Health Policy Intelligence, January 2012: 'Taking the pith out of the Health And Social Care Bill'

Many years before there was 'Cowper's Cut', I used to do a Health Policy Insight subscription product called Health Policy Intelligence. Clearing out an email folder, I found the January 2012 issue.

I copy its text below.

I do so partly for historical interest, but mainly because so much of it will seem wearyingly familiar in April 2023.

Integration debates; NHS money for social care; staff's uncertain futures; the NHS Commissioning Board trying to make plans that include shafting public health, which is nonetheless to ease pressure on the NHS; the Academy Of Medical Royal Colleges making fools of themselves ... it's odd just how little health policy debate has moved on in the past eleven years.

Health Policy Intelligence, January 2012

Wow.

That was insane. Really, properly insane. Insane for grown-ups.

The hog-whimperingly reality-free nature of the goings-on of recent weeks slightly defy belief - let alone summary and analysis.

However. It's time to catch up on the funniest show in town. Fill your glass with something warming; down it in one; refill; repeat. Deep breath.

OK. Here we go.

Towards undefined integrated care

The year arrived to the strains of a report on the need for integrated care from the Kings Fund and Nuffield Trust think-tanks. It's an important theme, although also one that can easily founder without a good definition of integrated care: the Walter Leutz integration rules remain useful ones.

Integration also cropped up this week, in the Health Select Committee's latest report on The Nicholson Challenge, AKA public expenditure. In the leak-furore media coverage of the report, the actual radicalism of it was missed almost completely: it stated, "the Committee believes that, as a matter of urgency, the Department of Health should investigate the practicalities of greater passporting of NHS funding to social care".

That means going right up to the hardcore-toxic area of means-tested-meets-universal. Whoo-eee. That is big stuff; the more so given Health Minister For Anonymity Paul Burstow's evidence session with the same committee.

Minister Who? showed a certain ... well, something to the committee, such as his messages that "trying to get a definition of unmet need is very hard", and then adding that unmet need causes costs elsewhere in the system, while suggesting that the Coalition's NHS reforms are designed to deliver integration using Health And Wellbeing Boards, pooled budgets and NICE standards.

Oh yes: not to mention his statement that he didn't believe there was a social care funding gap, but that if there were one, then it was down to the individual local authority (thank the Lord they're not capped, eh?).

I'm not sure what that something is. Ignorance is one possibility. Chutzpah  is another. Mr Burstow didn't giggle. This may be evidence of a Cool Hand Luke-style pokerface. Or it could denote extreme, hardcore stupidity. You will have to decide for yourself.

Connoisseurs of pain might also want to watch the appearance of the Care Quality Commission leadership before the Public Accounts Committee. It's really rather grim. Though in time, the pain will probably feel homeopathic, compared with the Francis Public inquiry's likely findings: again, decide for yourselves.

Deciding for yourself is rather more than staff in PCTs and SHAs have been easily able to do. HSJ reported on problems with their employers having a clue about their staff's future employment prospects, observing that one of the two letters is to be used "where there is no clarity about the destination of their current function".

HSJ also cites a DH email citing legal advice which states "I do not believe that any of the letters could be construed as promising jobs for employees in the future, but I have made comments that I hope will avoid any possible ambiguities. For example, it is important to distinguish references to 'functions' and 'roles'. A function may transfer but it will not necessarily follow that everyone working in that function will transfer and you want to avoid creating that expectation if there is a chance you cannot fulfil it".

Monitor over-reaching

Meanwhile, Monitor has been exhibiting a mixture of corporate schizophrenia over how many boards and chairs and CEs it will need. Not only that, but HSJ has found out that it is also experiencing 'mission creep' into advising CCGs on how to handle a well-run but financially unsustainable FT provider.

This really matters. I have gone on about the confusion between the post-Future Forum 1 ongoing regulatory role over FTs and the economic regulator for some time, never mind about Monitor's incomprehensibly confused role in failure.

Nick Timmins' excellent FT piece  makes a solution to one part of the problem clear. The Co-Operation and Competition Panel becomes the economic regulator; Monitor remains the provider.

Don't hold your breath. Monitor also took a good-sized step into the World Of Wacky, with its frankly insane proposal to let credit ratings agencies (yes, the people who brought you triple-A rated collateralised debt obligations on sub-prime mortgages) risk-rate providers of NHS-funded care. If life imitates art, this is public policy imitating a 'The Thick Of It' idea which was rejected as unconvincingly over-the-top.

The NHS Commissioning Board is making plans

Now the NHS Commissioning Board has published its own design plan (yes, it's all very meta-). There is not as yet clarity about how many jobs are to go, but it formally makes clear that (as has been evident for some time) clustered PCTs and SHAs create the new system architecture.

It also clarifies various exclusions from the £492 million running costs budget by 2014-15, which include the revenues of commissioning support units (which is clear, since they must win clinical commissioning groups' (CCGs') business, and are intended to become autonomous).

Also excluded are the costs of providing clinical advice to the wider service; commissioning public health services on behalf of public health; costs associated with the Patient Record and other technology functions.

Oh, and fans of the NHS University will have a wry chuckle to see that "new Improvement Body will become self-funding. Transitional funding will be required to achieve this". No shit.

It has also been suggested to HSJ that the NHSCB will not itself directly handle the budgets of those CCGs non-authorised or semi-authorised  by April 2013: instead, the CCG will either have a Nicholson-Commissioning-Board-hand-picked manager-troubleshooter parachuted in or be forced to use a Nicholson-Commissioning-Board-specified commissioning support provider.

To be fair to Comrade Sir David, this at least looks a bit arms' length, although you end up with exactly the same result.

Giving CCGs lemons to suck

Those lucky CCGs who get approved to hold budgets (as PCT sub-committees) from this April also get to suck a bit of a lemon, thanks to the DH new standard contract making provision that commissioners will not be able to impose the penalties on providers for long-waiting elective patients in the next financial year. Thus it will only be in the first year of CCGs' statutory existence (as of April 2013) that the penalties will be imposed.

Health Secretary Andrew Lansley announced in November that in the case of providers failing to achieve 18 weeks in the vast majority of patients, "for every 1 per cent they fail to meet that they could under the contract lose 0.5 per cent of their elective contract value".

It's all fun for CCGs - and even ardent supporters NHS Alliance are starting to feel the burn, as the rhetoric of devolution delivers Stalinism on steroids. Their chair Dr Michael Dixon's first-ever New Year's Message (which is OK, now that GPs are the new NHS royalty) asked some of the right questions of the Nicholson Commissioning Board: "will it be able to move out of the Department of Health mode of 'performance management"' and in to one of 'performance enablement'? Will it be fully connected to CCGs themselves, rather than consigning them to the lower tier of a new commissioning hierarchy? Will it have a primary care focus, given that the most crucial changes will involve creating better care close to home and increasing the ability of individuals and communities to care for themselves?  Will it support localism?  Indeed, will it be identifiably different from the Department of Health as it is today?"

Dixon called on the Government to offer more explicit support to clinical commissioners, suggesting that the treacle of centralisation is beginning to congeal around the (hopefully) fleet feet of clinical commissioning enthusiasts.

NHS Alliance also gave the DH a thoroughly unwelcome message when their new report on the NHS111 number for urgent but not emergency care saw unscheduled admissions in the pilot sites increase between 5 and 9%, compared with the control sites. Marvellous.

Not only will 111 further confuse a public who policy hopes will reduce their use of urgent care (think walk-in centres, urgent care centres and minor injury units), it would if replicated create huge new financial pressures.

CCGs may mostly be looking green to go, with 94% looking set to get some degree of authorisation in April, but they will need to start having a nice think about where their buildings are going to be. The legacy real estate of PCTs is, HSJ learned, being put into a new property company ('propco')+, with regional subsidiaries.

Andrew Lansley: saviour, liberator

For The Nicholson Challenge to be met, CCGs will need sensible debates with NHS Propco's regional presences - changing primary care services requires changing use of estate. NHS Propco's sole shareholder is Secretary Of State For Health Andrew Lansley (saviour, liberator).

It has not been a good few weeks for Mr Lansley - but when is it ever? He gave a rather self-pitying speech in Liverpool yesterday, in which he told the audience of his era in opposition and now in Government: "since the NHS's foundation no other frontbench politician has served in this post for so long. Or had the time and enthusiasm to talk to NHS staff at all levels, observe the system, get to know the many things that go right and the ones that also go wrong.

"I'm not an outsider. The NHS is my passion, my mission . and I would never do anything to harm it". Give that man a long-service award. Mr Lansley went on (and on): "several health organisations oppose aspects of the reforms I believe are essential. I wish it was otherwise.

"I don't seek out a fight. I'm not the sort of politician who delights in the sound of gunfire. I've paused. I've listened. I've worked with the independent Future Forum. I've reshaped the plans where my critics have a case". He may even believe it.

He added, "I'm proud that we are taking this reform through parliament, where opinions can be heard. It's been an ... interesting process. But soon it will be over. We will have a law, and we can end the squabbling about structures, and get on with what we all want, which is creating a better NHS".

The speech also found Mr Lansley up for a fight with the BMA: "remember 1948, when the British Medical Association denounced Aneurin Bevan as "a would-be Führer" for wanting them to join a National Health Service. And Bevan himself described the BMA as "politically poisoned people". A survey at the time showed only 10% of doctors backed the plans . but where we would be today if my predecessors had caved in?"

Mr Lansley's reforms earned the Prime Minister an NHS shoeing at PMQs this week on the loss of support for his reforms by the nurses and midwives. Calling for "a second opinion" on the reforms, That Nice Mr Cameron cited in his defence a GP in Doncaster (Labour leader Ed Miliband's constituency).

Yes, he cited one GP.

Even more unfortunately for the PM, Pulse established that the GP in question has since left that CCG. Mr Cameron gave a wonderful speech earlier in the month, where he emphasised that his Government respects nurses so much, it will have to tell them when they are shit. Oh, and that they have to tick boxes with hourly ward rounds to talk to patients. Truly, the era of top-down control is over.

The Government is satirising itself rather early in the electoral cycle.

Mr Cameron also replied, "I know that the Leader of the Opposition panics and backs down the first time a trade union says no, but this Government do not".

The narrative that the Government are trying to pin on the Bill's opponents is that these are issues of trades unions terms-and-conditions politics. It will be interesting to see if the furore of the last week resonates with votes in opinion polling.

Lansley's staying, say Tory insiders

An interesting piece on the Government's NHS reforms appeared in Total Politics by former Sun political editor George Pascoe-Watson, now with Portland Communications (which, amid controversy, recruited PM Cameron's former director of policy James O' Shaughnessey). Portland and GPW can both fairly be said to be on the inside track, which makes 'For The Good Of This Government's Health' well worth a close read.

GPW writes, "David Cameron is masterminding a mission to ensure health remains a neutral issue between now and 2015. The PM knows the Conservatives must do all they can to stop Britain's NHS become a concern on voters' minds. Neutralising the public's fears about the issue is part of the No 10 re-election strategy. Cameron can't do this on his own. He has placed huge trust and faith in health secretary Andrew Lansley to help him deliver on this objective.

"Those who have lined Lansley up for the axe in a 2012 reshuffle will be proven wrong, I understand. He stays put to deliver on a new plan to put patients first".

Mmmm.

Some mission. Some masterminding.

This piece will have been written before the past week's uber-turbulence. But we can certainly expect a forest of rhetoric about putting patients first.

The plans reportedly also include "a 'big bang' approach to public health aimed at easing the pressure on the NHS by getting us all to live better so we need it less". This may be hard, because public health budgets are far from a certainty, as indefatigable data diva Sally Gainsbury points out in HSJ.

Statement hokey-cokey with the AOMRC

It has been a lively week in other ways. The Academy of Medical Royal Colleges played an entertaining game of statement hokey-cokey, in which they released to The Guardian a draft statement ceasing to support the Bill, and then withdrew it after getting nice phone calls and unspecified promises from ministers.  In-out, in-out, shake it all about.

And the Comrade In Chief himself, Sir David Nicholson gave an interview to the FT, in which he told the PM and Health Secretary to damn well get out there and start selling service closures.

The article presents a confusing argument: it reports that "Sir David wants more evangelising from his political masters about the need to reshape the way healthcare is delivered. "We're going to absolutely require top-level political leadership ... from the very top, the prime minister, Andrew Lansley?" he said, adding that this is not a question of closing hospitals: "it's a shifting of service, it's a concentration of service".

But surely that means closing bits of hospitals? At the very least. And in high-profile London, maybe more. Maybe much more.