Battleship Lansley ploughs on through the fog of reform
HSJ readers will be familiar with the tensions inherent in the government’s reforms which are now beginning to leak into the public ken.
Nick Timmins, public policy editor of the Financial Times and number 20 in last month’s HSJ100 list of the most influential people in health, has taken to reciting a naval tale to sum up the developing scenario.
A US battleship was on manoeuvres in thick fog. A lookout reported, “Light on the starboard bow.”
The captain, seeing the two ships were on collision course, ordered a signal sent to the other vessel: “Change course 20 degrees.” The reply said simply: “Negative, suggest you change course 20 degrees.”
After the same exchange was repeated a couple of times, the captain exploded: “Tell him I’m a battleship!”
Back came the reply: “I’m a lighthouse.”
HSJ suggests the lighthouse in this case is Cabinet Office minister Oliver Letwin, whose policy spotlight has finally settled on the health reforms - one of the reasons why he was number 2 in the HSJ100. However, HSJ understands that Treasury chief secretary Danny Alexander is also providing much of the impetus to the review now being undertaken of health secretary Andrew Lansley’s reforms. Social care minister Paul Burstow is another wandering out of his brief to challenge the detail of commissioning changes.
However, these rising tensions will not sink the reforms in the House of Commons. The legislation will contain many discretionary powers, but not much that is compulsory or linked to a particular date. There will be few opportunities for political opponents to rally enough support.
Once again, for the real action, we must turn to the Department of Health and its twin track policy implementation. On one hand we have the desire of battleship Lansley and his close advisers to engender a “bottom-up revolution” by setting broad policy objectives and letting GPs and others determine the detail. On the other, is the inclination of the DH’s top officials to find a way to frame the new landscape. Mr Lansley refuses to say how many commissioning consortia there should be, meanwhile the DH’s top brass deduce what number would constitute the most financially stable set-up and drive the system towards that conclusion.
Those championing the purity of the policy insist GPs can draw their commissioning support from wherever they like, the pragmatists - mindful of costs, concerns of the new commissioners and the need to “grip” the new system - are finding ways to make primary care trust staff the default option.
The strategic goal is the same - but it is being approached with two distinct philosophies.
Nearly all these tensions are focused on the future of commissioning. The situation with provider reform is very different: PCT provider arms are all heading for their new homes; most reconfigurations are going ahead as planned; the foundation trust pipeline is flowing, while merger or grouping plans are developed for those that cannot win independence; the DH is driving forward to find the leadership of the economic regulator, just as it stalls on doing the same for the commissioning board.
All of this is happening with remarkably little controversy and reasonably rapidly. Encouraging news, as the majority of the initial efficiency savings must come from secondary care. However, there is a real danger that commissioning and provider reforms slip out of sync and that, as result, a more stable hospital sector will dominate emerging consortia.
The last government allowed a similar situation to emerge by failing to drive commissioning reform early enough. Mr Lansley was determined not to repeat that mistake, so he set sail as soon as he took command. But then the mist rolled in and the foghorns began to moan.
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Readers' comments (3)
Anonymous | 10-Dec-2010 2:04 pm
Dear AM
Battleship implies solid strength. Others call him LaLa Lansley but that is really very insulting to teletubbies. I like to think of him as Liability-Lansley because that's all he has created so far. For example: £1.9bn estimated cost of changing the structure of the NHS for example. Am I the only person who believes Politicians should not dictate form and function? Surely they must only set policy on outcomes and the NHS should be left to determine how best to deliver that policy using managerial and clinical expertise. Form then following function. There is a phrase for getting things the wrong way up but it's unprintable. Of course, none of the current DH/SHA/PCT CEs turkeys would vote for that Christmas given the majority have no relevant skills.
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Anonymous | 13-Dec-2010 10:09 pm
Its been a longer than usual silly season this year.....
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Calum Paton | 16-Dec-2010 3:18 pm
Of all the absurd characteristics of La La's White Paper, the 'consultation' and the 'response', the following seem to me to stand out:
- nowhere is the conflict between a purchaser/provider split-based, further marketised, fully-Monitored NHS, on the one hand, and the need for local primary/secondary integration, on the other hand, acknowledged. (So will MONITOR call local cooperation and integration anti-competitive? Steven Dorrell will remember that his predecessors at the DoH in the 1990s Bottomley and Mawhinney had to damp down an earlier version of such nonsense, then to prevent inappropriate competition between big-city hospitals where collaboration made more sense)
- the worrying failure to understand even what constitutes 'evidence' and how it might be used. In the December 15th response, it is claimed that the WP accords with evidence from the 1990s as well as from more recent years. In one limited sense, maybe..... there is some limited evidence (invoked by the HoC SC recently) that Labour's neo-liberal-tinged tinkering (my phrase; not the HoC!)produced a commissioning system and wider NHS that was less cost-effective than it might be.
That is, some of La La's 'diagnosis' may be correct......to the extent that it is understood as part of a warning against small-scale commissioning. But his 'prognosis' is to fly further and deeper in the face of evidence. For example, the highly detailed evaluation of Total Purchasing Pilots commissioned by the DoH's PRP - arguably the most relevant of evaluations as regards the WP, although even that must be a relative claim at best - suggested that, to be effective, primary care-based 'commissioning' (poorly-defined then as now) was likely to be expensive......and that effectiveness by local commissioners applied more to 'extended primary care' (my phrase) than to secondary care (with honourable exceptions). Yet this is the one area where the National Board rather than local commissioners will do the job (presumably because the market ideologues see a conflict of interest in allowing GPs to commission from themselves)!
Expecting a market ideologue like Oliver Letwin to constitute the cavalry to save the NHS from la La is like expecting Dracula to manage our bloodbanks.....although he might surprise us with pragmatism a la John Redwood in Wales in the 1990s (nothing like a dose of populism in late life after being over-educated in ever-decreasing conservative circles.)
By the way, if Lansley really is La La, what does that make his faithful executor, Sir David 'Auld Nich' Nicholson, now forced to re-invent himself yet again.....Dipsy, Tinky-Winky or Po? Nich has recently warned all NHS managers (see Public Servant, December 2010) against losing a grip on quality as reform hits.....as in 2005-6, he says. Yes, good advice....there are those of us who remember how some apparatchiks managing the newly-remerging SHAs in those days were on about cutting staff numbers and becoming FTs......
Probably we should go for Po....Red (like Nich used to be)......and Po-faced when eulogising the abolition of that which his team had eulogised (WCC, anyone?)
You couldn't make it up.
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