Scrap the Bill: they wouldn’t be that stupid would they?

Just when it couldn’t get worse for Andrew Lansley, it just did.  At least until today – and with the single, curious, exception of the prime minister’s office – the blows upon his collapsing health reforms were raining down from the other side.  But now Conservative Home, the self-appointed mouthpiece of the party grassroots, has lined up with the Labour Party to call for the Health and Social Care Bill to be scrapped. Worse, Tim Montgomerie, the Con Home’s eminence grise, claims in his article to be voicing the sentiments of three Conservative cabinet ministers (why only three asks Fraser Nelson in the Spectator) who have discovered a sudden vehemence against the Bill.  If I am reading this correctly, one of these Cabinet colleagues would like to see the Health Secretary hung, while the next one wants him drawn and the last in the line would have him quartered.

There is certainly a definite whiff of violence in the air towards both Mr Lansley and his ideas.  It was only three days ago that Downing Street apparently wanted the Health Secretary taken out and shot.  Now Conservative Home, ever the voice of moderation, says that it is only necessary to kill his Bill. Perhaps after all the Secretary of State should regard this as progress. Otherwise the only direction in which this ill-fated policy is going is backwards.

The problem that is now becoming ever more apparent is that the policy and politics of health reform have long ago become decoupled.  Arguably they were never terribly well-acquainted in the first place. To the extent that Mr Lansley was ever able to explain his reforms in a language intelligible to human beings – a debatable proposition – that language certainly never resonated terribly well with the Conservative of the species. Yes there was a brief flirtation with ideas such as competition and even the market, but the Health Secretary went soft on this almost immediately, after it turned out to upset the Liberal Democrats.  ”Localism”, another idea loosely associated with Mr Cameron’s modern compassionate thinking, was in there too, but got squashed as soon as it seemed to be smarter politics to revisit tough central diktats on waiting times or initiate Whitehall edicts over nurses taking the trouble to look after their patients.

This lack of an indeological core matters because it makes it easy for Tim Montgomerie, and others who think like him, to call for the Health and Social Care Bill to be ditched for no better (or, indeed, worse) reason that that it is making the Conservative Party unpopular.  If Conservatives felt that they had something at stake in these reforms, then they might be less willing to line up with Labour and call for them to be abandoned.  Sadly, I  don’t think Baroness Warsi’s tendentious and somewhat plodding arguments for the Bill in response to the Conservative Home editorial are going to tip the balance.

Nevertheless, there are several reasons why Mr Montgomerie’s call for the Bill to be dropped is the wrong advice. From a political perspective, the least compelling might be that there are some things the Bill does that make perfect sense, and which do enjoy broad support in the health world. One such is the move  to align more closely the responsibilities of the NHS and local government for public health. I accept that there are not many votes in Health and Wellbeing Boards. However,  if the ground were suddenly cut away from their creation we would soon enough hear plenty of it from various outraged quarters, thus further adding to the damaging perception of the Government being at constant war with the health professional classes.

The bigger political problem is that they cannot, as Tim Montgomerie says, stop the Bill before it is too late. It already is too late.  The house that is Mr Lansley’s reformed NHS, jerry-built as many people say it is, is now pretty much constructed. All the Bill will really do is join up the electrics and turn the power on.   Primary care trusts have been abolished and merged prior to their ultimate despatch. The sinister new NHS Commissioning Board is starting to flex its muscles. As David Cameron said at PMQs on Wednesday, 95% of the country is already covered by the new commissioning groups in shadow form.

Trying to unpick this architecture is not only impractical, it would come with its own immense political price, unleashing further waves of chaos and claims of wasted billions. It may be true that between now and the general election everything that goes wrong with the NHS will be blamed on the reforms. Too bad. It would be naive beyond belief to think that finding reverse gear now would immunise either the Government or the Conservative Party from these charges. The prime minister is right in his gloomy conclusion that there is no way to go but on.

Parallels with the poll tax are being made. We shouldn’t  forget that out of that same era also came the original internal market reforms to the NHS overseen by Kenneth Clarke. These attracted the same unremitting opprobrium and unrestrained hyperbole from the opposition and from the NHS. These too were going to be the end of the health service as we know it. These too were going  to cost the Conservatives the next general election.

There are, however, important and revealing differences between then and now.  For one thing, the Conservatives had a large parliamentary majority in their own right and didn’t find themselves pushed around by a junior coalition partner.  Just as importantly, the party itself stayed united behind the reforms. Ken Clarke may not have been Mrs Thatcher’s idea of an ideological soulmate, but he did not  have to put up with her people offering a running commentary on what a lousy job he was doing.   Andrew Lansley has indeed made a significantly poorer fist of explaining his reforms now compared to Ken Clarke’s breezy pugilism then. Unlike his predecessor, Lansley has also had to contend with undermining from within as well as assault and battery from without.

It is an ugly situation all round and an object-lesson in poor political management. However, to make another cardinal political error by abandoning the reforms at this late and impossible stage would just make things even worse, not better.  This, if they have got any sense, is what Downing Street will conclude. In other words, don’t count on it.

 

Monitor’s Big Job

The latest big report from the King’s Fund Economic Regulation in Health Care, promises a “dispassionate” look at this recondite but still discordant subject. The description is well-chosen for the Fund is anxious to pick its way through a continuing civil war between cavaliers for competition and the puritan planners and by and large it succeeds.  The report is fair and balanced and makes some important points about the role of Monitor in the uncertain landscape of the reformed NHS.

The authors’ way into the topic is to look to lessons to be learned from the experience of other economic regulators, particularly from the utility sector, which is a perfectly sensible analysis, especially since Andrew Lansley is said to have modelled his vision for Monitor from this sector himself. Their most important conclusion, it seems to me, is that regulation in these areas evolved from a fairly finger-in-the-air starting point, and adapted itself to the task as the sectors themselves changed and developed. Health care is a much more complicated thing, they say, than telephones or gas pipes, and the risk of failure for Monitor is very great. But there is no reason to suppose that it cannot become a valuable and effective part of the NHS, serving the interests of patients and the taxpayer alike.

The idea that competition and integration cannot co-exist in the NHS is given short shrift in this report and one of its observations is that the US experience “suggests that it is possible for competition law to be applied in a way that can also foster integration”, which is an important learning from a land sometimes regarded as the mother of all markets in healthcare. Here in this report we see a much more nuanced argument which is that Monitor needs to explore how its duty to prevent anti-competitive practices can be squared with allowing innovative integrated models of care to develop. Mobitor should be “facilitative”, the authors say, “encouraging providers to take risks and innovate”.  And its advice to providers should be clear enough for them to be able to determine when collaboration works in the public interest and when it might threaten patient choice.

The report is in no doubt that these are tricky issues to get right and it points out that Monitor will be working in often uncharted territory (though there is good experience from the Netherlands and the US to draw upon). But it is refreshing to see a contribution to the debate far-removed from the yah-boo battles about competition and the NHS that have blighted the passage of the Government’s legislation.

 

 

 

Calling David Willetts

Bad news for professional lobbying companies who are about to be by-passed.  According to a report in this morning’s Times, Britain’s top corporations are going to be given their very own minister they can call up when the going gets tough. Not so much it seems for a shoulder to cry on, or a ledge to jump off, but more a political dyno-rod service.  ”Leave it to me caller” says the obliging minister at the other end of an 0800 number, “one of our expert operatives will be with you immediately to clear out the policy blockage standing in your business’ way”.

Noticeably absent from the sectors reportedly to be afforded this privilege are the banks – although Lord Sassoon, a one-time investment banker and now the Treasury’s most junior minister, might play a part – but pharma it seems are very much included.  Their Mr Fixit is to be David Willetts,  the Universities and Science Minister. Not, it will be noted, Andrew Lansley or anyone else from the Department of Health.

Assuming that this idea is any more than the gimmick it first appears, then it is likely to raise once again the hoary old question of who in government “sponsors” Britain’s pharmaceutical and healthcare industries.  Of course, the upstream R&D activities of the life sciences sector are very much aligned to Mr Willetts’ ministerial brief. But what about the commercial downstream? To take an obvious example, if the boss of GSK or AstraZeneca were to call up Willetts on the special line with a beef about value-based pricing, what exactly is it imagined that he will do?  It took the combined weight of the medical establishment, the British media, the Chancellor of the Exchequer and the Liberal Democrats to get Andrew Lansley to listen to sense about his changes to the NHS. Is a middle-ranking minister from a different department going to have much effect when it comes to another of his pet projects?

Civil servants have already started briefing against the so-called government “buddy” initiative – a sure sign that this is one straight from the “what can we say that is new in the party conference speech” school of policy-making.  Any original spark in the idea is set to be smothered beneath a blanket of officialthink. No special privileges. Complementing the existing excellent links between the department and our stakeholders. Part of normal consultative processes. And so on. Even now a departmental lawyer somewhere will be drafting an opinion to the effect that if BP gets hold of something from government not theoretically available to the EzeClean Laundry on Streatham High Street, a case could be brought under the single market regulations, or possibly the convention on human rights.  And I dare say too that officials from the Department of Health’s medicines and pharmacy unit will be thinking of their own ways to keep the dyno-rod people at bay. That, alas, is the mentality at which Whitehall works.

Of course, the Government’s desire to support key industrial sectors, including life sciences and pharma, and to diversify away from over-reliance on financial services, is genuine. The history of these one-stop-shop initiatives, however, is not hopeful and too often the gap between the political will and the official machine is unbridgeable.

 

Andrew Lansley and the PFI

I am not sure that Andrew Lansley’s foray into the media went exactly as planned today.  The Health Secretary, limbering up no doubt for his party conference in 10 days time, came out of the silo with a pre-planned assault on how the on-costs Labour’s PFI programme was beggaring the finances of today’s hard-pressed hospitals. Obliging media outlets like the Spectator duly wrote this up as a story about the “debt legacy” of Gordon Brown.

On the Today programme, however, Mr Lansley had a tougher time.  For one thing, most people can recall that the Merlin magic policy that is PFI was in fact an invention of the Conservatives, first announced in 1992 by then Tory Chancellor Norman Lamont. Then King’s Fund guru John Appleby steadfastedly refused to sign-up to the Lansley proposition that the costs of PFI were the arrant disaster that the Health Secretary says they are. Plenty of hospitals, said Professor Appleby, blessed by having had new bits expensively added to them by the private sector, are living with the financial consequences. And some, which were never so blessed, are in deep financial trouble. In other words, the picture is just a little bit more complex than the headlines might make it appear. Public policy usually is, which always raises in my mind the question as to why we let politicians loose with it.

It was later in the interview though that I thought Mr Lansley really started to wobble. He was asked about the NHS’ efficiency savings target. Wasn’t this just too much – more indeed than any health service had ever been asked to deliver in the history of human civilisation?

Now you might have expected someone who is a member of a government committed to a massive belt-tightening exercise in the public finances to have brushed this suggestion off, with some words to the effect that we are all in this together.  Instead Mr Lansley’s first reaction was to point to the fact that the so-called Nicholson Challenge wasset during the previous government’s time in office. True enough, but the implication seemed to be that if the target is too harsh, this is another thing to blame on Labour. Mr Lansley likes to play the good guy, still splashing the cash.

It is not the first time I have noticed that Mr Lansley seems to be less than a zealot for efficiency savings in the NHS.  Of course the Nicholson Challenge continues, but the Secretary of State rarely seems keen to associate himself with it, or to pose as the ruthless guardian of the public purse.  Indeed, he might have used the whole episode to explain how the Department under his control is going to drill down on the excessive costs of many PFI contracts; not necessarily an easy thing to do, given the way contracts have been written, but then again not something to shrug away with no more than a dig at Labour for being profligate fools.

Some commentators think that Lansley’s outing today is a prelude to a party conference announcement about how he will tackle the financial straitjacket that PFI is for many hospitals.

Perhaps, but I am not holding my breath.  It would be out of character for a Secretary of State who rarely seems to approach the NHS save through the prism of his own elaborate reforms.

 

What is the point of Paul Burstow?

The thought has just occurred to me, reading about the latest – though surely not the last – chapter in the gothic horror story that is the NHS reforms, that there may not be a lot of point to Paul Burstow. This may be monstrously unjust. Mr Burstow is the minister for social services, and there must be a use for the minister of social services even in the most anarchic of societies; but bear with me while I develop the thesis.

Mr Burstow is less importantly defined by his ministerial brief than by his political party. It was part of the coalition deal that every government department – though there are a couple of exceptions – should have a Lib Dem on the team.  In the Department of Health, Burstow is the man.   It is true that social care is the traditional destination of internal exile for DoH ministers, but that doesn’t matter because Burstow had a more important job to do. It was, and is, to deliver political cohesion in matters pertaining to the Department of Health and to ensure that the vision for the coalition worked at the level of day-to-day policy.

This, it is fair to say, hasn’t gone entirely to plan. There are many reasons why the health reforms fell, but the single most important is that the Liberal Democrats couldn’t stomach them. So it is tempting to ask where was Burstow?

Where was Burstow when Andrew Lansley sketched out his plans to abolish PCTs and hand over theirs budgets to consortia of GPs? Where was Burstow when the health secretary was expatiating on the virtues of competition for driving a more efficient health service? Where was Burstow when he talked about creating an economic regulator for the NHS, modelled on the one that was set up when the then Tory government privatised BT?

Of course, it is possible that Mr Burstow was in total ignorance throughout and that the Secretary of State leapt out from a cake one day clutching a copy of his published white paper and shouting “surprise”. But somehow I don’t think so. Mr Lansley does not enjoy the greatest reputation for being a team player, but even he wouldn’t try to revolutionise the NHS (the “r” was only dropped later in a belated act of cover-my-tracksmanship) without mentioning it to his ministerial team.

The safety-valve failed.  If Mr Burstow had been both politically astute and paying attention, then there would have been ample opportunity for him to detect where the reforms were heading for trouble, where they were pricking his liberal conscience, and to flag it up with Nick Clegg. He then could have  resolved the issues quietly with the prime minister, before they became smeared across all the newspapers these last three months.

That this didn’t happen may have been the result of a conspiracy somewhere along the line but, again, I doubt it. It was a cock-up of monumental proportions and, at the risk of sounding churlish, I do hope that when we get to the point of dishing out the massive portions of blame that are coming for the health fiasco, a little bit of it in fairness is kept back for the minister for social services.

 

 

 

 

Dixon to GPs: take to the hills

I see that Michael Dixon, chairman of the NHS Alliance, has taken to the pages of the Guardian today to call for a GP-led insurgency against the attempts of the higher politics to rearrange Mr Lansley’s reforms. Writes Dr Dixon: “delay in the parliamentary progress of the health and social care bill need not mean delay on the ground”.  GPs around the country are, he says, “ready, willing and able” to take over commissioning. Don’t wait around for these foolish and feeble politicians to sort out their differences seems to be his message; just do it.

Dr Dixon appears not to have noticed that there is a very real chance that Parliament will mandate that commissioning should be led not just by GPs but by a broader range of clinical and other interests. The prime minister could not have been clearer in his speech earlier in the week: “our changes will now secure clinically-led commissioning, not just GP commissioning”.  It is widely anticipated that this change will be confirmed as one of the key “improvements” to the reforms when these are formally announced.

If it comes down to a struggle for control of the National Health Service between the prime minister and Dr Dixon, it will be interesting to see which one of them wins, though as Hugh Grant’s prime minister in Love Actually reminded us, the PM is the one with trained killers at the other end of a telephone call. Dr Dixon, an ally of Andrew Lansley, might share the latter’s disdain for politicians poking their noses into how the NHS is run,  but he would find it hard to deny that who gets their hands on looking after £60 billion of taxpayers’ money ought to get the nod to do so from Parliament.

It is easy to see what Dixon is trying to do here. He is trying to orchestrate a fightback for the reforms in their purest, Lansleyite existence, and to defend GP commissioning which has become a piece of collateral damage in the political firefight.  Yet it is a curious way of going about it, trying to imply that the political and legislative process is an irrelevance and that all that matters is facts on the ground. In any case, the facts on the ground are not quite as overwhelming as the NHS Alliance might want us to believe.  All in all, it is another example of the dysfunctional relationship between the NHS and Westminster which is at the heart of so much of its troubles.

 

 

 

 

Cameron fixes it?

According to a “Downing Street source”, quoted by the Conservative blogger Tim Montgomerie, David Cameron should now be regarded as the Secretary of State for Health. The top-down reorganisation of the top-down reorganisation is moving towards its climax.

It is instructive that this should be happening now, fully a week before the expected publication of the report from Professor Steve Field and his NHS Future Forum, set up to oversee the consultation on how the reforms might be improved.  OK, you would have to be a political naif to think so, but surely there is a case for awaiting the report, digesting and debating its content and then deciding how to proceed. This would be the rational, logical and mannered choreography of the “pause”, but it was never going to happen.

On the contrary, Downing Street, sorry the Secretary of State’s office, tells us that they want there to be as little as time as possible between the Future Forum report coming in and the response going out. On that performance measure at least, they are well ahead of target, since it turns out that we are getting the response before we get the report. So much for Andrew Lansley’s desire to detach politicians and politics from how the NHS works.

Not that anyone cares for what Mr Lansley thinks or feels anymore. He has long since been taken out of the driving seat of this process, and now has the status of the embarrassing relative in the back, drooling against the window and flicking V-signs at passing cars. The whole point of Mr Cameron’s “guarantees” speech yesterday, symbolically the first thing he did after coming back from his half-term break, was to proclaim that he is in charge. It is David Cameron’s agenda, not Nick Clegg’s and certainly not Andrew Lansley’s, that we are working to.

The only thing that matters to the prime minister is to have his Downing Street pollsters tell him that the NHS isn’t a political problem for his party any more. Cameron is smart enough to know that the Conservative Party will never actually win an election on health. He does though understand its capacity to stop them winning, and that is what he wants to avoid.  That is why his speech yesterday read much more like the utterings of a campaign politician on the stump than something an actual Secretary of State for Health might say. Mr Cameron is all about promises and pledges. The rest is detail.

Frustrating as it might be for the poor bloody infantry, the prime minister is not overly bothered about what that detail might be, so long as he believes it would play well with the punters. This was someone, remember, who once inadvertently revealed his disdain for the nuts and bolts of healthcare when he characterised Lansley as somebody who “spoke fluent NHS”.

So we are going to have broader-based commissioning groups instead of GP commissioning. I dare say Mr Cameron would be happy for commissioning to be carried out by a broad coalition of the boy scouts and heating engineers if he thought it would calm people down. Monitor, the threatened “economic regulator” will be charged with promoting “integration” and (even more meaninglessly) “the interests of patients” rather than competition. Contrary to what his political opponents might want us to believe, Mr Cameron is no free-market ideologue: if competition is too nasty, let it go. We are going to have (or try to have at least) low waiting times. Very popular, low waiting times.

The prime minister does, of course, also need to keep his Liberal Democrat allies sweet. They, after all, are the whole reason the health reforms are in such a political mess in the first place. It is often forgotten that, until the Libs started to cut up rough in March, the health bill was enjoying a relatively event-free passage through parliament.

Fortunately for Mr Cameron, his coalition partners are reasonably easily satisfied. They just want to be able to say that they “won” over the health reforms, and it was never very difficult to spot areas (such as the castration of competition) where victory could be accorded. The Tory right will moan, of course, but their problem is with the Lib Dems, not with the health reforms per se, and their ire will soon enough alight upon a different set of grievances. This is a long-term political problem for Mr Cameron, but it is not fundamentally about the NHS.

Even so, there are plenty of reasons for thinking that the prime minister is too optimistic in believing that his political fix will sort things out. Once the reforms are reformed, watch how those friends of GP commissioning, of competition, of the 2013 deadline, curiously muted in the debate so far, will come to the fore. The media will love it.  Watch too for a glut of stories about the administrative chaos and waste involved in marching the NHS first in one direction and then in another. Anything, anywhere going wrong in the health service can, and will, be blamed on the fickleness and incompetence of government policy. Always happens.

Above all, let us not forget that with NHS inflation galloping ahead and George Osborne determined to keep to his deficit-reduction plans, the NHS is still, and will be for years to come, needing to make savings and cuts unprecedented in its history. All that, and lower waiting times. Should be fun.

The former Secretary of State for Health, Mr Lansley – thus annointed by a Downing Street source and surely officially confirmed as such before much longer – wrote in the Daily Telegraph a week or so back that the implementation of the reforms was vital to enable the NHS to overcome its funding crisis. There seems little evidence that the prime minister understands them in these terms. And if only Mr Lansley himself had been a bit more convincing from the start in showing how and why his ideas would help, perhaps he would have been in a stronger position to face down the political storm when it arrived.