A radical, unavoidable future for the NHS, whoever wins: Health Policy Today 6 May 2010

Tom Smith, associate director of Health Policy Insight and chief executive of the British Society for Gastroenterology, discusses the impact of whatever election result ensues.

What will the election result mean for the NHS in the next few weeks?
Every year, starting at the end of November I start talking about things I am going to next year.  Paradoxically as I move forward into December and the Christmas distractions next year seems even further away .  I promise to do lots of things next year when everything will be different.

This election campaign has felt similar: after the election things will different; after the election we will spell out the actions to achieve the changes we would like to see; after the election it will time for some tough decisions.

After the election now means tomorrow, and it’s time to stop talking in the abstract about doing more for less and to face up to the concrete challenge, which is ‘how, exactly’?

We could still have three different governments
At the time of writing (5.30pm on Thursday 6th May), three governments are possible: a Conservative majority; a Conservative minority; or, in the event of a stronger-than-expected Labour vote, some kind of coalition between Labour and the Liberal Democrats.

The first is the most likely  - the Conservative majority - and even if the Tory party are short of a minority, media reports suggest they will ally with non-Liberal Democrats to strengthen their minority government / achieve a majority.

The idea of a Lib-Con government or a Lab-Lib government are less likely, but worth considering.

A Lib-Lab government
If Labour comes second in today's election and if the Conservatives fail to secure 326 seats, then Gordon Brown will still have the opportunity to try and form an alliance with Nick Clegg, Norman Lamb and the Liberal Democrats.

It is possible that Labour could come second.  Belatedly, Gordon Brown has made an effort to reach out to people and show there is human empathy to guide his undoubted passion.

There is also a logic to Brown trying to make an alliance with the Lib Dems.  Between them, they would represent the majority of the country.  They would also have a common issue that could bind them together: electoral reform and cleaning up the House of Commons.  If they sold it right, they could take the public with them on a mission to clean up politics.

So far, so good - until you turn to the personalities and the leaders.  The majority of Britons are voting for a party, it is true, but they are voting for those parties often on the basis of how their leaders personify the party.

Would the Conservative Party really be the same proposition without Cameron? The Lib Dems without Clegg?

Whatever the rules of our electoral system, we know the election is about choosing a leader.  If he lost the election, how could Brown carry on?

Swap the leader?  It would undermine a system already seem as in need of a fix to have a second unelected prime minister.

So Nick Clegg would lead the coalition government.  That would be difficult if he has come third in an election of leaders, which is the only basis on which there could be a possibility of a Lab-Lib coalition.

If the Liberal Democrats come second, they would not be able to form an alliance with Labour.  Clegg has already said he would not seek to undermine the Conservatives if they win the popular vote.

A Con-Lib government
If the Conservatives forge an alliance with the Liberal Democrats, they will have common ground on health policy in a number of areas.

Not only do both agree there should be no preferred provider status, they are unconstrained in pursuing this policy in the way the Labour Party has.  They also agree that serious efforts need to be made to move the management of chronic conditions out of hospitals.

These things combined would see a Lib-Con government provide more opportunities to the private and voluntary sectors - and an onus on commissioners to look to place contracts with those who are serious about changing care.

The Lib Dems might not publicly admit it, but they are also sweet on the idea of GP practices commissioning services.  They might differ in how they think this should be scaled, but the Liberal Democrats could work with this idea.

The Health Service Journal, Michael White and others have been dismissive of the Liberals’ idea of locally-elected health boards, but in the context of a hung parliament they would push hard to introduce an element of local democracy in the health service.
It is not impossible to envisage some kind of accommodation between this idea and the Conservatives' favoured option of forming a local consumer body, Healthwatch.

One way of doing so would be for the PCT to gradually evolve into a body that held local services to account with local representatives appointed / elected to take forward the findings of the local health bodies.

The major difference between the Conservatives and the Liberal Democrats has been over social care, but Norman Lamb tells me that beyond the 'DEATH TAX' posters, there is a lot more agreement than is first apparent.

Before being over-ruled by election strategists, Andrew Lansley thought he could broker consensus on how to approach the issue. He thought it would reinforce the image his leaders wanted to push - that the Conservatives could be trusted on the big human issues in our society - but those running the election thought it would further strengthen one of their negative messages about Labour.  They will tax you until death and then reach beyond the grave to tax you further.

The Liberal Democrats and Conservatives could reach consensus on this big issue.  They could form an agenda together. The real sticking point for a Con-Lib alliance is an issue that will undermine any government, alliance or minister.  It is reconfiguration, to which I will return.

A Conservative majority
One of the great ironies about a Conservative victory is that in healthcare, at least, they are picking up the situation where they left off in 1997.

Labour came into power pledged to dismantle the purchaser-provider split, but came around to re-adopting the basic policy levers that the Conservatives had set up before them.

So the Conservatives will find regional purchasers.  They used to be called Health Authorities in the last millennium, but the Conservatives will grasp the similarities with PCTs.  They will find some appetite for practice-based commissioning, but quite big differences between its different conceptions.

The Conservatives will recognise the maverick, go-ahead practices that want to provide minor hospital services.  They will also be familiar with more collective approaches to commission in concert.

The Conservatives will want to strengthen commissioning.  They will be pushing for GPs to take real budgets and bear real risk in managing local healthcare.  They will give them real incentives to avoid expensive emergency admissions.

The Conservatives see the real central control in setting the financial playing field in which managers operate. This means they can talk about local freedom and accountability with great abandon.

Indeed, their strategy will be to tighten financial rules centrally while pushing accountability locally.  And managers will be squeezed in the middle - working in a very different environment.

The Conservatives are genuine in wanting commissioners to take decisions locally; but they will also share Labour's impatience about wanting change to happen quickly.

And while Labour were awash with cash and could keep paying for another initiative that this time might work, the Conservatives will be operating within a tough financial regime.  

They will need the power to intervene.  They will set tough performance targets through the independent board, which will no doubt draw upon well-known and established management figures from outside the world of health.

I will write more soon on the challenges facing the next government as they wrestle with financial reality.  No matter who wins, two issues will dominate.
- Reconfiguration and all that it involves, dealing with local difference of view; and
- Closing services, and clinical engagement, winning over those that work within the health service.

Winning over NHS staff will be a major challenge
The Conservatives have at least one prominent medic on their side: Professor Sir David Kerr (who had advised Labour) said that he was tired of the target culture, and felt that the Conservatives were more genuinely pro-patient choice.  The Conservative Party said he would advise them after the election.

It took Labour a long time to take clinical engagement seriously, and when they started to, it was largely because they realised that reconfiguration had to happen.

Labour felt that they could win the argument on reconfiguration by using the doctors that were pushing for change to make the case to their clinical colleagues.  It hasn't worked so far.

But we all know that reconfiguration is going to be a huge issue.  How is anyone going to handle it?

How to convince the public that changes in the NHS are needed?
Professor Sir David Kerr may not be very well known to managers in England or those involved in commissioning or working in the policy community.

He is a huge figure in English and British medicine, and a big public figure in Scottish healthcare. He is a big figure in English medicine as the head of medicine at Oxford.
He is a Glaswegian by birth, is a working class lad done good, and he retains a brogue which is pretty intimidating to your average doctor. He is well-known in Scotland because he defused a bomb which was threatening to go off a few years ago. He won public support for reconfiguration.

When he advised Labour, it was in Scotland, at a time when local groups became fiercely opposed to each other over reconfiguration.

It had been agreed that clinical pathways would be the way forward - but only belatedly realised this might involve closing services or changing their use, as Kerr emphasised when he joined the debate.  In Lanarkshire, north of Glasgow, three A&Es were under threat.  It was agreed the area needed only two, and that one would close.  All three had campaign groups defending it.

Reconfiguration became a huge political issue.  Nearly 80% of MSPs (Scottish MPs) said it was their pet issue.  Everyone had a view, and barely anyone agreed.

This was the situation into which David Kerr stepped.  He spent six months holding town hall meetings (before Barack Obama) and this culminated in a special day in the Scottish parliament.  Not only politicians but consumer groups, nurses, doctors, local councillors were all invited to a day-long debate.  In the end they agreed with service change though this still moves forward slowly and is politically tense.

What Kerr did was to stop conversation about closing services, and make them about changing services.  He talked about steps of care, and networked and linked bodies.

It will be interesting to see if the Conservatives plan to use him the same way.  His Scottish solution might not work so well in an NHS with greater private influence, on a bigger scale.

Similar actions are required whoever wins
Whichever party is named the winner tomorrow, they will face the same problems.  In reality, they have the same policy levers at their disposal.  All three parties agree on the required action; all three differ on how to do it.

If the Conservatives lead a majority government, they will set in place an independent board that will set requirements for the NHS.

A Con-Lib coalition would lead to a different kind of body, but it could remain independent of the government, to an extent.  Even if the Lib Dems manage to exert control in health (which is unlikely), an NHS directed by the Department of Health is already being set up to be less directive.

The Independent Board for the NHS will be pretty guiding, I would imagine.  What it won't do is change its mind about priorities quite so often.

Whatever the result of the election, the NHS faces a broadly similar journey.  All parties are open to the idea of the private sector putting forward radical ideas for saving money.  All will face a real impetus for being radical (rather than just talking about it) - and to an extent we will see a greater localism.

There will be more freedom for commissioners to take different decisions.  But critically, along with this local freedom for commissioners will come much greater local scrutiny and a heightened political atmosphere.

The government will find ways to insulate national politicians from decisions taken locally and, when challenged, will talk even more about the need for local people to hold managers to account.  They will support local communities in finding ways to do this.

Managers are going to face a much more political environment locally.