Guest editorial Wednesday 23 February 2011: U turn if you want to - towards consensus?

Irwin Brown of the Socialist Health Association suggests a strange consensus is emerging on the real way to deliver reform – and it’s not SOS Lansley’s.

In the 2010 election, the NHS hardly featured as an issue. The coalition agreement was cast as if the NHS was to be spared funding cuts and major changes – neither of which turns out to be true in practice.

So, the White Paper came as a bit of a shock and met with almost universal criticism; not so much of its principles but of the scale of reorganisation.  Deeper analysis hardened opposition. The more people examined what was on offer, the less they liked it.

The GPs who were portrayed as the architects and beneficiaries of the proposals now don’t appear to like it either.

To market, to market
Nobody seriously doubted the Bill would launch a huge reorganisation to introduce a free market into the NHS – a genuine market with genuine competition.  Services provided to the NHS would be opened up to free competition, with price as a factor.  The legislation would remove the barriers, bring competition law into the heart of the NHS and replace a managed system by a regulated market just like water or telecoms.  Ofsick alongside Ofwat.

Removing barriers to entry would mean patients would have a wide choice of provider for every aspect of their care, from blood test to complex surgery.  No provider who could offer a service could be excluded if they met the quality and price standards; patients would be free to choose.  Traditional NHS providers would all be freer versions of FTs and free to fail - and they would have to open their facilities to be used by competitors.

Superficially, the change was about how services were provided to the NHS.

The real argument was about how the NHS was run; how decisions were made about priorities; and how the £100bn of public money was spent.

Public accountability was removed, giving the powers in the short term to quangos that were kept in check by an economic regulator.  In the longer term it allowed the market to determine how money was allocated and any element of strategy or planning became unnecessary.

The centre cannot hold
But it is all falling apart!  The idea of price competition has apparently been dropped, at least until after the BMA has had its special meeting.

The ‘any willing provider policy’ has been completely undermined by the Department of Health making clear it does not mean what Ministers say it does.

The idea that GP-led Consortia would be free to do what’s best has been totally  undermined by the Department (sorry, Commissioning Board) making clear who is in charge and how almost every aspect of commissioning will be defined in regulations from the top.

Preferred providers and deals with single providers are back on the table.  

The strange consensus
In a strange way, a sort of consensus is emerging, excluding a few evangelist Tory MPs who are desperate for price competition and a free market.

Have clinical commissioning consortia but open them up to public and patient involvement and ensure a wide spread of clinical input not just GPs.

Give them the freedom to commission, ensuring they are not inhibited by competition rules or top-down intrusion.

Keep the NHS Board and its 50 outposts but open them up to make them publicly accountable and embracing PPI and clinical engagement.  The outposts could bring stability to the system; arbitrate on disputes; lead on commissioning of rarer conditions; deal with complex reorganisations; lead on reconfigurations; ensure any gaps in service provisions were plugged; and pool risks across a larger population base.

Use the existing Cooperation (sic) and Competition Panel to prevent abuse in procurement.

Have a more intelligent settlement with local government, giving them the responsibilities but leaving them free to decide how they discharge them.  The idea of the DH telling Councils how they should run their affairs is laughable.

Bring an integrated approach to all public services, including health, through elected councils; it is the only way to tackle the multiple causes of poor health and to drive wellbeing.

Give local government the strategic role over all commissioning with some levers to ensure the strategy is followed but delegating the details and implementation around healthcare to the local clinically-led bodies.

This has in fact all been said before, but ignored.

The reality is that driving quality improvements in our NHS has little to do with the structures, but instability brought about by reorganisation of structures is definitely a bad thing!  Competition can have some benefits for some services; but the scope is quite limited - and price competition is definitely bad.

Integration along patient pathways, collaboration between providers, developing the relationships between clinicians and patients and valuing public involvement through co-production are far more important.  Using information to highlight the major variations in clinical standards and then doing something about it would also be valuable.

You don’t need an NHS economic regulator.  You don’t need a high-risk, high-cost reorganisation.  

But most of all we don’t need a “genuine” market – not for healthcare.