Wednesday, April 6, 2011

At half time it’s KONP 1 – Cameron and Lansley 0

The government yesterday said it was in listening mode over health reforms, a significant victory for all the Keep Our NHS Public, Save Our NHS, NHSDirect Action, Health Emergency and other campaigners fighting its health reforms.

But the Health and Social Care Bill is not dead yet and there is plenty more lobbying to do. Thanks to this government pamphlet and Andrew Lansley’s own patchy media performances on Wednesday, there should be some easy wins ahead for the campaign...

First, let’s look at Lansley’s interviews. He told Radio 4’s PM interviewer, Eddie Mair (click here, from 10 mins to 22 mins, with Mair asking if Lansley would resign around 21 mins) that health professionals and the public agree with the principles and policies of his reforms, and are worried only about their implementation.

This is simply wrong. Medical and public opposition is centred on fears about opening up the NHS to private competition, a matter of principle not implementation. Lansley can ignore it all he likes, but it's the biggest barrier to his reforms and it’s still there.

Funnily enough, Lansley made a similar slip in his earlier myth-buster document (myth 4), when he argued that the reforms did not count as privatisation because the NHS would still be publicly funded, even if the providers were now private. Obtuse or dishonest? You decide.

Next, Lansley told Newsnight’s Gavin Esler that the BMA supports GP commissioning. Let’s look more closely at this claim: the BMA is in favour of more clinical commissioning but has serious doubts whether GP commissioning is the right way to do it (see BMA's response paper):
The BMA has consistently argued that doctors and other clinicians should have much greater autonomy and flexibility to shape services for their patients...The BMA believes successful [GP] commissioning will only be achieved if consortia are able to draw on the expertise of other clinicians...GP-led consortia will also require significant support from managers and other non-clinical staff
It is true that GPs are queuing up to join pathfinder consortia but that is because they have to avoid being disadvantaged, most of them don't actually support the reform. A few do, perhaps inspired by the financial opportunities, but according to this Royal College of GPs survey , more doctors think GP commissioning will fail to achieve the government's aims. As the BMA said, joining a pathfinder is no more a sign of approval than passengers jumping into a lifeboat is an approval of their ship sinking.

Lansley then told Esler he wants to slash a third off NHS administration costs by handing commissioning to doctors. The implication is that we must choose between administrators doing it badly or doctors doing it well. This is a false choice: GPs will have to hire ex-PCT staff, so quality and overall staff levels can only change so far. The best that can be said of the change is that it might bring a one-off benefit if GPs leave the worst administrators behind.

Lansley's war on managers is simplistic, you cannot just wish them away. Better to improve them than remove them. Also, the clinical/admin divide apparently provides a source of productive tension in well-run hospitals that would be lost under his reform.

Lansley spoke of clinical-led commissioning and patient choice as the heart of his reform but has not explained why it should be GPs and not other doctors in the driving seat. Why not take a mix of doctors across specialisms? (this may now happen as the BMA wanted, according to the FT).

And instead of turning GPs upside down, why not simply appoint more doctors to PCT boards? Making GPs join large consortia will probably reduce diversity and choice, at least as far as choosing a GP is concerned. The policy looks self-defeating.

What about David Cameron's arguments? He promised to stop private companies from cherry-picking services and leaving NHS hospitals with the dregs. Doing this while leaving "any willing provider" in place is contradictory.

If the aim is to create a market for health services, it will only work if buyers and sellers can act in their own interests. Private firms will naturally want to cherry pick, as will charities and NHS units – since they are all competing for the same revenue. Rules to stop cherry-picking will stop the market from being a market and add red tape; it’s hard to see the point of it.

The first draft of the Bill sheds some light on this – it originally allowed for price competition, taking us firmly into the realms of US-style health provision. Mercifully, this was removed in the government’s first small U-turn on the Bill, but the “any willing provider” rule is still there in all its cherry-picking glory.

If the government wants an element of internal competition, it already has it from the reforms brought in by Labour. Instead of trying to marketise things further, it could look at ways to improve public sector provision through new ownership models, such as social enterprises that reinvest profits in their community, as proposed by Cameron's favourite Tory think tank, ResPublica in its report, The Ownership State.

Next, Cameron says that the status quo is not an option. This is his biggest area of personal risk as the claim is dubious, ties him to bold reform and makes it harder to ditch Lansley and his troublesome Bill.

So why is status quo not an option? The NHS is famously in constant evolution, patient satisfaction is a near record high and health outcomes are on an upward trend, all for lower expenditure than any other developed country: the status quo actually looks pretty good. As these Financial Times and Guardian editorials say, the reforms are fixing a problem that doesn’t exist.

The pamphlet puts it down to funding: it says Lansley's reforms are needed because demographic changes and rising treatment costs will squeeze the NHS budget.

But this is a funding not an operational problem. Funding the health needs of an aging society will need a mix of fiscal and other policies that focus on where the money comes from. Lansley’s reforms are operational and look only at where the money goes to (which happens to include private providers such as Lansley benefactor Care UK).

In fact, GP commissioning and private provision are likely to increase pressure on funding by adding transaction costs and reducing the NHS’s scale economies: countries that share our demographic outlook but not our universal health provision spend 1-4% of GDP more on healthcare. Like us, they also have aging populations and are probably looking at the UK as a model to bring their costs down!

If the biggest challenge is funding, Cameron is talking to the wrong person. He should be speaking to George Osbourne about economic growth and reworking inheritance tax rules to fund end-of-life care.

Meanwhile, to keep the best bits of Lansley’s reform without ruining the NHS (and possibly his own career), here’s what Cameron should do next:
  • abandon the Bill completely,
  • appoint someone to explore fiscally-based long-term funding options for end-of-life care,
  • put more doctors on the existing commissioning structures,
  • make PCTs smaller, more local and more accountable,
  • consider letting NHS units adopt social enterprise models,
  • promise to protect the NHS’s integrated, public provision model.

These small changes would make the NHS safe again for the Tories and would not need a Lansley Bill. In fact, they would not need Andrew Lansley at all.

Ladbrokes this week shortened the odds on the health minister being the next to leave the cabinet from 10-1 to 5-1 and today to 4-1. Put your bets on before it gets to evens!


  1. One of the most succinct and coherent analyses I have seen on Governemnt policies and the real issues facing the NHS and society.

    Thank you Greg, I struggled to find any serious points worthy of comment.

  2. Excellent! You hit all the nails on the head.