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The NHS might be being rewired, but its electricity runs to much the same effect

The Health Bill has set a new record as the largest piece of NHS legislation ever tabled. Health secretary Andrew Lansley described it as “evolutionary” – the mind boggles at what he would consider “revolutionary”.

The bill also set another record – albeit one harder to definitively validate. It is probably the worst received piece of NHS law making in history. A lot of noise came from the privatisation fantasists, but much more telling was the response from those who understand how the NHS works and how it responds to policy.

By Sunday evening our online coverage of the bill had attracted 73 comments. Three had something positive to say. Mr Lansley’s agreement to appear for five consecutive days on Radio Four’s PM programme was one sign that he knows his “hearts and minds” mission is of Afghanistani proportions.

HSJ has commented at length on the government’s folly of attempting to deliver reforms that – at their heart – are desirable in such a disruptive and ill-timed manner. But we are where we are, so what does the bill tell us about the NHS of the next three years?

To begin with it seems Mr Lansley has as firm a grasp of the word “independence” as he does of “evolutionary”. The Department of Health says the bill significantly restricts the secretary of state’s “general power of direction” over the NHS. Not quite true.

True independence is like virginity – you cannot partially give it away. Mr Lansley’s chaperones (Messrs Osborne, Alexander and Letwin) have made sure things will not go too far.

The bill is clear the secretary of state can direct the NHS Commissioning Board not only in what it does, but how it does it. He will also now have as much control over Monitor in its new role as economic regulator as he already does over the Care Quality Commission.

One of the lessons of public policy is that a power does not have to be actively used to be influential. To know that it is there is enough.

These powers of direction mean the secretary of state will be unable to escape being held accountable for, say, controversial hospital reconfigurations driven by local commissioning decisions because campaigners will know he could do something about it if he really wanted to.

Some will argue that it is right and proper that there is political oversight of NHS decisions – they just do not include this government. Paul Corrigan – a man no stranger to controversial health legislation – explores how the government may not be able escape the “nightmare” of responsibility whatever their intentions. 

The bill also states the NHS Commissioning Board will have similar powers of intervention with consortia. In what is beginning to look like an increasingly paternalistic role, the board will closely manage financial risk (i.e. decide on brokerage) and reward what it sees as good behaviour. It will also be able to veto the appointment of a consortium’s accountable officer.

The man who will run the Commissioning Board, NHS chief executive Sir David Nicholson, is clearly warming to this fatherly role. Government policy is that below-cost tariff competition will be allowed, where commissioners and providers agree, from April. Sir David’s comments to last week’s Public Accounts Committee made it clear that – if he had anything to do about it – it was not going to happen any time soon.

We supposedly live in a post target world. Within the last few days the Department of Health issued the technical guidance for the 2011-12 Operating Framework. It runs to 261 pages and contains over 100 indicators “against which the NHS will be held accountable nationally during 2011-12”.

The NHS may be being rewired – but the electricity will still run through it to much the same effect.

The reason for this, of course, is the need to find £20bn of efficiencies.

This imperative also lies behind another aspect of the Commissioning Board’s power which became clear this week: its enormous direct spending budget – probably in excess of £20bn. The implications are explored by the Audit Commission’s head of health Andy McKeon here.

Finally, the guidance published alongside the bill suggests the majority of the staff currently employed by strategic health authorities and primary care trusts will need transfer to the new organisations to make the new system work (and keep redundancy costs under control).

There seems to be a belief in some parts of the Department that these people are unemployable elsewhere and will happily troop off to their next posting once commanded. However, to the contrary, without an urgent and concerted effort to champion the importance of these new roles to the best and brightest, the government may soon find its NHS evolution is heading for a Neanderthal-style cul-de-sac.

Readers' comments (6)

  • All this in the cauldron of coalition politics which has already developed several fault lines. Alastair's analysis above reminds me of the old Who song which ends "meet the new boss - same as the old boss" or is "plus ça change, plus c’est la même chose" more appropriate?

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  • Ah Yes, 'Won't Get Fooled Again'....

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  • What does "below-cost tariff competition" really mean? It is against competition law isn't it? On OFT's website it says that you are supposed to report major a competitor who "charg(es) extremely low prices that you suspect would not cover its costs". How is a major competition defined under the health geography I wonder? How can a kind of competition that is not allowed in other markets allowed in the provision of health?

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  • This is great analysis; particularly the comparison of what Lansley and Nicholson say and do. They both appear to suffer Jekyll and Hyde moments, well at least when they appear in front of the Select Committee. If my name were Dorrell, I'd be dragging them back and asking: why are there two plans, and why did you misinform a parliamentary committee?

    Shall we sum up the changes so far:

    - There is a growing struggle to find anyone with credibility supporting the bill
    - The implementation plan (Nicholson challenge) is a completely different set of plans that are secret or worse there is no plan to save £20bn (put back a year)
    - The change will cost £2bn which is the same as the total annual cost of PCTs and SHAs
    - SHAs are planning on strikes happening later this year
    - The NHS will be 18% privately run and delivered, when consortia are in place
    - So profound are the concerns about consortia capability the plan is to transfer as many SHA and PCT staff to them
    - Lansley lied about top down reorganisation but we are asked to trust him this time
    - Every service change Lanlsey stopped has subsequently been approved (last one will go through shortly)
    - Despite the headline that the NHS budget is ring fenced it is not (see inflation 3.7%) and job cuts in providers will be in their many thousands. Provider savings are bailing out the failure in the SHA/PCT reorganisation (Lansley's plan). Had Lansley reduced PCTs by half, closed SHA, the cuts would have been delivered earlier, at less cost and the risk to patients would much less.

    Tell me why we let politicians directly manage our biggest and most important services (health and education) when they have not even had relevant work experience training.

    Tell me why the spineless administrators in DH just comply with every political whim.

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  • Paul Tovey

    Meanwhile as new superstructural mechanics get ready for Galaxy Class Doc-Rock Commissioning some of the public beamed up into the Scarship USS Enterhell to find a better flaming red abyss out there in the fire stars..

    Anyone for a last drink of fizzy asbestos with me in my cool Oort kennel ..

    Alastair's analogy of neanderthalism is moving towards a truth which I would Easter islandishly add to and say the weak will be sacrificed for the contrary failures of the UK "un-exporting" economy over many years and in some atavistic unconscious sense there will be a weeding out process of what is not "fit for purpose" ... I do not have to agree with it - it will just happen.


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  • anon 9.44pm
    I didn't know SHA's are planning strikes - is this common knowledge?

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