The listening exercise needs to reach grass roots voices

As a charity chief executive I get a fair number of chances to express my views. But it’s not every day that I get to do so when sitting opposite the expectant faces of the prime minister, deputy prime minister and health secretary and their new Future Forum, with a phalanx of cameras over my shoulder, ready to record the occasion for that day’s news.

Yes, I was one of those charity health leaders invited to meet David Cameron, Nick Clegg and Andrew Lansley at Number 10 as part of the listening exercise on NHS reforms.

As the presence of the cameras attests, it was something of a staged event. But that doesn’t mean the politicians weren’t paying attention: Mr Cameron was in bargaining mood and clearly saw patient groups as being natural allies for the government’s reforms.

“Your organisations, which are hugely trusted and understood by the public,” he argued, “can help us make the argument that change, that choice, that diversity is not about privatisation, it’s actually about improving healthcare.”

So we had Mr Cameron’s ear, but what he really wanted to know was whether patient groups would support the Health Bill. That will require more than changes to the language of the reforms.

Patient groups do support the principles of reform. We know the NHS is already a mixed economy, want to see a bigger role for the voluntary sector and were disappointed when Labour retreated from a policy of any willing provider. We want to see continued change to drive improvements for patients. Some parts of the opposition to reform can look like an unjustified defence of the status quo.

But patient groups are concerned that the detail of the legislation does not deliver the principles it espouses. The intention is to put patients at the heart of the NHS, but there are no seats at the table in the new governance structures. We support clinically led commissioning but that needs to involve nurses and hospital doctors and not just GPs. We believe in plurality of provision but want there to be stronger incentives for collaboration. Essentially, the improvements we are looking for would “hardwire” the principles of reform into the incentives, payments and lines of accountability of the new operating system.

We also need more clarification. The powers given to GPs to charge for NHS services and for foundation trusts to charge for accommodation will come as a nasty surprise to patients and have not been adequately explained. Has there been an adequate public debate? I don’t believe patients are even aware of the possibility.

Other questions will be for Sir David Nicholson as he shapes the NHS Commissioning Board. Patient groups want to see scope for regional planning and national improvement strategies. And we are concerned about the variability in commissioning consortia. The authorisation process should not allow them to proceed without the necessary expertise and governance.

Like most of my colleagues, I had no appetite for further reorganisation and am doubtful about how it will facilitate productivity gains. Before the general election, I heard Andrew Lansley state his intention to put GPs in the driving seat of commissioning. But he also criticised “re-disorganisations” which distracted attention from improving quality and productivity.

Now that “creative destruction” has been unleashed, however, there is an urgent need to build the new system and give people a sense of certainty.

My anxiety about variability of GP performance cannot be resolved by legislation. I fear that while GP commissioning will improve the best care it could weaken the worst. Primary care needs to change to deliver a more productive, preventive NHS: too much resource is used treating people when they have become ill, not enough on education for self-management or on risk management.

Will the changes be sufficient to ease our concerns? At the listening event, David Cameron talked of “tweaks”, Nick Clegg of “changes” and Andrew Lansley seemed to be resisting the temptation to argue that he’d already thought of the answers. Sir David Nicholson was silent, possibly wondering how changes will work when they land in his in-tray.

One message I hope the government has already heard is that creative destruction is not the best way to manage change in public services.

There is now a genuine opportunity to make this a better bill, more likely to achieve its stated aims. The NHS needs the right kind of reform, not a retreat from reform.