Getting down to nuts and bolts

Published: 22/09/2005, Volume II5, No. 5967 Page 14 15 16

For the second year running, HSJ has teamed up with 36 leading health organisations at the Health Hotel - so called because all their meetings will be held at the same Brighton hotel during next week's Labour Party conference. A news service reporting on events from the Health Hotel will be available at www. hsj. co. uk/ labourconference2005, and this week's HSJ carries a seven-page section on the state of health service policy in Labour's third term.

First, Daniel Martin tells the story of the healthcare outside hospitals white paper, while on pages 18-21, the UK's leading health lobbyists give us their view of health policy in 2005.

Policy-making is like pressing on a lumpy mattress. Push down on one part and you may solve a problem, but more often than not another lump will appear in a quite unexpected place.

The latest policy 'lump' is due to be tackled by the healthcare outside hospitals white paper. Policy-makers at the Department of Health and Number 10 are starting to draw up the document that will usher in a wholesale reform of primary and social care in England. But where did the idea come from, and who will write it?

It is a difficult question. So many people are involved in policy-making that it is almost impossible to say definitely who wrote what. One insider comments: 'It is very hard to see a clear line of delivery from [policy] wonks having an idea to the policy being implemented. There are so many competing influences and different hands at work. Now more than ever.' Some believe the focus on primary care has its roots in an incident during the election campaign which brought actute embarrassment to Labour - and the prime minister in particular. Tony Blair was harangued by an audience member on BBC1's Question Time over the difficulty of getting an advance appointment with her GP.

With campaign nerves at their height, the DoH received a call from a rattled prime minister's office asking what the hell was going on with primary care. Moments like this can have more impact on policy than the weightiest document from the most respected academic.

But this incident was not the birth of the white paper. Number 10 will be keen to ensure that GP access is tackled. However, the need for a wide-ranging look at the future of primary care was in the minds of policy-makers long before the election. After eight years during which the reform spotlight had shone mostly on the acute sector, it was time for primary care to feel the heat.

Indeed, it had to suffer the attention of the reformers if the government's other health policies were to work.

System reform and the wholesale implementation of payment by results would require a stronger commissioning side if providers were not to have the whip hand.

Without stronger commissioning, genuine contestability would be impossible because there would be little incentive for providers to raise their game. And without better primary care services, too much cash would stay in the hands of acute trusts because money would follow the patient to hospitals. The success of choice would depend on primary care reform.

But what shape should this reform take? Work on the national service framework on long-term conditions in 2004 hinted at it.

Sufferers said they wanted more healthcare provided in the community. The need for a shift from secondary to primary care was also highlighted by the Big Conversation, Labour's pre-election consultation on the party's priorities.

Voters called for better access to their GPs and flagged up continuity of access as a key issue. Along with documents produced by Labour's national policy forum on health, the consultation exercise fed into the party's manifesto, which promised an expansion of the expert patient programme and greater choice in primary care.

When Patricia Hewitt became health secretary after the election, she took soundings from stakeholders and decided to merge primary and social care reforms into one white paper, entitled 'healthcare outside hospitals'. In fact, this had been a buzz phrase in the department for some time. Back in 2004, NHS chief executive Sir Nigel Crisp said that the first thing to land in the next health secretary's inbox would be 'out of hospital' care.

One of Ms Hewitt's earliest tasks was to appoint her team of special advisers. Number 10, too, had to find a replacement for the prime minister's senior policy adviser on health, Professor Julian le Grand.

These appointees would have crucial roles to play over the next few months. All have different standpoints and objectives, and the relationships between them can be crucial.

The traditional picture is that civil servants, heavily immersed in systems reform, concentrate on dayto-day matters and policy implementation. Blue-sky thinking is the exclusive domain of the DoH special advisers, concerned with the shape of NHS policy two years down the line. Mr Blair's health adviser must think beyond even that - maybe five years ahead. In fact, the web of policy-making interaction is more complicated.

Career civil servant Ian Dodge was the man chosen to advise Mr Blair. The prime minister has been the principal driver of change in the NHS since 1999, and in terms of domestic policy, only education and the 'respect agenda' can compete in grabbing his attention. His appointment of Mr Dodge, a former head of primary contracting at the DoH, was a sign of things to come.

As the eyes and ears of the prime minister in health matters, Mr Dodge was given the task of ensuring that the DoH is doing what has been agreed with Number 10 and of continually looking ahead to question whether current policy directions will deliver what the public will want in five years.

Despite Mr Dodge's remit, the relationship between Number 10 and health is understood to be unconfrontational. He speaks to DoH special advisers a number of times a day and, since Downing Street faces Richmond House across Whitehall, face-to-face meetings can be organised with ease.

Ms Hewitt appointed three special advisers. Liz Kendall (pictured left: top), who had been the health specialist at think tank the Institute for Public Policy Research, was brought in to push through ideas such as choice, patient involvement and changes to the NHS workforce. Paul Rodgers (pictured left: middle), a former Fabian Society chair, took charge care of media presentation and communications. Royal Surrey County Hospital trust chief executive Matthew Swindells (pictured left: right) looks at the detail of policy.

DoH special advisers are sometimes more influential in policy-making than their political masters. They are not simply their masters' voice in the department; frequently they persuade them what to say. They are also often said to be 'joined at the brain' with Mr Dodge.

The four advisers are the centre of the policy-making operation.

That is not to say there is a barrier between advisers and civil servants.

The two can work very closely on policy. As one insider put it: 'There can be tension because part of the job of the adviser is to put a bit of grit in the oyster. But most of the time it is more oyster than grit.' The main function of civil servants is to suggest how policy dreamed up by elected representatives can be most effectively put into practice. Sections of the department dealing with especially complicated pieces of reform such as payment by results can have little time for blue-sky thinking. However, some sections of the DoH are well-respected and are given autonomy to come up with innovative policies of their own, while less well-regarded parts of the department are marginalised. In a similar way, some of the national directors - the 'czars' - are more influential than others.

There is one ace that civil servants will always have up their sleeve: while special advisers are often generalists, civil servants are usually specialists. Many a high-flown initiative from an adviser has been brought crashing to earth by a civil service that understands the complexities of health policy and can highlight unintended consequences that may not have occurred to a generalist adviser.

The person with the potential to have the greatest impact on the white paper is, of course, Ms Hewitt.

The personalities of previous incumbents of the top job at Richmond House demonstrate the potential extent of that impact. Alan Milburn was very hands-on: he knew exactly what he wanted and was a key driver of policy, even to the point of sitting down at his computer and writing parts of the NHS plan. At the other extreme was Frank Dobson who, despite his Old Labour credentials, was more of a chair of the board, far less dogmatic about policy direction and willing to listen to interested parties on the basis of 'what works'. The ebullient John Reid, Ms Hewitt's immediate predecessor, was somewhere in the middle: he had a far looser grasp of policy detail than Mr Milburn, but was single-minded in pushing forward the Blairite agenda.

In contrast, junior ministers (with the exceptions of Mr Milburn when he was a member of Mr Dobson's ministerial team, and John Hutton) have rarely been influential on broad policy ideas.

Insiders say Ms Hewitt is shaping up to be a mixture of Mr Milburn's strong-willed nature and grasp of policy detail and Mr Dobson's desire to reach out and listen. She is a tough operator - she will not take claims made by those she consults at face value - but she will be genuinely open. It is this that could be her biggest impact on the white paper. She has opened up the primary care reforms to the most genuine consultation exercise the health sector has seen for many years (see box, below).

A team of DoH civil servants led by Alan Doran has now been appointed to put together the white paper.

Given that their task will be unusually large, they were told to contract out work to teams in other parts of the DoH and - most radically - to working groups containing members from outside the civil service. There is a precedent: in 2000, the NHS plan was drawn up with the help of six working groups which had representatives from charities and patient organisations, as well as clinical and managerial staff. Professor Chris Ham, a special adviser in the department at the time, says they had real influence. 'A lot of people were sceptical that this was token engagement, but in the end I think many could see that what they had said had made a real difference.' This time round, the task groups may have an even greater impact.

They have been told to come up with hard practical solutions for change. Supported by a team of civil servants providing data and secretarial assistance, each task group will discuss the future of primary care, taking the results of public consultations into account. Civil servants will draft the chapters, after which the task group chair will sign off their section of the white paper. All this will feed into the work of the central white paper team, which will write the final white paper with input from Ms Hewitt and Mr Blair.

Number 10 and Richmond House will continue their close working relationship. But if there are any tussles, Ms Hewitt will have a strong hand. She will be able to point to the public consultation she has initiated to convince the prime minister what will go down best with voters.

This year's Labour Party conference will no doubt be the arena for many groups to put forward their views directly to the health secretary. The white paper itself will be published at the turn of the year. More than ever before clinicians, managers and patients will be able to have a real impact on its content. .

'LISTENING EXERCISES HAVE BEEN A BIG JOKE IN THE NHS, BUT I am VERY IMPRESSED WITH THIS ONE'

NHS Alliance chair Dr Michael Dixon is pleased with the nature of health policy-making in 2005.

'Policy is not made in cliques any more, ' he says. 'There is far more asking around and testing out ideas. Groups are having far more ability to put points forward face-to-face or over the phone. We have been consulted already on a wide range of issues, such as GP registration, contestability and improving access. I used to get calls on a fairly intermittent basis, but now they're continual.' He adds: 'When I go to the advisers to say There is a problem I am often told than three or four other people have been on the phone about that, and that they're looking at the problem and are going to fix it.'

Special advisers have made a marked effort to get out and meet stakeholders to ask them what should be done with primary care. And the public will be consulted on a greater scale than ever before.

'Listening exercises have been a big joke in the NHS but I am very impressed with the way this is going, ' says Dr Dixon. 'We have had nice consultations in the past, but the plans had already been made. But this is different: It is not just PR.' The extensive consultation does not mean the department has no idea what will be in the white paper.

'I am sure there are ideas in germination, ' says King's Fund chief executive Niall Dickson.

'It would be an abrogation of responsibility to have a blank sheet saying please tell us what to do.

Henry Ford once said if he'd asked the public what they'd wanted, they would have said 'a faster horse'.' Much work will have to be done to translate the public's vague wishes into practical reality.

Other health systems will be scoured for ideas, and lessons are being learned from Australia and the US. Think tanks, such as the Institute for Public Policy Research, the Social Market Foundation and the New Health Network, are also consulted: they write influential reports and organise behind-closeddoors seminars where policy makers can discuss ideas with those closer to the front line.

The National Leadership Network has been developed to enable the Department of Health to hear the voices of around 100 health groups from the NHS Confederation to the British Medical Association, as well as leading managers and clinicians. It is not as influential as the smaller modernisation board was under former health secretary Alan Milburn, but it is gaining ground and members are seeking a commitment from government to bring policy ideas forward earlier.

Managers are also consulted regularly through the 28 strategic health authority chief executives. The 'top team', which meets once a month, has an impact on the pace of change more than the direction of policy. Some chief executives - notably Mike Farrar, Sir Ian Carruthers, David Nicholson and latterly Gareth Goodier - are more influential than others.