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The government’s changes will only delay the tough decisions

One overarching conclusion can be reached from the changes to the government’s reforms: there will be a continuation of the planning blight that has afflicted the health service since the decision to scrap primary care trusts without thinking through the implications.

The changes will all have to be considered and revised as unintended consequences emerge. Issues such as the strengthening of “commissioners’ duty to promote choice” will have the British Medical Association sounding the alarm. While those closest to the reforms – not just politicians – who believe the changes are “keyhole surgery, not amputation”, will battle to maintain the thrust of the original reforms.

This blight will distract and confuse. Quality will suffer, as will efficiency – despite the efforts of NHS staff, including HSJ readers, to compensate.

Some will argue that health secretary Andrew Lansley should pay the price for getting reform so wrong. We disagree. He should stay and help sort out the mess and answer for any consequences that emerge.

So, as far as it is possible to tell, have the reforms been improved enough to make a longer period of uncertainty a price worth paying?

A stronger role for the NHS Commissioning Board, the arrival of clinical senates and the greater role of networks should mean a surer hand on the tiller. However, as HSJ warned last week, many of the more go-ahead GP consortia will feel shackled. In short, fewer car crashes are likely as the new system develops, but we are also likely to get fewer breakthroughs. 

Compromise, not innovation, will rule.

This more evolutionary approach is underlined by the extended timetable for reform. The government declares its intention not to let a two tier commissioning system develop, but by not setting a drop-dead date for change they are guaranteeing it. As with foundation trusts, there will always by areas which struggle to meet required standards. The willingness to take the hard decisions required is likely to be in short supply. Spooking the horses once was bad enough.

Expect the NHS to arrive at the next election with perhaps 10-20 per cent of non-specialist commissioning still being effectively handled by the local arms of the NHS Commissioning Board.

The goal to make every NHS trust a foundation will also not be delivered by the next election. Scrapping the April 2014 deadline removes a key driver to tackling the financial and structural barriers preventing some trusts from making the grade. Each trust will have its own deadline, but readers will know how easily these can be shifted as circumstances change.

The same slackening off in the perceived need to tackle difficult issues will also be experienced in the drive to reconfigure services. The decision to drop the system of “designating” essential services means there will be no pre-agreement about which services are open for reconfiguration.

None of this, of course, means the efficiency challenge is going away or will reduce in scale or urgency.

The changes effectively mean a wider group now have a greater say in how efficiency will be delivered. A good thing in principle, but as HSJ readers know, everybody having responsibility can mean no one taking ownership. NHS chief executive Sir David Nicholson will have to tighten his grip further.

The reform changes also signal the energy draining away from the desire to encourage greater private sector input in provision or commissioning support.

Overall, the effect of the changes is to push the most difficult decisions back towards the end of this parliament, where it will be most difficult to make them. The changes to the health secretary’s responsibilities are largely cosmetic – but they will have the very real impact of increasing the expectation that it his job to fix local problems.

Readers' comments (3)

  • Can't disagree with this. One of the major failings of Lansley's vision was that he thoguht that real change and the Nicholson challenge could be driven by year on year salami slicing and the mutltiplicity of thousands upon thousands of individual market exchanges between patients and GPs, focused largely on choosing elective care. That was naive.

    The reforms talked a good game about the rising elderly population and the challenes of long term conditions. But it ducked the fact that the future demanded a massive reshaping of healthcare; more support in the community setting, less hospital care, tough decisions. That's a serious strategic planning challenge, needing strong nerves, convincing arguments and clinical and patient buy in to create bold solutions. And it won't happen in neat annual packages of 4%. And the amendments presented yeaterday, to my mind, still don't creat the environment for that kind of necessary, robust, innovative and inclusive thinking.

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  • Mike Jackson

    For staff the most corrosive aspect of delay is the impact of uncertainty. Where does this now leave SHA and PCT staff? How can they plan their future in the promised new world. How can they make their future when it is so unclear? Can these organisations function effectively when the date of their demise is now effectively unknown? Will they need to start recruiting again? Can the new organisations be formed on different tracks and timelines when there is so much inter-dependence? How will commissioning staff transfer seamlessly to new organisations when some may be up and running years rather than months before others?
    DN has been comparatively quiet during the pause but one thing is clear is that he is now in an even stronger position. Either as NHS CEO or as Head of the NCB, he will be relied upon by Ministers more than ever to steer the ship through uncharted waters on a dangerous voyage to a destination as yet unknown.

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  • DH managers are undoubtedly strengthened in the short term as as uncertainties from 'pause' give way tighter grip. But in the longer term, as the NHS fails to meet its savings targets? Seems to me, they are setting themselves up for a mighty fall not least because they seem incapable of designing change management programmes capable of reconfiguring services to meet contemporary patterns ofneed

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