Cameron phones friends to help answer tricky reform questions
It is a year since the general election that brought the coalition to power and Andrew Lansley to Richmond House.
This week’s HSJ focuses on the successes and failures of the NHS reforms that have assumed growing importance during that first year – although not in a way the new administration would have wanted.
Two former health secretaries – one Conservative, one Labour – and two other senior figures, who were summoned to Number 10 this week to give their views, pick apart Mr Lansley’s record. Their verdict? The principles are, mostly, right; the execution has been woefully lacking; and the efficiency/cuts drive is where the real action is.
Just under a year ago, after the publication of the coalition agreement, HSJ wrote: “Judging from the feedback on HSJ’s website, the broad sweep of policy is seen as logical and appropriate to the challenges ahead.”
So why did things go so badly wrong?
Well, while praising this “impressive start” for its “speed and consistency”, HSJ suggested 20 questions the coalition needed to address to “achieve its goals.” Analysis of the government’s success in answering those questions shows us why the NHS reforms are now floundering.
For a start – and to be fair – one question has been fully answered. Transforming community services has been continued and, largely, delivered.
In five cases partial answers have been delivered. We know the plan for non-foundation trusts, how GPs are meant to sign off hospital reconfigurations, that primary care trusts are expected to develop GP commissioning capacity; that the government is still keen on personal budgets and, theoretically, the use of non-NHS solutions to personal health records.
But for the great majority of questions, an entire year has passed without convincing answers.
The plan to increase patient choice and information has gone – effectively – nowhere, with the thorny questions about the practicalities of choice of consultant and GP practice virtually ignored.
Confusion reigns over the involvement of the private and third sectors in NHS commissioning and provision with the government tearing itself in two trying to reassure every pro- and anti- interest group and convincing no one in the process.
The questions over the accountability of GP commissioners have actually multiplied tenfold, although the government has avoided having to work out how to incentivise a change in the GP contract by deciding not to renegotiate this year.
Our question about election to PCT boards – which should now be redundant – has found a new lease of life in the debate about patient and public representation on commissioning consortia.
Most tellingly of all, the government seems to be in denial about the fierceness of the efficiency agenda, which ratcheted up a notch with Monitor’s latest intervention. Even Mr Lansley – who should know better – believes the rapid loss of management capacity is irrelevant; that marginal financial tweaking will counterbalance the knock-on effects of local authority cuts; and that clinical posts are safe from the efficiency drive.
This denial is one reason for the creation of the prime minister’s new NHS “advisory panel”. It is a response to concerns expressed by some of the most ardent reformers in the NHS that by ignoring the harsh financial realities – and failing to answer important questions – that the reform baby is in danger of being ditched with Mr Lansley’s bathwater.
HSJ predicts the panel’s experience and willingness to address the tough reform questions will make it highly influential in the weeks and months to come.
How telling that four of the eight members are present or former NHS managers and that a fifth – Nigel Edwards – is the most effective spokesman for good management. Sense at last.
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Readers' comments (5)
Patrick Newman | 5-May-2011 3:27 pm
Few reforms of a major public service would have had such a lengthy development path before legislation emerges. Mr Lansley has been at it since 2003 and Dave should have been in touch for most of the way. Yet so much is unanswered and in my opinion will remain unanswered.
The so called efficiency agenda will dominate but outcomes will be in the form of service cuts because there is not too much low hanging fruit after which the road is long and hard. After today's elections it is not inconceivable time's up for the Coalition and incrementalism will resume.
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Anonymous | 5-May-2011 3:59 pm
Cameron's rant against structural reform at the 2009 RCN conference - still available as a video on the RCN website - is in direct contradiction to what he has allowed Lansley to do over the last year. It's a classic mistake. Focus on structures not on deliverables. Re-organising an army rarely helps it to fight the battles and achieve it's objectives: this is done through training, leadership, clarity of purpose and good equipment. No-one objetcs to clinically safe commissioning (but why turn GPs into managers and exclude other clinical groups altogether?); No-one objects to a robust approach to use of the resources (but why set arbitrary targets that paralyse everyone?); no-one objects to regulation (but why allow monitor and the CQC to tear at each other's throats?). And underneath it all is a sense that someone is on the make ... including the very GPs who we are supposed to trust with leading commissioning in the future. Reality is most GPs can't run a street corner practice without their local PCT's maternal support, let alone take over the £60-£80b we hear they are supposed to manage in future.
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phil kenmore | 5-May-2011 4:11 pm
The question is 'too little too late?' It is good that Cameron at least is going to get some sound insight and advice - presumably specifically about how to now turn this around, either with Lansley or the next SoS. But swift action on the advice will be needed if they are going to claw back a sense of engagement and achievement of positive change well before the run up to the next election.
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Anonymous | 5-May-2011 8:30 pm
If/when Lansley does go, how will his legacy be judged?
He has been there a year. Waiting times have gone up. Morale has gone down. Finances look shaky.
And apart from some as yet unknown impacts from stopping hospitals being paid for readmissions through tariff meddling, what real tangible improvements in patient care have been planned or delivered?
All talk and no (constructive) action. A service retreating into ideological pontificating, and now consumed by its own instability with less focus on patients than in over a decade, energies consumed with controversy, and dark politics of empire building as the survival of the strong leads the commissioning organisations to turn in on themselves and each other, without a hint of equitable process in determining peoples futures. The rebranding of previous organisational iterations (regions / health authorities / PCG... now clusters / zones / GPCC) permeated with Jobs for the boys.
Is it just me or are others BORED of this? Itching to get back to delivering real changes that patients notice and value?
Perhaps the prime minister needs an outcomes framework by which to judge health ministers. Somebody is in 'special measures' methinks.
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sjburnell@focused-on.com | 5-May-2011 10:44 pm
It's a mess & hurting.
If Lansley goes will we get the swift certainty we all need or even greater confusion, bun fights, & delay?
It seems like nothing useful is getting done @ present. The system is spending all of its time & energy sacking people & cutting services when the work itself still needs doing.
If QIPP is now just short-hand for Cost-cutting, then another battle is lost. Who is thinking about delivering service improvements? Who is promising higher quality of care? Who is working on genuine improvements in resource productivity through more intelligent resource allocations? Who is making better informed, evidence-based decisions? Who is successfully executing robust invest-to-save initiatives? Is it only the precious few?
Why do so many high impact initiatives look negative with no counter-balancing improvements?
Mr Cameron, we need big doses of clarity, sanity, & certainty. Then we can plan & adapt accordingly.
Let me know if you need a hand.
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