the market structures.  The central idea is about going back to the “Health Authorities” model of the 1980’s; a model alive and well in similar form in Wales and Scotland.

Two major problems with this approach are immediately obvious.  It sill treats the NHS as a separate entity disconnected from the rest of the public services, especially social care; it gives the NHS its own structures when what we need is proper accountability across the public services.  And it would require a top down reorganisation on a scale that dwarfs the Lansley farce.

If this idea is to be discussed properly then there needs to be a lot more clarity about how these two apparent problems might be addressed.  It would also be vital to know how accountability works and how the money flows; neither of which is clear from the scant outline we have so far.

Progressively moving away from the commissioner/provider separation is clearly necessary but a whole new understanding of what replaces “commissioning” has not yet been fully worked out even in Scotland and Wales, even though they are years ahead of England.

Some kind of “Health Authority” which is responsible and democratically accountable for the planning and delivery of all care for a defined population and funded through direct grant from the centre would be ideal for many.  But like ideal solutions generally it is almost certainly not possible; at least in England.  The huge complexity we have stupidly imposed on English systems for healthcare and for local government and the significant inroads made by private providers makes transition to the ideal structure impossibly complicated and expensive.

Juts as an illustration we can take one geographical area which is a shire County.  It has two embedded unitary authorities, five acute providers, two mental health providers, various primary and community care providers many in the private sector and a social care system almost totally privatised; the ambulance service is regional; out of hours and urgent care is a mostly privatised mess; there are five CCGs, three HWB’s, and thirteen districts which have a role in various health related functions.  None of the boundaries tie up with anything helpful, some NHS bodies have contracts to provide services outside the county as well as inside.  How you get that lot resolved into a single body which plans and provides for the County defies analysis.

So the debate continues and all contributions should be evaluated but we have to accept there are no magic answers.  Removing competition and resolving the tensions with private contracts is actually the easy bit if the political will is there; the rest is very hard and will take a long time and involve along the way some unpalatable compromises.  Wales and Scotland should be thankful they don’t have to face this mess.