The NHS deserves a better, more open debate over health reform

31 January, 2012 | By Alastair McLellan, Jenni Middleton, Fiona Godlee

The Health Bill enters the crucial report stage in the House of Lords next week amid huge controversy. To mark this, the BMJ, HSJ and Nursing Times have, for the first time, cooperated to publish the same editorial.

As the editors of the BMJ, HSJ and Nursing Times, we have divergent views on the NHS reforms and its beleaguered Health and Social Care Bill. But on one thing we are agreed: the resulting upheaval has been unnecessary, poorly conceived, badly communicated and a dangerous distraction at a time when the NHS is required to make unprecedented savings. Worse, it has destabilised and damaged one of this country’s greatest achievements: a system that embodies social justice and has delivered widespread patient satisfaction, public support, and value for money. We must make sure that nothing like this ever happens again.

Health interest groups differ in their stance on whether to oppose the bill outright or to work with the government to try to improve it. But there can be no doubting the deep distress and lack of confidence in the plans among those who must deliver the service.

A chief executive of a primary care trust cluster admitted to one of us last week that the breakdown of the relationships between commissioners and trusts caused by the reforms’ structural mayhem had left him with no way of knowing for sure “if I’ve got another Mid Staffs on my doorstep”. He was only reassured by the fact that “nothing much happens up here, so the local paper does a lot on health”.

The reforms did not have to result in this unholy mess. The coalition agreement released in the honeymoon period immediately after the election focused on clinical leadership and patient and public empowerment. It was generally well received by those whose daggers are drawn against the reforms.

But through a combination of poor political judgement and reluctance to engage with criticism, a set of (mostly) reasonable objectives morphed into an old fashioned top-down reorganisation. This was the very thing the agreement had pledged to avoid. It also resulted in a bloated piece of legislation, whose goals could have largely been achieved by other, more effective, means.

Despite the campaign to “kill the bill”, the heavily amended legislation is likely to be passed in March. So what will we be left with once the bill hauls its battered hulk across the Royal Assent finishing line some weeks later? First, despite the costly debate and scrutiny, we will still be in the dark about how much of the new system will work. Guidance and secondary legislation affecting the function of key bodies – clinical commissioning groups, Monitor, and the NHS Commissioning Board – are not due for many months.

Second, thanks to health secretary Andrew Lansley’s initial tunnel vision followed by the government’s hasty compromises in the face of growing opposition, we will have an unstable system that is only partially fit for purpose. In order to work, the system will have to rely on a set of complex and sometimes conflicting relationships between the Department of Health, the commissioning board, CCGs, as yet undetermined clinical commissioning services, local authority health and wellbeing boards and a host of other national, regional and local actors. Care integration – now shoehorned into the legislation as a supposed antidote to the drive for increased competition between providers – is ill defined and lacks any meaningful incentives to encourage its adoption.

It is possible to feel sorry for Mr Lansley when, after years of being told that politicians should get out of the NHS, his proposals to loosen the health secretary’s grip on the service were thrown back in his face. But those proposals were poorly thought through, and the government amendment restoring his responsibility for the NHS has failed to reassure most critics.

Third, because the proposed new system will have little resilience or cohesion, the next government will find it necessary to overhaul the NHS again. This is not good for anyone, least of all frontline staff. But ironically this may be Mr Lansley’s one great achievement: reforms designed and implemented so badly that another major NHS reform programme is guaranteed within five years.

What lessons can we learn from this debacle? Sustainable reform requires politicians to be clear about the problem they are trying to solve. A recurrent and justified criticism of these changes has been their failure to express a clear rationale. There also needs to be clarity on the methods proposed to solve the problem.

There has been a broad consensus among policy makers from all major parties for over 30 years about what is required to deliver an effective and efficient health service. Cornerstones of this worldview include a division between commissioners and health providers and the use of choice and competition to drive improvement. Yet relatively few healthcare staff share these views, while most of the public remain ignorant of the approach that is being taken and why. Both New Labour and the coalition failed to illuminate this debate – the Blairites because they were scared of frightening the party horses, the coalition through a failure to properly explain its proposals.

The NHS is far too important to be left at the mercy of ideological and incompetent intervention. Health policy has to respond rapidly to demographic and technological changes. But rather than relying on policy makers to build brave new worlds in back rooms, we need a broad public debate on, for example, the principles that should underpin the NHS, how decisions on priorities should be made in a cash-limited system, and what role clinicians and private sector organisations could and should play.

This debate will require restraint on behalf of all involved if it is to escape being characterised yet again by polarised views, (often disguised) vested interest, political point scoring and conspiracy theories to the benefit of none. As part of this process, Parliament should now establish an independently appointed standing commission, similar to the Sutherland and Dilnot commissions, to initiate a mature and informed national discussion on the future of our national health system. Let us try to salvage some good from this damaging upheaval and resolve never to repeat it.

Readers' comments (34)

Anonymous | 31-Jan-2012 9:15 am
Alastair, that's a really strong article, thank you. I agree with everything you have said - this has been a debacle from the start and the only possible outcome is another reorganisation post-election. I hope every MP and member of the House of Lords reads this.

On another note, I'm surprised there's been no coverage of the massive reduction in MI and cardiac arrest we have seen in the last decade. I'm even more surprised we haven't seen the credit that roger Boyle deserves for his leadership of the strategy being given. Any chance of HSJ redressing this?
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Alastair Mclellan | 31-Jan-2012 9:58 am
We'll have a look.
Alastair
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David Booth | 31-Jan-2012 11:07 am
A powerful article - just what needed to be said!
Rational debate leading to social consensus about the continuing principles of our healthcare system has to be the starting point to develop effective progressive change - with due recognition to just how much has been achieved so far and a clear focus on the major challenges ahead.
Time to step back (but not backwards) and consider more objectively, whatever the apparent political loss of face.
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Bob Hudson | 31-Jan-2012 11:08 am
Well done to you Alastair, and the other editors, for taking this stance. There are now very few influential organisations failing to make an overall judgement and where this is the case it is time they did so. Your analysis of the policy chaos is spot-on, but I think you could have also said more about the effect of AQP and competition law upon the (allegedly) holy grail of integration. Once some sort of legislation is passed, Lansley will begin to discover the important distinction between policy and implementation. We can look forward to little more than several more years of skirmishing, guerilla warfare and chaos.
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David Pencheon | 31-Jan-2012 11:31 am
At last: sensible balanced comment which is realistic and positive and not polarised. What is particularly strong is that there is a) call for a wider debate b) a call for transparency of interests and c) an agreed long term vision that it is in EVERYONE's interest to get this right
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Anonymous | 31-Jan-2012 11:55 am
Fantastic article, brilliant idea for the 3 editorials to be the same, strengthens the message, thank you.
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irfan ullah | 31-Jan-2012 12:14 pm
Really good article, the one thing everyone agrees on is the fact that no one can agree on anything
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Anonymous | 31-Jan-2012 1:01 pm
I would agree with the sentiments expressed in the article, however, if this is indeed something that can't be stopped, then we have a duty to patients and the public to start working on some damage limitation. Politically no one is really going to want to say at this stage that this whole business has been a complete fiasco, however, we need as NHS managers to get a grip on how we are going to continue to safeguard patient care. Helpful to have some thoughts on that please.
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Anonymous | 31-Jan-2012 1:13 pm
Fully agree. well done HSJ and others for so clearly and prominently ariculating what we all already know.

It is our representatives at the Confed and FTN that should have been saying these things but they have judged mistakenly that it is better to stay on the right side of the government.

Before long there will be a reshuffle, Lansley will go and a new SofS will start to rebuild relationships with us all and dismantle the nonsense that is still being created. At that point, HSJ will be able to say I told you so, but our elected representatives will have no such vindication.
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Anonymous | 31-Jan-2012 1:18 pm
I think this is very interesting, and I have been a long suffering commentator that says “look what the devolved nations are doing” (e.g. Wales have removed the internal market and focusing on local area budgets where everything is about patient delivery and cost base, rather than arbitrary market management and artificial national tariff price). Yeah, they did it out of the shear necessity that they were financially bust, but do we need to wait until the English system gets to a similar financial position (fast forward 5 years) before we too have to wake up and move to this model?

I am fed up of hearing that this is the most radical change programme the NHS has seen (“can be seen from outer space” etc). All I am seeing is a lot of tinkering around the edges, and big doses of sheer madness, but the same old internal market in operation but with EVEN MORE layers of beaureacracy what with CCGs, CSOs, NCB field force, NCG sectors, NCB itself, uncle tom and all. What others (the devolved nations) have done is much more radical and “seen from space” stuff. What we’re doing has the potential to throw the baby out with the bathwater, even IF we can retain a mere fraction of the talent we currently have on the commissioner side of the ‘divide’ – which itself is a career risk only the foolhardy would subscribe to. The best are hatching their exit strategies as I type… when I am hearing PCT cluster CEOs (lots of them) openly saying “COMMISSIONING IS DEAD”. And that’s the ones who are still here – in our “sector” at least 3 have already disappeared since being appointed last July so what does that tell the rest of us mugs that are still trying to retrofit an ill conceived policy on the ground??

What’s the phrase…? Oh yes, “you can’t polish a turd”. La la indeed.
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Anonymous | 31-Jan-2012 1:20 pm
It genuinely scares me that three people who have a better understanding of the reforms than many of us can write such a damning editorial with so little hope for the future.

Previous re-organisations of the NHS have never provoked this level of opposition. How much longer can the Coalition ignore the storm that is inevitably coming?
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Anonymous | 31-Jan-2012 1:24 pm
Great article, by why does it leave me feeling that we are impotent to divert this juggernaut? Who is listening?
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Jonathon Tomlinson | 31-Jan-2012 1:33 pm
Will the health bill streamline NHS management?

Here are 2 interesting links for the benefit of readers who do not follow my blog.

The first is an organogram of NHS structures from the Financial Times last year showing the difference before and after the bill. http://blogs.ft.com/westminster/2011/08/organograms-show-nhs-becoming-even-more-complex/#axzz1l1XR4ufQ

The second is a blog from Paul Corrigan (previously health policy advisor to Tony Blair 2005-7) published today, in which a GP explains to his constituency MP who is responsible for local health services. http://www.pauldcorrigan.com/Blog/reform-of-the-nhs/we-will-radically-delayer-and-simplify-the-number-of-nhs-bodies-health-white-paper-2010/

The answer to the question, “will the Health Bill streamline NHS management?”, is an emphatic, ”no”

Not one of the other justifications for NHS reform including: putting doctors in charge, empowering patients, improving health outcomes, the ageing population and containing costs, stand up to scrutiny.

This, at least as much as the privatisation agenda is why professional and public opinion is so hostile to the reforms.

The health bill can be stopped:

The consequences of abandoning the Health and Social Care Bill. BMJ http://www.bmj.com/content/344/bmj.e748.full?ijkey=wkZhJYt4cwjQjt9&keytype=ref

http://abetternhs.wordpress.com/
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Anonymous | 31-Jan-2012 2:16 pm
Brilliant article, well said. The only glimmer of hope does seem to be the next reorganisation, but I don't think I'll hang around that long. After all we've achieved in recent years, it's heart breaking to see it wrecked....
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Mark Cannon | 31-Jan-2012 2:40 pm
A very good, well written piece. There is a wellbeing myopia (http://goo.gl/mVKH8) among our leaders that is leaving them blind to the purpose of the system from the users perspective. My evidence shows that building and tending to relationships over time are a major lever for change, something which is completely at odds with the world view you describe our policy makers have. I remain optimistic that all is not lost but all senior leaders need to stop worrying about levers, incentives and structures and start getting knowledge about what matters to people.
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David Booth | 31-Jan-2012 3:16 pm
A powerful article - just what needed to be said!
Rational debate leading to social consensus about the continuing principles of our healthcare system has to be the starting point to develop effective progressive change - with due recognition to just how much has been achieved so far and a clear focus on the major challenges ahead.
Time to step back (but not backwards) and consider more objectively, whatever the apparent political loss of face.
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Andrew Craig | 31-Jan-2012 4:12 pm
Thank you and the other two editors for this excellent piece. Reform of the NHS in England is inescapable. But it is also clear that a new Bill is needed, and quickly.

There is a clear "Plan B". Kieran Walshe's editorial in BMJ today talks about it and Roy Lilley has been banging the drum about it for months. We have the way forward for reform marked out clearly in the recommendations of the two Future Forum reports, all of which the present government has accepted with alacrity.

These reports constitute pretty much all that needs saying about what sort of NHS England needs. It is built on an understanding of needs and engagement with users and carers, the public, clinicians and managers.

The longer we delay shifting course in this direction, the worse the problems with the present system will become. No amount of baying across the floor of the House of Commons can disguise that. The time for blame is long past. And keeping things as they are now is also a recipe for disappointment and probably also bankruptcy.

There is a strong narrative for change that is simply not being heard clearly over the party political noise. If we do not act on that soon, there is a danger of straying into the wilderness so far that we cannot find our way back to reality.
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Martin Rathfelder | 31-Jan-2012 5:37 pm
What do we want? No more top-down re-organisation!
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Anonymous | 31-Jan-2012 5:48 pm
A hugely sad waste of energy.

Imagine what £1bn and all the working hours of current staff could achieve if we put them into, say, providing patients with clear information about outcomes, adopting new innovative technologies, or up-scaling prevention to reduce the future burden of disease.

Consider.....We already had before the bill
1. Clinically led commissioning (just needed action to tackle the managerial blockers and Quality assure PBC groups)
2. Clinicians on the board of every NHS commissioner (PEC chair, Medical Director, Nurse, Director of Public Health)
3. Some emerging commissioning support services (courtesy of Mark Britnell / WCC) and procurement hubs.
4. Plurality of provision and clear plans to widen the range of services in which patients can have choice
5. A nuanced approach to competition which required board level justification of decisions, and a regulator (the CCP) to tackle excesses.
6. A local field force for system assurance (10 offices not 50)
7. Co-terminosity with Local Authorities (now a requirement of CCGs)
8. Joint working with local authorities (called LSPs and Total Place pilots, rather than HWBs)
9. Public health at scale (through the Association of Public Health Observatories rather than 'public health England')
10. Foundation Trusts and Social Enterprises

Remind me again, what is the bill FOR exactly?

Andrew Lansley is the only person I've ever known to use a hand grenade when his intent is window dressing.
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Anonymous | 31-Jan-2012 8:51 pm
An important and powerful commentary on the state of the NHS some two years post election. HSJ you MUST forward a copy to every Member of Parliament in a campaign to overtuen this ill thought through legislation before it is too late - we must at least try.
Given the top slicing of PCT budegts by 2%, the removal of the 70% penalty on non-elective admissions to Regions along with readmission penalties going the same way, the NHS is going to be in dire straits next year as base funding is removed to bail out those in serious financial difficulty, which will result in the rest moving into serious financial difficulty mid-way through the year. There will be some serious collapses of Acute Trusts in the coming financial year; God help those who crumble first because they will get no sympathy given the brutality of the current regime.
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