The effects of recent broadsides of scorn and abuse appear to have dismasted HMS HSC Bill. What happens next? Will the whole Health and Social Care Bill be shoved over the side? Despite the shrill noises off, in and outside of Parliament, I think not. There is wreckage on the deck, but the risk of hacking it all away is too great without also entangling not just the odd ministerial foot but the whole Coalition government as it basks in the achievement of its first anniversary. So what does my crystal ball say will happen as a result of last week’s electoral shambles and the political appeasement that will likely come in its wake?
Mr Clegg not selling the Big (or even the Main) Issue (yet)
Many people say the biggest clue is in what DPM Nick Clegg told Andrew Marr in their recent Sunday morning chat. It made good headlines, but in truth there is not much there and what he did say doesn’t address the biggest issue.
Mr Clegg said that GPs who don’t want to take part in commissioning won’t be forced to do so. That is not helpful for two reasons:
1. Having some practices in commissioning consortia but some outside will increase geographical fragmentation and make public health work with local authorities much harder.
2. It will also encourage two-speed or worse local arrangements and just encourage cherry picking and excluding under-performing practices, further disadvantaging their patients who will have no say in the arrangements.
Both of these will be disadvantageous for addressing local inequalities and they exclude patients from decision making. We hope this does not happen. All practices must be in consortia so that all their patients can benefit. That is what “Nothing About Me Without Me” means.
Mr Clegg also pledged there would be “no back door privatisation in the NHS”. He means by this glib and much parroted phrase that there should be no easy profit taking by private companies from public services that results in breaking up clinical linkages and local partnerships.
Who could argue with that? But the reality is that the service is already fragmented in many places because it has never been integrated. Patient care pathways – particularly for long term conditions – that unify primary, secondary and tertiary care and health and social care services would be wonderful if they existed, but in many places they don’t. We are still struggling to get cancer services right, much less things like long term neurological conditions.
Irony of irony, privatisation started by the front door of the NHS in July 1948 when most of the service that people actually use – primary care – was based on fiercely independent small businesses called GPs. Dealing with the consequences of that has bedevilled efforts to have an integrated health care system ever since.
Elephant in the room or shark in the water – take your pick
The DPM ignored the underlying problem which government could address in the “pause”. It has nothing to do with GPs and consortia. Put simply, it’s called the “Nicholson challenge”. It’s about eye-watering savings targets in all parts of the NHS year on year to 2014. Long before the Coalition appeared and Mr Lansley’s unexpected fiat of death on PCTs, implementing the savings demanded by Mr Nicholson under the previous government was eating away at the heart of the Primary Care Trusts which were in many places actually getting a grip on the underlying issues of service reconfiguration and integration which could deliver economies. But sadly, not soon enough or big enough.
Why current ministers haven’t questioned and seriously revised “Nicholson” is a mystery. Or maybe not? They wanted the best of both worlds by having a root and branch English NHS reorganisation on top of its imperatives to slim things down by some recurring £20bn by 2014. But the hapless matelots of NHS HSC Bill are ignoring the Big White circling in the water. That’s what is causing the trouble.
What Government should do now is put more distance between themselves and what Stephen Dorrell and the Health Select Committee has effectively tagged as the “Nicholson challenge” in order to distance politicians from it – pinning something that big it on an equally Big Beast like Sir David Nicholson, NHS CEO in England, as a target makes it much easier to fire the elephant gun in that direction if you have to.
From the PCT-land perspective where I labour, we have struggled with the savings targets linked to QIPP reconfigurations because of the difficulty of changing the acute sector and achieving shifts of care while simultaneously losing much of our management resources, which means that the clever people who could get the job done are leaving. New commissioners from GP-land will undoubtedly also struggle to prevail against the acute sector because it will be increasingly dominated by Foundation Trust mega integrated healthcare businesses, especially in urban areas. That is the biggest threat to the NHS I see and I am amazed that so few people are talking about it.
Serving two policy masters at once is asking for trouble – one has to go
It is the risks of giving the NHS two big things to do at the same time and not enough time to do them which was always going to cause problems. QIPP improvements/savings targets and big and unexpected structural reorganisation running in parallel can’t be done year on year by mere mortals in the timescale Mr Lansley envisages by mid 2013. So why not delay the “Nicholson challenge” to later than 2014? Yes, there might be more international financial disruptions along the way, even a Euro default or two, but it would lessen the intolerable financial pressure at the grass roots now, allow us to keep the focus on QIPP changes and let us get on with making the new “post-pause” system work.
Instead of that, what we are getting is an attention default to the new structures before the Bill is even on the statute book because that is where people see their jobs and futures. That means the service redesign improvements are left to later, the reconfigurations don’t happen on a big enough scale or quickly enough to make much impact and so the required “Nicholson” savings are then made hastily by slash and burn to get the big numbers. That is not only bad management, but doubly destructive for the NHS. It frightens the public, who dig in against even rational changes to local provision, and it alienates politicians who see it as votes against them. That feels like what is happening now.
For want of a narrative
Paul Corrigan’s recent excellent blog nailed the issue of what happens when a strong and persuasive narrative for change is lacking. Mr Lansley had a good narrative in the beginning, but it was built on times of plenty. When the economic signals switched to red, it didn’t persuade people. As Prof Steve Field who is leading the hastily assembled NHS Future Forum said this week, most of the problem with the Bill “is because the vision for what the government are trying to do with the NHS isn’t clear enough to the average person on the street”. That is putting it mildly.
Despite what some may wish, we can’t now just change the PCTs to get more clinical and local authority influence. This would have been the smart move that most people would have supported. Why not? Because PCTs effectively died on 31st March. The tumble weeds are blowing down the corridors. The new “PCT clusters” spanning large sectors are quite different animals and too removed from the grass roots to interest GPs and local Councils anyway, certainly if the London experience is anything to go by.
Taking people with you on a journey
We are adrift on a cruel sea threatened by all manner of perils. And unnecessarily so. You would think people would have learned the lesson that you must have a convincing story to tell when you ask people to go on a journey with you. Alan Milburn and even Andy Burnham finally realised that, but too late.
Why has Mr Lansley not done better with persuasion? It was very telling in a recent appearance at the RCN Congress in Liverpool that he told an invited group that he was sorry that his ideas had not been more convincing: “I am sorry if what I set out to do has not communicated itself. ” It is not the intellectual constructs that need to do the convincing, but their author. That was and remains the problem.
It just shows the need for continuing challenge, even at that high level, by some well informed but critical friends. Mr Lansley needs some of those now. We hope he gets them.
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.