Editor’s blog Thursday 19 May 2011: “Twenty-Two” dreams of an unaltered, competition-heavy Bill?

UnitedHealth global health president Simon Stevens (who spoke yesterday at an excellent event held by the think-tank Reform) has previously joked that the tense Blair-Brown axis of New Labour was in its own way a ‘coalition government’.


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Political junkies will recall the briefings and counter-briefings, and collateral damage to ministerial careers, that became annually more explicit throughout the New Labour’s period of office.

PM David Cameron and company appear to have a fetish for New Labour, and in particular That Nice Mr Blair. They appoint ex-Blairite advisers, and they now try to sell the Bill by emphasising its continuity with new Labour’s health policies.

However, tensions within the current, explicit Coalition government over NHS reform are becoming common knowledge to the Westminster Village People, as they did under New Labour.

Nick Watt, Guardian political editor, reveals that Secretary Of State For The Time Being Andrew Lansley got a rousing reception from the backbench 1922 Committee.

The constitution of the “22” was altered last year, at the behest of That Nice Mr Cameron, to permit ministers to attend its meetings. It is probably reasonable to say that the “22” is not essentially the centrist bit of the Conservative Party’s MPs.

But the “22” is important. Its chair oversees the election of Tory party leaders, and also handles any requests for a vote of confidence in the party leader.

On Politics Home, Paul Waugh reveals that Deputy Prime Minister Nick Clegg’s diary commitments mean that his planned attendance at a listening event with PM Cameron and Andrew Lansley today has been cancelled.

Waugh is a good cynic, and questions quite reasonably whether we are witnessing a choreographed performance of dissent over NHS reforms to shore up the Lib Dem leadership’s position with its members and wider public opinion.

It may be so. Equally, the issue of the promised changes to the Health Bill may polarise the left and right of the Conservative Party as much as it has done the Lib Dems.

Of course, the disagreement might also polarise the two parties who form the Coalition.

The White Paper, and the original draft of the Health And Social Care Bill, envisaged a huge role for competition in driving NHS reform. It is clear from the recent announcements by Cameron, Clegg, Monitor CE David Bennett and even Liberatin’ Lansley that the redraft will be more linguistically aware of the need to emphasise collaboration and integration of care.

It will be interesting if the “22” dreams of the Bill passing without substantial changes. Or even substantive ones.

My view is that using the right kind of competition can have a role to play in certain situations of episodic, elective care that is (to borrow Simon Stevens’ taxonomy) highly measurable and highly contestable.

The evidence from research by Carol Propper and colleagues and Zac Cooper and colleagues is that there are positive associations between elements of competition in hospital care and improved quality and reduced cost.

Equally, there are valid points about the opportunity costs of markets in the NHS. There are likewise consequences to the viability of providers we might deem essential if whole services are tendered out of hospital (which may of course be the correct thing to do) – the residual viability of what is left requires attention.

There are also interesting issues around patient choice and provider response (required for competition) in the recent Kings Fund work with Picker, RAND and the OHE on the subject.

If competition is to be a tool in the work of improving patient care, it must have a defined purpose, and its benefits must demonstrably outweigh its opportunity costs.

It’s also worth remembering that many clinicians in this field (one that certainly requires co-operation to deliver good care) are very competitive people.

Stephen Dorrell, by no means a right-wing Tory, yesterday warned on BBC News of the risk of irrational polarisation of the debate.

The current debate over competition and collaboration is tending towards the theological (‘I believe / do not believe in competition’) and politically chauvinistic. The proper role for competition in the NHS should be, in the words of health policy expert Father Jack Hackett, “an ecumenical matter”.

I’ve been asked to appear on The Guardian NHS reform LiveBlog today at 4 pm, and if any Health Policy Insight readers want to ask me a question, I’ll be glad to do my best to answer it.