Filed Under (Conservative party, Health Policy, Labour Party, Reform of the NHS) by Paul on 31-03-2014
There have been some interesting responses to this month’s posts. It’s encouraged me to think about perhaps resuming for a month in the autumn and then again in March 2015. It’s been especially interesting over the last week to gauge people’s response to my attempts to challenge the gloom being spread about the pressure on the NHS by too many of NHS leaders.
In this last post for the moment, I want to try and think through how the current political leadership – that which might be in charge of the NHS in the period after the May 2015 election – can help make the necessary transformation.
And in thinking through the possibilities I want to introduce the fact that from tomorrow there is a new CEO of NHS England – Simon Stevens. Between 2001 and 2004 he was a close colleague of mine, and is a friend, so I wish him well. But too much expectation is being placed on the ability of one person to make everything happen. He can and will achieve a great deal – but no-one can do this on their own.
When Pete Seeger died in January one of the many brilliant sayings that were attributed to him was, “Be wary of great leaders and hope that there are many many small leaders”. To succeed Simon will need many many small leaders.
And I don’t know about you but it seemed to me that there was something really odd in what his predecessor David Nicholson said in an interview last week. He said he would give NHS England “5 out of 10”. Given that he ran the transition body that set up the organisation, was responsible for the hubristic change of name to NHS England, and then ran it throughout its life one wonders, if the organisation is not very good, just why is that?
But the rest of this post concerns the interaction between political leadership and the NHS.
There is near universal agreement between the two major political parties who will either form the next Government alone or will form the larger part of any coalition. (Incidentally we don’t yet have UKIP’s NHS policy but I’m sure that if you visit any Home Counties’ saloon bar on a Sunday lunchtime you will hear it there first).
Both the Conservative and Labour parties agree that:-
- There will be standstill funding. Money won’t go up, but it won’t go down either. (But by 2020, even if the money is still the same for the NHS, most other areas of public expenditure will go down so the proportion of public expenditure being spent on the NHS will rise considerably).
- There will be no new structural reorganisation. (phew!)
- There will be many more older people with co-morbidities who will need different and better care than they are getting at the moment.
- There need to be many fewer emergency admissions.
- There needs to be a rapid development of integrated health and social care.
- This new model of care will have a radical impact upon the existing models of health and social care.
They also know that these changes need to happen quickly, need to happen across the whole of England, and that given the rise in demand they will need to reduce the amount of money spent on each patient.
Now of course we don’t know what the manifestos will bring but at the moment, given the pledge that there will be no more top down reorganisations, the levers that are available to bring about these radical changes are limited to what they have to hand at the moment.
The problem with this is that none of the political parties really agree with the current organisation of the NHS and the existing levers for change and so none are at all happy with what they have to hand.
Let’s start with the Conservatives. We know that the current Conservative Secretary of State Jeremy Hunt voted for the Health and Social Care Act on many occasions and supported the reforms in Cabinet. He was lucky enough to be in the job of Secretary of State when all the reforms he had consistently supported came into effect. Few politicians enjoy such a luxury.
But, as we know, a curious thing happened during the time between the passage of the Bill and his having the opportunity to enact the reforms.
Over the intervening year he came to disagree with the central idea of his legislation, that the NHS should be run by a series of arm’s length bodies – separated from the Secretary of State.
Instead of following the core principle of the reforms – to liberate the NHS from Whitehall – he instead runs the NHS from his office (in, er, Whitehall). Most of the time he ignores the legislation he supported (and, it might be said, much of a decade of earlier legislation.)
You would have to spend a long time searching through his speeches to find any reference to the changes that he wants being made by the actions of the 211 clinical commissioning groups that his legislation established.
Let’s look at an example of what he might do if he believed in the legislation for which he voted.
A few weeks ago the Times uncovered the fact that over 150,000 older patients are moved around our hospitals in the middle of the night. If he used the powers in the legislation that he voted for, he would read the Times and think hard about changing next year’s mandate to NHS England to cover this issue. He would in turn talk about how CCGs should commission care from hospitals that did not involve such nocturnal movement of older patients.
Instead the anxiety that the Times headline immediately raises in him leads him to try and ensure the NHS acts differently. Since he won’t do that by using the levers his reforms gave him, he has to resort to shouting at the NHS as loudly as possible.
And this will be the problem for the NHS if the Conservatives are in charge of making the changes to bring about integrated care from 2015-2020. Since they don’t believe in the purchaser/provider split that is the keystone of their legislation, they have no other levers available to bring about these radical changes.
What they have instead is the traditional activity of shouting at the NHS to “just do it!”. Since the NHS knows that if, a week later, there is bad publicity coming from trying to create integrated care at pace, it is likely to be shouted at to do the reverse, there is little likelihood of reform taking place at the scale and pace that is necessary.
Labour of course has yet to outline the detail of its policy. But in the last month the leader of the Labour Party and the Secretary of State have both agreed that there will be no top down reorganisation of the NHS. That good news means that the levers for change contained in the current system are the only ones that will be available to a Labour Government in May 2015.
Which in turn means that commissioning at a national and local level will be the levers to bring about the move towards the integrated care outlined above. Yet the Shadow Secretary of State has made clear that the last thing he want commissioners to have at their disposal is competition. He wants to grant the existing NHS suppliers a monopoly of what health care is supplied and who supplies it.
He will therefore be asking the NHS to carry out very different integrated health and care but taking away any ability that commissioners have to challenge the monopoly of existing institutions. This reduces commissioning to an allocation mechanism with commissioners simply handing out money to existing NHS providers.
If this were to remain Labour Party policy after the next election, they too will have no levers to bring about integrated care except for the time honoured method of shouting at the NHS.
So, a year away from the next election, this is the problem.
- We have unanimity about where the 2 main political parties think they want the NHS to get to.
- We have agreement that there will not be a reorganisation to give the Secretary of State new levers
- We have agreement that the current levers aren’t one they want to use.
- They have no way of getting the NHS to move to where they want it to go.
Over the next year this may change.
I’m hoping that it has by the time I start blogging again.