David Cameron has made passing the Health Bill a matter of confidence – making it close to impossible the legislation will fail. We now need to ask what kind of bill will be passed and what will happen afterwards.
Once again the prime minister felt the need to put his reputation on the line over the reforms because parliamentary opinion was in danger of swinging against his health secretary. Part of that change in opinion came with the realisation there was a Plan B for NHS reform which could achieve much of its original intention without much of the current cost and disruption.
The Department of Health denies outright that there is a Plan B. But HSJ understands senior civil servants have informally discussed what would happen if the Health Bill was pulled. Broadly, the solution would see the NHS Commissioning Board remain a special health authority and, as planned, take responsibility for commissioning development and oversight, and resource allocation. Primary care trust clusters would be maintained. Clinical commissioning groups would continue to go through the authorisation process and would operate as cluster subcommittees.
However, HSJ understands most of these civil servants now believe, with so much water under the bridge, that just getting on with the structural reforms as is would be the best outcome.
However, they have also discussed a Plan C which would see the bill passed, but with section 3 – which deals with the regulation of competition for NHS services – dropped or amended, perhaps severely.
Andrew Lansley makes it clear in his article for HSJ this week that he believes competition has a “critical” role in delivering better NHS services. However, despite this defiance, there is widespread cross-party belief that concessions are on their way.
The issue is fiercely complicated, but three broad scenarios are possible. The most likely is that amendments counterbalance requirements to compete with those to cooperate, weaken the impact of competition law, and prevent foundation trusts being abandoned to the market by maintaining Monitor’s existing regulatory role. Next in likelihood is some attempt to push the introduction of the new regulatory regime further into the future. The least likely outcome is the complete abandonment of the proposals – something which would force Mr Lansley’s resignation.
Almost exactly a year ago HSJ declared competition should not be the first choice for NHS services, as “it too often has unfortunate consequences and costs”, but that it “may sometimes be the best option”. We hope that peers – and just as importantly those same senior civil servants who are responsible for drafting the secondary legislation and guidance which will provide the substance of the new policy – will deliver something proportionate and workable. Certainly a longer timescale would help in that regard.
But those who take a harder line on increasing competition and a resulting larger role for the private sector – most notably the British Medical Association, but also the Royal College of GPs – may have some hard thinking to do.
If the bill is passed with the competition provisions more or less intact, what guidance will they give members? Readers can judge for themselves the impact of a statement from the BMA or RCGP declaring members should not be involved in decisions giving private providers a greater role in determining or delivering NHS services. But if that was deemed possible and desirable it might mean walking away from clinical commissioning, or at least fighting a guerilla war against the policy.
The passing of the Health Bill is only likely to mark the end of the beginning of the war these reforms have ignited within the service.