Editor’s blog Monday 17 January 2011: What is the question that SOS Lansley’s NHS reforms are trying to answer?

A major media offensive is under way to launch NHS Week (as the Downing Street 'media grid' has it.) This is the first step in the effort to tell the story of 'liberating the NHS'.

Policyland is a funny little bubble, and it is probably useful for us to remember that most people don't plough through vast policy documents. So for many people, the news of a vast, whole-scale, whole-system NHS reform throughout this week is going to be the first they have heard about it.

It is likely that quite a few people will be shocked. They may wonder why they heard so little about such NHS reform plans during the election campaign, and more specifically why the promise to end top-down NHS reorganisation in the Coalition Agreement was, frankly, bollocks.

Health Policy Insight has been over this ground A Lot since the election campaign. The NHS is iconic - this we know.

So it will be interesting to see how, or whether, NHS Week changes public attitudes to the reforms.

What is the question to which the reforms are the answer?
The most signal failure of the health policy aims of the Coalition in general and SOS Lansley in  particular has been to articulate the question to which the Health Bill reforms are the answer.

There are a range of candidates.

First is the need (due to lower economic growth) to save a total of £15-20 billion over the next four financial years. This is a sum which in total represents almost 20% of the current  £106 billion annual NHS revenue budget (2010-11). It is A Lot Of Money.

This is so politically charged that its name changes every few weeks - the QIPP challenge, the quality and productivity challenge and latterly (courtesy of health select committee chair Stephen Dorrell), The Nicholson Challenge. Jim Easton must have done something smart in a former life in that his name has not been publicly attached to it. Yet.

So is that the question? Um, doubtful. Think tank Civitas and health policy expert Professor Kieran Walshe have pointed out that the financial and opportunity costs of the reforms are high. Its ability to save these kind of costs is unproven.

Can we find the question in Kings Fund supremo Professor Chris Ham's blog of 10 questions on the reforms? All are, naturally, very good questions - but they are about the coherence or otherwise of the reform proposals. They do not contain the questions to which the reforms are the answers.

Professor Paul Corrigan's always-interesting blog Health Matters has for months been pointing out the dichotomy between the Conservative policy drivers to de-nationalise,  decentralise and localise healthcare decision-making and the political reality of what closures will mean in Conservative seats (safe or marginal).

So. Is the question to which these reforms are the answer one about the relationship between the local and the national?

You get a sense that PM Cameron would like it to be - his RSA speech (of which I will write more later) proposed that the answer to that question is "the Big Society".

(Which reminds me: I haven't told you my 'Big Society' joke yet. What's the difference between The Big Issue and The Big Society? Some people buy The Big Issue.)

It is all very unclear. At times, SOS Lansley portrays his changes as completing the New Labour contestability reforms. At other times, Mr Lansley and his ministers emphasise the radicalism of the reforms. It is not immediately obvious how radical continuity with the Blair / Milburn / Stevens NHS reform agenda leads us to this equitable and excellent liberation of the NHS.

The media day today
I will do PM Cameron's RSA speech separately, but some interesting messages have emerged in the media day today.

BMA Chair Dr Hamish Meldrum and Professor Chris Ham told John Humphreys on BBC Radio 4 Today about (Ham) “very radical plans that essentially turn the NHS upside down” and (Meldrum) “we’re not so much against involvement of GPs and all clinicians in design and delivery or against the focus on quality – it's more to do with pace and size of changes, and persistence with marketisation of healthcare and brining in more competition, especially competition on price”.

Humphreys suggested to Meldrum that “more competition might increase efficiency”; “there’s not much evidence of that” replied Hamish.

Chris Ham signed off with the thought that “GPs are being given £80 billion of public money – this is a huge organisation change for the NHS at a time when money is tight … the NHS is a huge organisation whichj needs to be well-led and well-managed”.

A bedraggled-barneted SOS Lansley told BBC News“we have to get out of this idea that the whole of the NHS can be best managed from a top-down, centralised, bureaucratic system - we have to move to something that is more clinically-led, with clinical leadership, with patients enjoying more control themselves”.

PM David Cameron told John Humphreys in the key 'after eight' slot on Today that "“there was a lot of rebadging of existing bureaucracy … this is about reducing bureaucracy - £2bn a year by the end of this Parliament. It’s fundamental change that gives real power to the patient and the GP”.

“We are piloting these changes .. it is gradual … there isn’t a ‘quiet life’ option … change is necessary because we’re falling behind the rest of Europe … I don’t think we should put up with second-rate, second-best healthcare.”

“Health inequalities are worse at any time since Victorian times”

“The better-off are able to opt out of the public system”

“Choice and competition and diversity drives up standards makes people aim for excellence and that’s exactly what I think we can achieve in the NHS … there will be more choice, competition and diversity and that will help to raise standards”

“Doing nothing is an option that I think could end in tears”.

In sum, what were SOS Lansley and PM Cameron saying they want to achieve?

Lansley wants clinical leadership and patient control. (Interesting that he has just made Sir David Nicholson leader-designate of the NHS Commissioning Board)

Cameron wants less management (which is what bureaucracy is); reduced health inequalities; and choice, competition and diversity.