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NHS Reform, Wherever Next?

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Andrew Lansley's woes are multiplying by the hour this week as efforts mount to block the Health and Social Care Bill. Resistance might be expected from the BMA and RCN and other unions, but it is now more widespread and even reported from deep in his own party, among cabinet colleagues. The public are bewildered as are the staff doing a difficult job while debate rages and the restructuring proposed by the Bill has already begun. It's all a long way from the proud unveiling of the White Paper back in July 2010. Where did it all go wrong? As some now suggest, should the Bill be ditched?

It's a story in two parts. The first is the political process of reforming the NHS. The second is the substance of the Bill - despite everything, is it along the right lines?

The keen irony is the Secretary of State is highly knowledgeable about the NHS, appears to be well-meaning, supportive of its ethos, and wants to end political interference and micromanagement. And every minister naturally wants an administration-defining policy and to be first off the marks in implementing it. Thus incremental change is favoured less than bold visible, speedy and larger scale reform, with a White Paper and a Bill.

But the NHS is large, operationally and technically complex, close to the public's heart and contains ranks of organised stakeholders with diverse views. With public satisfaction levels at an all-time high, creating a mandate for change on the huge scale envisaged by the White paper was always going to be hard. Add in the bomb of explicitly promoting more competition and the backdrop of a very challenging budget settlement for the NHS, a coalition government, and the difficulty multiplies. And the keener irony was the Coalition agreement statement "there will be no major top down reorganisation."

The result has been to an extent predictable. The case for change, particularly legislative change, has not convinced the public or key groups. The focus on structural change and promoting competition has divided rather than united opinion on the important question of how the NHS can develop in the face of budget squeezes and rising demand. That stakeholders are in no mood to trust is evidenced by the trouble there has been over the wording of the Secretary of State's precise duties towards the NHS, which must seem arcane to the public. The Bill itself has been scrutinised for longer (40 sessions) than any other Public Bill in the whole period from 1997 to 2010. Nearly 2000 amendments have been moved by the Opposition in the Commons and the Lords, and 600 or so by the government itself. The opportunity cost of this effort is worth sober reflection.

Politics aside, what of the Bill's substance? Should it now be scrapped? The three main elements are attempting to end political micromanagement, handing more budgetary responsibility to groups of GP practices to buy hospital care for their patients and encouraging competition between NHS facilities as a means to improve quality.

The first is laudable, but almost impossible while the NHS remains a tax-funded service. Witness the Prime Minister as late as 6 January this year telling an audience at Salford Hospital that nurses should make hourly ward rounds. The last two are in keeping with the longer run direction of health care policy not just in England under Labour, but also across Europe.

Competition has its place to improve performance, and it could be argued that the dose currently in the NHS in England is sub-therapeutic and should be upped. Is competition the main means of motivating professionals to do better? Probably not, but it is a means worth trying alongside others given the evidence of its impact. As for giving budgets to groups of general practices, we've tried some of this before with some positive results. The rationale is that the trajectory of health care spending is mainly down to decisions by clinicians. This is behind attempts across OECD countries to align this power with the responsibility of holding a budget, and other financial incentives. So again the broad direction of the Bill is not wrong.

Broad direction is one thing, but whether a policy is workable depends on detail especially with such sweeping and interconnected changes. And politicians, or officials for that matter, may not have time to work out enough detail with the current penchant for over-rapid policy-making.

The answer in future may be to load less into Bills, and move forward more steadily with changes to regulations. This might result in greater and more thoughtful progress, albeit perhaps less politically visible - therein lies the rub for governments. The answer to whether this Bill should be dropped is more a political one, than a substantive one for the NHS, since regulations can achieve most of the changes without legislation.

However, whether or not the Bill limps to the finish, it should be a text book case study for new ministers.

This blog is also available to read on the Nuffield Trust website.

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