The 11 page Government document published yesterday Government Changes in Response to the Future Forum does contain a considerable set of changes to the Government reform programme. This is a genuine reform of the reforms.
Going through each paragraph, most of them contain significant amendments to last Julyâ€™s White Paper and will require extensive changes to the Bill. (This is why the Government is correct to ensure that the Bill has to go through the Commons Committee stage again. You canâ€™t politically say that the Bill is being radically changed and at the same time procedurally say that it doesnâ€™t need a completely new Commons Committee stage)
But what I am unclear about is where this leaves the NHS reform programme. The Future Forum was asked to think through a set of reforms to the original reforms. It was not, nor should it be, their responsibility to ensure that the entire package of reformed reforms is coherent.
But that is the problem for the Government.
I think there are threeÂ problems that are likely to emerge.
First, nearly all of the amendments to the original proposals are a softening of those proposals. I can understand politically why this was necessary to get the reforms through not only Parliament but also â€˜throughâ€™ the NHS. For the last few months however we have been told that the strength of the original programme was necessary to achieve significant improvements in value for money within the NHS. Commissioning for example, was being strengthened by putting GPs in charge…
But using that example, every additional check and balance on GP commissioners will limit the effectiveness of GP Commissioning in creating value for money and bringing about strategic change.
Most commissioners, for example, want to restrict the number of emergency admissions into hospital. Commissioners have wanted to do this for the last 5 years or so but few have managed to achieve it.
Two of yesterdayâ€™s new checks on GP commissioning power will limit their capacity to reduce hospital admissions. First, having a hospital doctor on their board will not make it easier to lower the number of hospital admissions. Second, since GP Commissioners now have to have their plans agreed by the local authority Health and Wellbeing Board, the likelihood of moving care away from a politically iconic hospital will diminish.
At the very least this will make it harder to implement the very changes that the Government have identified that the NHS needs.
The second problem with the new reform programme is that there are now two very different authorial voices creating this single reform programme and the Bill. The phrase â€œauthorial voiceâ€ is one that novelists use â€“ it lets readers know who is telling the story. If you have a strong authorial voice the story, characters and dialogue all fit together. If you have two different voices, especially if the second has been introduced to criticise the first, it can lead to much greater incoherence.
And that will become clear for the reform programme as it progresses. There are very different ideas here that will clash and murmur against each other.
The third problem is the completely new idea that has become important to the new reform of the reforms – the integrated care programme. The Government are right to single this out since their problem is not a general increase in demand for health care but a very specific increase in the numbers of people with long term conditions. They are right in believing that we need integrated care to provide a new and more â€œjoined upâ€ approach.
Whilst nearly everyone agrees with this view, there are very very different ways of bringing about such integration. There are those who believe that it is this new idea about competition that is preventing the NHS from collaborating in building integrated pathways. Then there are those who believe that without competition the NHS has failed to collaborate to create integrated pathways – and that we need competition to bring it about.
If integration is as important as it seems to be (and it is) then sorting out this difficulty must also be important.
Sundayâ€™s Andrew Marr programme contained the best public discussion I have heard about this issue so far – between Clare Gerada of the Royal College of GPs and Stephen Dorrell, Chair of the Select Committee on Health. I will post about this tomorrow.