An interesting (to me, but I hope to others) question is exactly why there has been so much opposition to the NHS reforms. When I ask this I don’t mean in terms of their content, which seems to me to be entirely unworkable. What I want to ask is why are we complaining now, when most of the things Lansley wants to are continuations of what Labour were doing in the 2000s. Let’s consider the most contentious elements of the reform package, which we might take to be competition, the pace of reform, the delegation of budgets to GP consortia, problems with accountability, and the dangers of services becoming fragmented. I’ll deal with each (briefly) in turn.
Competition isn’t new. We tried to introduce it between public providers in the 1990s, but it didn’t work out because of the lack of alternative providers of any particular service, but also because GPs didn’t refer to new providers and patients wanted to stay local. We extended competition in the 2000s by allowing private provision in, but it’s still small – less than 5% in the areas where it has made the most impact. The present bill wants to expand private provision, but complaining now seems to be odd – wasn’t the time to complain in the 2000s when private providers were subsidised into the marketplace? It might be that we are reaching some kind of tipping point now, but that isn’t the way the debate is being conducted – it’s as if non-public providers have never been in the NHS before. That simply isn’t the case.
The pace of reform is certainly pretty alarming, especially as we don’t have a final Bill yet. But when did NHS reform proceed at a leisurely pace (post 1970s anyway)? Governments want to get things done quickly – they are working on short political cycles and want reforms in place so that they aren’t still being implemented during elections. So no real surprise here.
The delegation of budgets to GPs is striking, but again, hardly new (remember GP fundholding and practice-based commissioning?). The innovative bit was to (initially) not allow any other commissioning form, but that’s entirely gone now with what looks like an increasingly big bureaucracy developing around GP consortia and the National Commissioning Board. And PCTS used to have over 80% of the NHS’s budget, so it’s not like we haven’t delegated budgets before.
Accountability problems in the new structures are everywhere. It’s not clear how anyone is going to hold any particular NHS body responsible (to me at least). It’s a mess. However, it’s always been a mess. The NHS has always been terrible at complaints (look at Judith Allsop’s work) and trying to hold local health providers to account has never been easy. This isn’t an excuse for the NHS’s lack of accountability, but I don’t think the new structures are much of a change here really.
Service fragmentation is an issue that the reforms raise because of the increased use of an increased number of providers. But again, we’ve had a marketplace spanning public, private and not-for-profit providers for some time now, so this is an expansion rather than a new thing. Equally, we can’t really say that the boundaries between health and social care have ever been particularly well dealt with, even when entirely in public hands. So yes, maybe a small change, but hardly one to warrant the level of complaint and protest that we’ve seen.
So in sum, what we are seeing is a continuation of what Labour did in the 2000s rather than anything new. Why are we getting so vexed?
Now I’m genuinely interested in thoughts on this, as I’m going to try and write about it in my academic life, so please leave comments. But here’s a few initial thoughts.
Are we cross because it is the Conservatives reforming the NHS and not Labour? If you accept my argument that most of what is involved in these reforms is not new, then is it because it is the Conservatives suggesting market-based reform that makes us upset? I think there are two parts to this.
We might object to Conservatives proposing reforms that we’ve not criticised under Labour because we believe that they are being conducted in bad faith in some way – that they are meant to lead to privatisation or to undermine the NHS in some other way. So we trust Labour more with NHS reform than the Conservatives, even if they are proposing many of the same ideas.
Objecting now might also be due to the frankly awful way the reforms have been handled, so that the initial White Paper was all rather secretive until it appeared – contrast that with the NHS Plan of 2000 which came with a raft of medical signatures on its front. Then the Bill seemed to go further than the White Paper in terms of competition meaning that it looked more radical and perhaps we all felt misled.
Now please let me make myself clear – I really don’t think reforms based around competition can work in the NHS whether they are being introduced by Labour or the Conservatives, and have written along those lines for nearly ten years now. But I do want to ask why we didn’t get angry about this in the 2000s in the way that we are now?
Ian Greener's Academic Blog 
August 12, 2011 at 9:10 am |
In my innocence I believed that politics was about issues, but have since realised that predominantly it is about politics, which means that issues are merely a stick with which to beat the opposition. There has been deep and widespread unease about the NHS privatisation for years, Health Emergency has been going for 25 years and KONP for several years. I’ve been campaigning since 2008. I agree that its much easier for campaigners to mobilise support when there is an identifiable opposition (the Tories) rather than a an ideology (neoliberlism) As far as the NHS is concerned I still don’t think there is a fag paper’s worth of difference between the parties. I suspect that’s because Labour still intend to finish the project they started.
August 12, 2011 at 9:04 pm |
I think much of what Lansley put into the white paper had already been announced in a collection of Conservative policy documents, in particular the Autonomy and Accountability paper.
The anger is two-fold. First, the NHS was *not* an issue at the election. Although it was clear to anyone who could be bothered to read the manifesto and policy documents that Lansley intended *huge* changes, the Press did not put him on the spot. Whenever the Conservatives were pressed (*I* put a question to Cameron on a Radio 4 phone in) the replies were always generic platitudes. It has been said that Coulson told Cameron not to talk about the NHS, and this has lead to the widely held opinion that the Conservatives did not tell us about the changes they wanted to make. (On a more personal level, at a public meeting I asked a series of detailed questions about their NHS policy to the Conservative candidate in my area – now elected, and a whip – and he was totally clueless about their policy. I genuinely think most Conservative MPs were surprised when the white paper was published because they simply thought that a Conservative government would run the NHS *better*, not tear it apart.)
The second issue is the incompetence and the cackhandedness of the reform. I think that Lansley felt that there should be a free market and wanted to be totally hands-off. His policy has been mangled over the last 13 months, so it no longer looks like his original plan.
One simple example: GP consortia. Lansley refused to give any guidance on the size, legal status, or geographical local of consortia. Studies in Europe and the US of commissioning groups could have been used, but Lansley refused, preferring a free market. First the Treasury insisted that consortia must have an accountable officer, then months later DH confirmed that consortia must be statutory bodies. Then the Future Forum pressed for them to be NHS and locality branded, and have co-terminosity with LA boundaries. In the last few days we have seen leaked DH documents saying that the size and shape of CCGs will be taken into account when they are registered (the rumour being that they must cover a population of at least 50k).
The CCGs are very different from what Lansley intended and this has come about not through consultation or through an evidence based study, but through adversarial threats.
The public has seen this car crash developing from the start of the year. Rather than reform the NHS – carefully sculpting it with a trowel and mortar, Lansley is seen by the public as knocking bits off it with a lump hammer.
When Lansley announced the pause he said that he could have made his changes without a bill. Nick Timmins of the FT reported that in response Dorrell mouthed “so why didn’t you?”. if Lansley hadn’t pushed the huge, unwieldy bill through Parliament he could have had his free market up and running now. Obfuscation before the election and lack of obfuscation after: these are the reasons why no one trusts the Conservatives with the NHS.
August 13, 2011 at 7:56 am |
Thanks Richard. I agree with both the points you raise. I wonder if your first point (Conservatives not telling us about extent of reform) was conspiracy or cock-up? My money tends to be on the latter – Lansley is a friend of Cameron’s and I wonder if he was just left to get on with things until it was too late?
August 14, 2011 at 4:19 pm |
Why did we not complain before? I think that a great number of NHS workers did not complain because it is not at all clear who to complain to, and there has not been a focus of complaint. (On the whole, there is precious little debate, analysis, collective action; lots of dissatisfaction, grumbling, but this is not usefully channeled).
The fact that there is a new government and a White Paper and then a Bill, this provides something to react to. And the fact that some sort of critical mass has begun protesting, this has perhaps galvanised others. New Labour just introduced things by stealth, a few things at a time, with the words ‘Reform’ or ‘Modernisation’ attached. Not enough to galvanise horror. I suppose we might have been worse off if Labour had stayed in power, then would have just continued on the same trajectory. See George Monbiot’s comment in relation to The Plot Against the NHS http://bit.ly/iZv9ZX : ‘The difference between David Cameron and Tony Blair is that Blair was better at disguising his intentions.’
August 14, 2011 at 5:12 pm |
I think that’s exactly right George. Thanks for the link to Monbiot – hadn’t seen it. Fascinating (from a political perspective) about the moments that we find time to reflect on what’s going on rather than going along with it. I tend to be angry with the Royal Colleges, BMA and RCN who should have been savvy enough to see the direction of travel by the mid-2000s…..or was it that the first two groups were bought of by pay settlements……?