At a recent senior company team meeting, I was discussing the changes envisaged in the Health and Social Care Bill and raised the notion about writing this article and calling it “any willing price”.

I described the repeated dream I was having linked to a recent Panorama programme on local authorities using bidding to gain the lowest prices for home care.

The outcome, for those who didn’t see the programme, was not in the best interest of patients or carers.

Not that the individuals delivering the care were not trying their best, but the margins for those providers had been cut so small they had to push intervention rates and both reduce the terms and conditions and the numbers of people to deliver.  

The outcome was poor patient care, reduced carer support and increased anxiety for those who deserve the best from our services, whether public service delivered or independently delivered through public money.

The concerns I expressed to the team were, first, that within health we could unintentionally end up making the same mistake in a system that is going through the biggest change in its history towards reducing excess bureaucracy and subsequently reducing costs.

This last bit has a sense of irony about it. I am not sure which bit of evidence based policy is being followed, but most evidence shows that such scale and change do not really deliver the expected in terms of cost or delivery.

Second, from our organisational perspective, we will move from a manageable three local level commissioners of services to a set-up in which, taking the example of children and young people’s services, looks as if it might be part commissioned by one or many local commissioning consortia, part by a local authority for certain public health functions, and then by the NHS Commissioning Board for another aspect of its routine delivery.

How does this benefit localism or add clarity to joined up delivery to meet the quality, innovation, productivity and prevention programme?

If it happens like this then the only saving grace will, hopefully, be a reduction in the 470 or so performance targets to be found in the community contract alone. Naive, I know.  

Let’s return to the team meeting and the notion of any willing price.

I described a situation of the introduction at speed of any willing provider, locally agreed variability in tariff, suspension of the two-tier workforce requirements, and some GPs who may see the change as a way to commission for increased self-provision.   

Put these into the pot with the possible changes from the Hutton review of public sector pensions, which apart from causing great concern within the workforce will, I am sure, propose some radical shifts in benefits that could aid further market easing and competition.

Taken together, you don’t need to be a rocket scientist to think about how the levers line up for a period of rapid change during which newly forming consortia, presented with large QIPP targets and financially pressed providers, might introduce less than robust mechanisms to drive down costs.  

Without a structured economic regulator to manage the provider market and the whole system there is a risk of fragmentation of care driven, unintentionally, on cost alone.

Hence my concern for the people we are here to support - the very people we are told these changes are being implemented to help.  

It was at this point that one of the team pointed out that the wider gamble being taken in the current approach is similar to the game Kerplunk, where marbles are poised on a nest of straws.

When it comes to your turn you remove a straw and hope the action won’t dislodge the marbles balanced precariously above.