Guest editorial Thursday 7 April 2011: Reform absurdities outmanoeuvre realistic strategies

Irwin Brown of the Socialist Health Association on reform absurdities and realistic strategies

The longer this week goes on, the more the brilliant April first piece in the HSJ looks like reality.  The fact that they printed such a piss-taking article shows how low the stock of LaLa has fallen.  What with that and the LaLa rap song by MC NxtGen, things are getting a bit silly.

We have the DH denying there is to be any pause or changes, followed by the announcements that there will be both.  We have tweaks and we have substantial changes.  

We have fundamental change and we have just changes to implementation and timing.  We have listening and a panel of experts – which sort of ignores the months of initial consultation and 6,000 responses – why not just read them properly this time?

Oh, and there was the evidence sessions that the Bill committee started off with.

We have the PM on the telly going on about involving the staff in the NHS as if there were not in place a set of formal partnership structures to do just that - not much sign that any listening has been going on so far.

We have the DPM (prizes offered for best suggestions about what these letters should stand for) going on about the problems with a Bill he signed. Other signatories to the Bill were Dr Cable (likely to be the next Secretary of State) and that LibDem Minister on the committee, old wotsisname. The same Bill allegedly went through the Coalition star chamber when the going first got rough and Olly Leftwing came in to do a hatchet job but was rebuffed by the PM, DPM, LaLa collective.

After many weeks and hundreds of amendments the Bill comes out of Committee unchanged; sensible amendments which covered just about every aspect the LibDems now claim must be addressed were all voted down by the LibDems on the Committee.  You could not make it up.

To try and bring clarity we have a sensible set of proposals coming out of the Health Committee, which if adopted would make the Bill unworkable – in fact you could probably achieve the aims without any primary legislation at all, and with far less of a reorganisation.  

Sadly, the Health Committee were a bit reticent on the core of the Bill, which is the move to a regulated market like gas, water, electricity, telecoms and of course the trains.  They treated this bit with contempt which is probably right.  Oddly this aspect of turning our health care into a regulated utility with increasing price competition, as strongly advocated by newly appointed Chair of the said regulator, has not rated a mention in the uttering of the PM and DPM.  They can’t have read the Bill – maybe that’s the problem.

Whilst there is a pause the DH under the Commissariat are getting on with implementing their version of what they think ought to have been in the Bill.  No pause there.

Commissioners desperate to balance budgets and free of intrusive top down monitoring of access targets start to make patients wait longer in pain; good managers continue to leave the service and everyone looks for a home to park the responsibility for delivering QIPP and the £20bn of savings.  

The LaLa revolution, prophesied in his 2005 article has hit the buffers, fallen of its perch and is deceased.  It will take time to realize it is dead but that is one thing about our NHS - it has the time - it has seen off a lot of “reforms”.

If you took a synthesis of the amendments offered by Labour, the position of the BMA and RCGP and the considered evidence based views of the Health Committee you might have a way forward.

Broadly-based commissioning consortia coterminous with local authorities (and sharing back office services) could work through the public health functions to develop the needs assessments and well being strategies required.

Have an independent chair and other clinicians on the properly publicly accountable Boards, alongside some GPs, as well as councillors (bit like a police authority, or maybe not).  With that spread of Board members they could also be responsible for commissioning almost all services (localism) and they could performance manage GPs, as conflicts of interest could be dealt with.  Working together, and freed from any top down interference or any “promotion” of competition by an unnecessary regulator they could develop the services and pathways to meet local needs and set about making sure they were provided in a way which delivers best value for tax payers.

The NHS supreme soviet could sit at the top and keep an eye on things generally, and just possibly commission a very small number of highly specialised services.  Simples.

We don’t need an economic and  competition regulator; don’t need Health and Wellbeing Boards; don’t need an NHS Commissioning Board with thousands of staff reinventing all the worst practices of the Department; we don’t need price competition and we don’t need healthcare to be commoditised like gas, water, etc etc.

Doing what I have suggested above would be cheaper, less risky and if the right programme for change was developed over a sensible period, using some proper pilots and listening to evidence, then there need be no major reorganisation.

Sadly, it’s too late.  Without any electoral or legislative authority, the “reforms” are already too far advanced to put back.  By mid-year, SHAs and PCTs will have ceased to have any real existence; many of the managers will have gone, along with the knowledge and experience and cultural memory.  GP consortia will be functioning in some fashion and working to complete the check list to get authorisation – so they can get the money.

LaLa, DPM and PM should have listened long ago.