There is a lot of hand wringing going on in high places just now about the “real” intent of Mr Lansley’s NHS reforms in England. Some of the talk about conspiracy or cock-up is self-interested, some ill-informed. We don’t deny that there are causes for concern – about haste, disruption and loss of talent. But let’s make sure we’ve got the right targets in our sights before we start the wailing and garment rending. We should be focusing on the things that matter for the public and service users, not siding with the special interests who have not delivered a responsive public service for the past 60+ years.
Whatever changes the English NHS may be facing, privatising and post-coding aren’t among them. If reading that makes your blood boil, then you’d better get over it. We’ve got them already. One is a problem; but the second shows a way forward.
The legacy of 1948
Fact – the NHS was effectively privatised in 1948. The main providers – GPs – and their union the BMA – insisted on it or they wouldn’t play ball. Having private businesses (GPs are contractors not employees) at the heart of the NHS has caused problems ever since. The great irony is that most people – even GPs, don’t get this. Why the blind spot? It stems from an opaque combination of illiteracy about public services; the warm bath of welfare state mythology (who reads Beveridge nowadays?); and complacent and cowardly politicians who prefer myth to reality (and many of us like it that way too, it must be admitted).
Our privatised primary care has the perks of public employment with little of the accountability that should come with it. GPs should expect to be controlled as contractors much, much more than they are. They could get a big dose of it in the form of responsibility for outcomes in the reforms, but naturally they are resistant. GP leaders articulate the main fear in the reforms: not wanting to “ration” care. But we have to ask – isn’t that what clinical judgement – their other sacred totem – is really about? Safety, effectiveness and satisfaction are tough calls, to be sure, but they are well rewarded and should be accountable to the public for it. The GP status quo is a colossal example of having your cake and eating it. At our expense.
An “identikit NHS” is not what’s needed
The NHS offer shouldn’t be the same everywhere as if stamped out by an unthinking machine. England isn’t homogeneous. “Post-coding” the commissioning and delivery of services is legitimate and defensible, but it is NOT synonymous with quality variations, shoddy services and poor patient experience. Making things local encourages rational, justifiable and shared decision making.
In contrast, “post-code lottery” talk as peddled in some quarters just panders to confusion. Staff organisations should stop doing it. They should explain to their members and the public that planned local variations are OK and should reflect intelligent commissioning. Differing health needs and inequalities need addressing through public health, community development and user-led interventions. Doing that would eliminate the “lottery” element by definition. But it would make for less emotive headlines.
What really matters
So what does really matter in these reforms? The answer we think is simple: governance, governance, governance – which has to be at the heart of the “owner experience”. The public are the moral owners of public services, so the ownership principle “no commissioning about me without me” should be the test for everything else.
If we started with that, then the rest would slot into place and management would be clear what they have to deliver.
It isn’t being disloyal to the fundamental principles of the NHS to insist that it turns into a customer responsive – and safe and effective too of course – service. We are paying for it after all! It is the perversities, the historical baggage, the special interests and restrictive practices that have to be be moved aside.
The Moore Adamson Craig Partnership supports user and public participation, trains lay representatives and develops responsive health, care and education organisations. We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing. Feel free to contact us to discuss the opportunities.