Editorial Thursday 24 January 2013: Before thoughts on Labour's health policy review launch

The Mascara Kid, also known as Labour’s shadow health secretary Andy Burnham, will give details of his party’s launching of its health policy review at the Kings Fund this morning.

He has an article in today’s Telegraph, and has also briefed details to Health Service Journal.

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The Mascara Kid and colleagues have reached the conclusion that the NHS has a major problem with frail comorbid elderly people in hospital for whom it’s probably not the best place for care.

They’re right on this, although the tradition of cost-shunting from means-tested and long-squeezed social care is nothing new to those with long memories who will remember happy debates about what’s a health bath and what’s a social care bath.

What do we want? Redisorganisation! When do we want it? 2015!
We would face another NHS-wide top-down redisorganisation of commissioning under the Labour proposals, as they currently stand - although helpful, this is a wiki-announcement of the start of the review, rather than its conclusion.

Labour might forgive those in NHSland for a certain ‘oh no, not again’ attitude.

HSJ reports that all commissioning would go to local government, with CCGs retained in a advisory role. This fig-leaf of clinical engagement – all the rage back in the prehistoric Darzi era – may not enthuse those who have just spent two and a half years applying for their jobs back in the new system – and crucially, if the intention is to move care upstream and into community settings, may not enthrall GPs who will see themselves answering for local performance to local government. Time will tell.

It is an interesting idea, though: retaining the purchaser-provider split, but moving the local purchasing away from GP-member groups and into politically partisan local government.

It is of course a kick in the nuts to those who have gone for leadership roles in CCG-land. And here The Mascara Kid and team will face some dilemmas if, come May 2015, they are getting their posteriors comfortable on the fourth floor of Richmond House.

Because some CCGs will have started to do some good work by that time. Some PCTs did: remember the much-lionised integrators of Torquay and Cumbria, as well as innovators in Birmingham East and North, Newcastle Bridges and Tower Hamlets.

The Tower Hamlets question
Tower Hamlets brings us to another question: where is the evidence that local authorities will commission competently, rather than in partisan ways? You don’t have to have read much to know that local government is scarcely a paragon of governance virtue.

Of course there could be workarounds: a local authority or its Health and Wellbeing Board with a well-functioning CCG might choose to delegate or vire its budget to the CCG re-invented as a sub-committee. At the least, this may encourage sillier CCGs to reconsider their relationship with their local authority and HWB if it is not good.

The overall intention of considering care more holistically and looking at public health determinants is admnirable. Its politics may be fraught.

I have written previously about how ill-prepared I think public opinion is for NHS closures and reconfigurations, and why they’re hard. Sentimental attachment to bricks and mortar in healthcare is understandable if we think a) of the national attitude to home ownership and b) that there isn’t a community-based alternative currently in place, not the money for double-running any such.

Of course, Jeremy ‘Bellflinger’ Hunt may heroically take a certain number of bullets on this over his tenure in post (and if Hunt is a political survivor, he may want another portfolio sooner rather than later).

But reconfigurations and closures there are likely to be. And the majority of the media will remain in right-of-centre ownership. This means that the media may be leery of disinvestment in a hospital that serves the better-off (and is staffed by a fair number of highly-educated and articulate professionals with the uber-trustworthy title ‘doctor’) to improve the living conditions of poor people that determine their health.

Changing determinants of health also doesn’t deliver very quickly – possibly not within the lifetime of a Parliament.

It will be politically courageous.

How to sack those in charge?
There is also a key question to address: how does accountability work in the new system?

Under the current system, if I am unhappy with how the NHS is being run and don’t fancy the ‘lump it’ option, I can vote for another party to bring in another Health secretary to do things more to my liking.

Under the system that starts on 1 April, if I am unhappy with how the NHS is being run I can’t do this any more because I don’t elect the NHS Commissioning Board.

How do we sack the person in charge in the new system?

Because local accountability would only be genuine if local taxation raised the entire NHS budget. At present, Council Tax raises about 30% of the local government budget: the rest is from central government.

Interesting times. More later.