Passing judgement on Lansley's vision

Can the health secretary rebut the charge that he is about to wreak havoc on the NHS, or will his vision be vindicated? Four leading figures give judgement.

Stephen Dorrell

In order to understand the coalition’s health policy it is important to be clear about the answer to one question; does it represent the continued evolution of existing ideas, or does it represent a major break with the past? Is it evolutionary or is it revolutionary?

I believe it is both. It seems hard to argue that the proposals in the Health and Social Care Bill represent a revolutionary break with the past.

All recent health secretaries (except Frank Dobson, and he wasn’t regarded as a runaway success, even by himself) have made the case for powerful, effective commissioners who are able to use taxpayers’ resources to shape a health and social care system to meet the needs of patients. Effective commissioning is about both clinical standards and value for money; it is about ensuring traditional patterns of care are challenged and the delivery of healthcare responds to changing clinical practice and the changing needs of patients.

Nor have health ministers only talked of commissioning; they have also recognised the value of choice and competition. These ideas are hardly cutting edge. And it has long been regarded as common sense to draw on the resources of both public and private sector to provide free high quality care to patients.

Of course commissioners need to have regard to the consequences of their decisions for other services, and of course intelligent commissioning needs to balance sometimes conflicting objectives, but none of this is very startling and it certainly isn’t revolutionary.

Even the language is familiar; choose and book, any willing (now “qualified”) provider, practice based commissioning, foundation trusts. These are not the raw phrases of a new radical sect; they are the polished orthodoxy of the status quo. It’s an unusual revolutionary tactic to adopt as slogans the clichés of the ancient regime. So if all the concepts are as familiar as carpet slippers, why do I begin by saying that coalition health policy is both evolutionary and revolutionary.

The answer is that those who search for revolution in the turgid prose of the bill are looking in the wrong place.

The real advocate of revolution is chief executive Sir David Nicholson. He secured the support of both Andy Burnham (before the election) and Andrew Lansley (after the election) for the revolution which, in the health select committee, we refer to as the “Nicholson challenge”; that is the requirement for the NHS to achieve £15bn-£20bn of efficiency savings over the next four years. The select committee describes the challenge as “4 per cent efficiency gain, four years running”.

That really is revolutionary. No healthcare system has ever delivered anything close. The decision to adopt the Nicholson challenge is the result of a cross party recognition that no government could afford to continue to meet rising demand out of budget increases on the scale we have seen.

Given the state of the public finances, the only, and unacceptable, alternative to meeting the Nicholson challenge is that demand for care is simply left unmet.

But it isn’t just a matter of economics. Change is also driven by the changing demands of clinical care. Some of the greatest current inefficiencies are because traditional institutions and structures are being used to deliver care to a quite different type of patient.

Systems designed primarily to treat occasional episodes of care for normally healthy people are being used to deliver care to people who have long term and often complex conditions. The result is too often that they are passed from silo to silo without the system having sufficient ability to coordinate the different providers. Anyone who has recently tried to achieve coordinated and high quality end of life care for a relative will be familiar with the problem.

The requirement for the NHS and social services to manage a change in the way care is delivered so that it is more coordinated, more integrated and less episodic is therefore driven by both the clinical desire to deliver high quality care and the economic imperative to deliver the Nicholson challenge.

It is the same challenge viewed from two different perspectives. But no one should doubt its revolutionary implications. It will require fundamental changes in the way care providers and professionals behave. Delivering that revolution is central to the future of the NHS; which is why I continue to believe it is essential to create more effective and empowered commissioners able to achieve change on this scale.

Of course it is possible that the sum of individual small decisions will precipitate a smooth revolution in the pattern of care provision, without the need for commissioners to manage the process. It is also possible that pigs might fly.

But I wouldn’t count on it.

Stephen Dorrell is chair of the Commons health committee and a former health secretary.

Alan Milburn

The coalition government’s health reform plans are the biggest car crash in recent NHS history. From the outset they were devoid both of advocacy and advocates. Now David Cameron and Nick Clegg are trying to ride to their rescue. With a screech of tyres we are in U-turn territory. Where we will end up no one quite knows.

Of course managers, clinicians and staff in the NHS will make the best of a bad job. They always do. But many are left wondering how on earth the government got into this mess in the first place.

The politics of this change has always mystified me. David Cameron’s project was supposedly about decontaminating the Conservative brand. Playing safe on the NHS was central to that strategy. By bigging up its reforms the government has managed to conflate precisely the four words it was trying to avoid – cuts, privatisation, health and Tory. Even here confusion has been rampant. At the outset the reforms were dubbed a radical departure. More recently they’ve been repositioned as following in the footsteps of my time as health secretary and Tony Blair’s time as prime minister. They can be either a revolution or an evolution. But they can’t be both.

The reforms are a failure of politics. They also contain failures of policy. Giving local services greater freedom through foundation trusts was a bitter internal battle during Labour’s time in government. Today they are the most efficient and highest quality NHS hospitals, so it’s a good idea to rapidly make them universal. What is a bad idea is to let hospitals off the accountability hook by abolishing the national standards and targets that drove better clinical outcomes and lower waiting times during the last decade.

Of course, cutting waste is a good idea, but it is a bad idea to assume that NHS structural change save cash – at least in the short term – rather than costing it. Abolishing PCTs and creating many more GP consortia to replace them hardly sounds like a recipe for cutting bureaucracy. With demand rising and £1bn of NHS cash being shifted into social care the NHS budget will fall, not rise. As Stephen Dorrell has wisely argued structural change can only distract the NHS from making the £20bn efficiency savings it needs to make.

Similarly, it’s a good idea to get politicians out of day-to-day NHS management, but a bad idea to move power sideways to a national commissioning board. It should be moved downwards to where health decisions are actually taken, in local services. NHS chief executive Sir David Nicholson has cannily blessed his board with far reaching powers over the GP consortia that were supposedly the kingpins of these reforms.

Finding ways to get family doctors to own the financial consequences of their prescribing, treating and referring decisions is a good idea. But it’s a bad idea to assume that GPs can easily do the complex business of commissioning local services – and in the process weaken public accountability over £60bn of public money.

Then there is the move to an any willing [now “qualified”] provider policy. When I first introduced private sector providers into the NHS some claimed it would be the end of the health service as we have known it. In fact it strengthened the NHS with waiting times and death rates both falling faster in areas where new providers were brought in. Monopolies in any walk of life rarely deliver either operational efficiency or customer responsiveness.

That’s why there should be no preferred providers. Market mechanisms can work in healthcare but only when properly managed and regulated not when there is a free-for-all. So while it is a good idea to extend competition it is a bad idea to allow it to fragment local services or to be on the basis of price rather than quality.

These policy failures cannot be put right by better PR. Despite Andrew Lansley’s protestations they will require substantive amendments in Parliament to the Health Bill. Of course that risks a health policy that is neither one thing nor another at a time when the NHS needs reforms to meet the challenge posed by an explosion in chronic diseases. That calls for policies that integrate services between primary and hospital and health and social care rather than fragment them. It suggests a bigger focus on prevention not just treatment. Above all else, it argues for patients being empowered to take greater charge and have more responsibility for their own health. This is the future health policy agenda. It is one this coalition has failed to grasp.

Alan Milburn is a former health secretary and government adviser on social mobility. He declined Andrew Lansley’s invitation to apply for the position of NHS Commissioning Board chair.

David Kerr

The past few weeks have seen an extraordinary intervention in health policy by the prime minister and his deputy, giving pause to reconsider the detail of the Health Bill.

This time last year I signed up as health adviser to the Conservative party for two reasons; the obvious drive and desire that Andrew Lansley had to reform the NHS around a quality agenda built on clinical engagement and David Cameron’s personal commitment to me and, of course, the notion that the NHS would remain free at the point of delivery and universally accessible.

The NHS would remain true to its founding principles and clinicians would be “set free from the centrist, target-driven culture imposed by the previous administration, to improve the service they deliver, which would be judged on clinical outcomes and patient feedback”.

To me, clinical engagement in management is not to have doctors and nurses involved in some deeply jargonised, unsatisfactory management-speak, but rather working to improve the quality of their own service, focusing on the clinical outcomes that make a real difference to the quality and length of our patients’ lives, developing the multidisciplinary teams that characterise a good service and working across sectors to ensure seamless, managed care over the primary-secondary interface.

How has this compellingly simple vision of health reform progressed since the election? Has it garnered support from every corner of the NHS, civil society, the commentariat and the professions? Is the Health Bill passing quiet and unchallenged through Parliament? Is there political unanimity? Above all is it possible to envisage how the changes will lead to the NHS to which Lansley, Clegg and Cameron aspire?

Although there was strong support for the basic tenets of a clinically led, outcome oriented NHS during the initial consultation, concern was expressed about the redistribution of the majority of the NHS budget to commissioning consortia at a time when the service was being asked to make unprecedented efficiency savings. The consultation and parliamentary debate have led to modifications in the structure of the bill, perhaps most importantly that competition would be quality rather than price based, but despite this, there has been a hardening of attitude against the reforms. There is a degree of daft shroud waving from the unions, The Guardian and the generally uninformed that the NHS will be “privatised” – this canard should be dismissed as there is absolutely no ideological case being made for this. Competition from any willing provider is a mechanism to enhance quality.

The more thoughtful commentators have noted an evidence gap linking the planned reorganisation to value added care, so there must be a strong element of evaluation built into the plan.

Perhaps the weakest element has been the failure to articulate how these plans will make the NHS demonstrably better. Clarity of communication describing the essential shape of the reforms, especially to patients and to clinicians working in the front line, has been noticeable only by its absence. There is a real and ever widening hierarchical disconnection between the authors of reform and its recipients. The truer narrative has been subtly corrupted by the Greek chorus of those with axes to grind and it felt as if the opportunity to debate, modify and refine the key elements of the plan was slipping away from those with the greatest experience to offer; clinical staff, patients and their carers.

We are reassured therefore by the recently announced “pause for thought”, supported by David Cameron and Nick Clegg, who openly acknowledge the need to engage further with these constituencies, deliver a lucid view of this reformed NHS, listen to feedback, adapt the plan where appropriate and persuade these communities that the reforms set the NHS on an improved path. The cynical have already written this off as a PR exercise.

But I believe the NHS Futures Forum will have the ear of the powerful and the attention of the secretary of state and represents an opportunity for us to refine the plan and make sure it is geared to deliver its underlying principles – a quality driven NHS, supported by a culture which aims to improve key clinical outcomes, which will be published and shared with our patients.

David Kerr is professor of cancer medicine at Oxford University and a member of the government’s NHS Future Forum.

Bill Moyes

David Cameron must wonder how, after allegedly years of detailed preparation and relationship building with everyone in the healthcare sector, the government’s reforms can be in such a mess. The scale of opposition is remarkable, probably unprecedented. Even the Iraq war had some supporters at the time. These reforms appear to have none.

Worse, the “listening exercise” has effectively put the content of the legislation up for public negotiation. Every day brings new challenges and threats, and new timetable slippages. It’s no way to make good law.

More dangerously Cameron and Andrew Lansley are unwittingly creating the conditions for a future government to conclude that free hospital care is no longer affordable. Already the political commitment to maintain health expenditure in real terms is creating tremendous strains in other valuable public expenditure programmes. That will get worse if hospital admissions continue to grow unchecked and if unsustainable hospital services are allowed to continue. The time will come, perhaps not too far off, when some form of charging will emerge as the only solution. It isn’t. But, that’s the real danger of the current crisis.

And yet, the vision is right. I firmly believe that. We need:

• a clinically led commissioning system that brings together clinical and financial decisions and ensures coherence between the two;
• GPs to have incentives to devise effective care out of hospital, the resources to make these plans a reality and the clinical information and financial clout to ensure that hospital admissions and services align with commissioning intentions;
• reliable, comprehensive information on clinical outcomes and quality of care;
• autonomous hospitals to compete to offer better quality within a regulatory system that promotes improvement through competition, prevents price wars that drive quality down and manages failure if it happens.

All of this was promised by Lansley’s vision. But in politics, unlike in war, surprise is seldom a successful tactic. The combination of previously unannounced policies, a complete failure to build the necessary political and professional consensus and an apparent disdain for the detailed planning of implementation means that the vision has been lost and the government may be reduced to salvaging who and what it can from the wreckage.

So, what to do?

Don’t give up on GP commissioning. But don’t believe that large numbers of GPs joining pathfinders is evidence of support or shared understanding of how GP commissioning will work in practice. GPs are rightly apprehensive about taking on contract negotiation and management, budget control, strategic service planning and service procurement within a competition framework.

GPs need to understand what commissioning responsibilities will mean for their working lives. Will they spend less time with patients? Some will, many shouldn’t. Will they have access to management expertise? Not unless more is done to encourage support service providers to start addressing this market. The governance and accountabilities of GP commissioning consortia needs to be clarified and to command confidence. Adding a hospital doctor, a nurse and a local authority representative to the consortium’s board won’t do it.

Getting commissioning right is fundamental to securing the future of the NHS. Fleshing out the detail and getting real support should be the first priority. Rethink the approach to foundation trusts. It’s good that securing an all-foundation trust hospital sector is now accepted wisdom. But the announced timetable is unrealistic. And forced mergers/acquisitions for those hospitals not capable of becoming foundation trusts is high risk.

The bill as it stands seriously reduces the freedom of foundation trusts. Rethink it. Placing the detection and management of financial failure in the hands of an NHS bank which is part of the Department of Health, and giving the secretary of state unconstrained power to demand information and to set the financial reporting rules effectively places control back in the hands of the secretary of state. This is the wrong approach.

Giving the governors the prime responsibility for ensuring that the board of a foundation trust is tackling effectively clinical or financial shortcomings is a high risk strategy. It may be the right objective for the long term, but it will require a lot of investment in the training of governors. It’s not obvious that the government is planning to make that investment.

Don’t rush into creating a competitive provider market. Get the fundamentals right first. A competitive market requires well governed and financial strong providers, with the freedom to respond to the market without political interference. The bill as it stands won’t deliver this. The government should give priority to creating a strong all-foundation trust hospital sector and to getting the statutory framework right before it moves to create a competitive market.

Don’t expect retailers and food manufacturers to deliver a credible public health policy. Their duty is to make money for shareholders. They’ll do the right thing when their customers stop buying the wrong things. Focus on the customers.

The government’s position can be rescued, but that requires some changes of approach. The vision is good. Stick with it. It’s the detail that needs attention.

Bill Moyes is the former executive chairman of Monitor.