The health bill is distracting both government and opposition from the massive challenges the NHS faces

By Neil Churchill

It is easy to forget, in the storm of protest against the government’s health bill, that the underlying principles of reform met with widespread agreement when they were published in 2010.

Sadly, some sensible reforms around clinical leadership, contestability and patient power were allowed to morph into a top-down reorganisation which coincides with the largest productivity challenge in the history of the NHS. As a result, one set of organisations is being closed down before a new set has been established; the detail of how the new system will work is not clear as the bill becomes law; and many people who the service relies on to save £20bn a year are facing redundancy.

In 2010 some new MPs believed ‘creative destruction’ would be good for the public sector. That now looks like hubris and the after shocks will certainly be felt for longer than the six months we are led to believe the prime minister is now expecting.

While New Labour waited too long to begin public service reform after 1997, the coalition leapt too soon, before it knew how to lead successful change. But opposing the bill now may have brought Labour short-term advantage but no long-term credit. The big question and emerging policy battleground remains how to achieve an unprecedented step change in productivity while maintaining quality and access, about which Labour has been silent. If there is a battle to save the NHS, it is the battle to meet rising demand and improve outcomes now the tap of rising funding has been turned off.

Rather than managing episodes of illness, a modern NHS must be organised around the needs of patients with chronic conditions, many of them older people. Money can be saved through early diagnosis, supported self-management and coordinated care for those most at risk. But Labour’s experience in government showed that stronger levers were needed to make this happen faster and more equitably than it would if left to the professions.

More clinical involvement in commissioning was needed to deliver significant changes in service design and referral patterns. Patients needed to be given more clout in order to ensure care was oriented around their needs and not those of the professions. And whoever commissioned services needed the option of competition in order to increase the pace of change or improve outcomes where existing services were failing.

The performance of the NHS improved as a result of Labour’s policies of choice, clinical leadership and – yes – managed competition. The concern over the government’s new reforms is, therefore, not about the principle of policy but the detail of implementation. Labour’s approach now, I believe, should be to hold the government to account for the changes it has said it wants to bring about.

In two areas, the government seems to be behind the curve. On productivity, Stephen Dorrell’s health select committee laid out a clear challenge to the government’s thinking. The ‘Nicholson challenge’ of finding efficiency savings, it rightly concluded, can only be achieved through service redesign. Yet it argued that savings so far had come from salami-slicing existing processes, instead of redesigning them to prevent more ill health. Incremental progress is being made but too many savings are coming from squeezing hospital budgets, without reducing demand by transforming care.

On patient choice, the promised information revolution is stalled at Richmond House. Labour made the performance of hospitals and doctors transparent, which has driven up standards. The coalition, rightly, wants to push more care into the community. But its attempts to extend transparency into primary care have so far been feeble. To ramp up patient choice as a driver of quality, much more ambition will be needed.

Elsewhere, the signs are mixed. On localism, there is potential in the health and wellbeing boards and in the move of public health to local government. But there is the danger of fragmentation too and some analysts of NHS finance suggest that, in places, 60 per cent of commissioning will be done not by local GPs but by the National Commissioning Board. This is likely to feel like centralisation rather than devolution of decision-making.

The jury is also out over whether clinical leadership is being enhanced. GP commissioners have discovered that they are getting the lowest estimated figure to run clinical commissioning groups. Yet despite the stance of the British Medical Association and Royal College of General Practitioners, GP enthusiasts have not walked away from the reforms. And NHS managers are doing great work to prevent them being handed a legacy of deficits. But how ready will GPs be to drive changes to the system? Studies of clinical commissioning in other countries concluded that results can be delivered from mature organisations that have had years to develop. Clinical commissioning groups do not have that luxury. And yet the NHS does not have the money to give them time to learn.

It is now hard to find a health specialist who believes the health bill delivers the reforms the government intends, but many sympathise with the original policy objectives. There is no doubt that the bill is now a very mixed bag indeed and we can expect an endless stream of subsequent policy and guidance. But the new NHS will be shaped more by culture, money and practice than by legislation, and Labour should focus its attention next on whether the government is delivering what it has promised. From this vantage point, there is a mountain to climb. And if the government fails to meet the ‘Nicholson challenge’, it will not be enough to have opposed the bill. Labour will need an alternative vision for how it will save the NHS.

—————————————————————————————

Neil Churchill is chief executive of Asthma UK. He writes in a personal capacity

—————————————————————————————

Photo: nrares