The term “assumed liberty” has been rattling around in my head since HSJ highlighted it in reporting Andrew Lansley’s latest explanatory letter to NHS Commissioning Board chair and university apparatchik Malcolm Grant, and his handsomely unfashionable moustache.
Contrasting it with “earned autonomy” only adds to the frisson.
When I asked a clever Conservative MP what he makes of the debate as policy makers and the rest of us try to make sense of what the Health and Social Care Act will mean in practice, he replied that Whitehall has been stressing “earned autonomy” to the emerging clinical commissioning groups. As HSJ’s editorial pointed out, it’s a balancing act between incentivising GPs who have other things to do with their time and not alarming those who fear they may run amok.
My Tory friend went on to say that Grant and Sir David Nicholson, sharing the new board’s tiller, “will settle for assumed liberty at the commissioning board if it is on offer, though I am less sure about voters”. That suggests a shrewd wariness based on years of electoral politics. Voters want Westminster politicians to “stop interfering with the NHS”. When they don’t like the consequences they tell ministers to sort it out. Isn’t that why we pay you?
And liberty for CCGs? We’ll come back to that. By coincidence I have spent some time lately monitoring a parallel devolved universe also created at speed by the coalition: the flickering campaign for directly elected mayors which is expected to have (mostly) flopped in Thursday’s referendums in 10 major cities by the time you read this. Labour – and those growing micro-parties? – will have made some gains in the day’s council elections. How many? You tell me.
What’s striking is the same ambiguity between the town hall version of assumed liberty and earned autonomy. Older readers will remember how Whitehall first reined in reckless overspending by usually left wing councils by Jim “the party’s over” Callaghan’s Old Labour in the ’70s. Despite her liberation rhetoric Margaret Thatcher pulled the reins still tighter.
So have all the rest – until David Cameron, Eric Pickles and their Localism Act, complete with mayoral refos. And yet. I have lost count of the times I have heard municipal enthusiasts, not just councillors, complaining in recent weeks that ministers are refusing to say how much extra power (public health matters here) they will concede to directly elected mayors who they hope will revive flagging Victorian cities. It’s a blind bet. Whitehall really wants to let go, but daren’t.
What’s more, sceptics add, the Localism Act actually contains around 140 additions to the powers at Eric Pickles’ disposal. “It ought to be called the Centralism Act,” I heard a learned professor protest the other day. That studded ambiguity may all sound familiar to NHS-watchers. To such faint-hearts, Michael Heseltine – ever the buccaneer – says power is there to be taken by the bold: just look at Alex Salmond. That’s always good advice, though bad or reckless pirates can also be bold.
So what about bold CCG pioneers’ hopes of assumed liberty? Searching the web for enlightenment, I found this elaboration from Mr Grant at the clinical commissioners conference. The act embodies “autonomy from government for the commissioning board and autonomy from the commissioning board for CCGs. CCGs will not be the only relationships the commissioning board will have, although the bulk of the annual £90bn revenue spending will go through you… The board has [other] powerful financial means to secure the outcomes we all wish for. Beyond that, it’s over to you.”