The problem with the government’s attempts to make the NHS Bill more acceptable is that it has gone from being an ideologically-driven mistake to an incoherent ideologically-driven mistake.
I could understand what the first version of the Bill was trying to achieve. I thought it was a huge mistake, but could understand it on its own terms. Provided you are coming from a place where competition is always good, and GPs and patients are able to drive improvements in health services through their treatment decisions, it makes a kind of sense. As I’ve made clear frequently in this blog, I don’t think any of those assumptions actually hold any water, but they do make a kind of sense if you go through the Bill with them in mind.
The first version of the Bill, of course, also makes a great deal of sense if you read it as an attempt to increase private involvement in the NHS. Now that’s not new, if you read Norman Warner’s ‘A Suitable Case for Treatment’ or Player and Leys’ ‘The Plot Against the NHS’ or Pollock’s ‘NHS Plc’ you can see that this sort of thing has been going on for a while now. But I think we get more suspicious when the funders and friends of the governing party appear to have quite so much to potentially gain from such reforms.
However, by modifying and amending the Bill, it has changed from being unfeasible because it makes assumptions about competition and choice that will never work, to unworkable because it imposes a bureaucracy over the top of competition into a mess. What they’ve done is taken a model that isn’t likely to work and added layers of top-down control that make sure it won’t. The whole idea of competition and choice was meant to take the NHS out of the control of the centre, and to generate self-improvement within the system. What the new plans have done is to add a strong element of central control over this through the national commissioning board and its outposts, while still trying to impose competition on local health areas through Monitor’s new role (which is still ambiguous to say the least).
So what we’ve done is take an ideologically-inspired model that won’t work and wreck it – a dog’s dinner. So should we drop the Bill?
I think there’s a problem with getting the Bill removed – in what seems to me to be gross breach of democracy. This comes from the government effectively implementing their reforms before they had been fully agreed by Parliament. Circulars were sent from the DH actively encouraging NHS bodies to proceed as if the reforms are going ahead. All over the country PCTs and SHAs are losing staff, selling buildings, and not renewing leases. What this means is that we are stuck with some kind of reform, even if we would seek to oppose the Bill and get it dropped as being bad.
So what do we do? Seems to me that we have a choice of watching while the whole thing goes down or trying to get involved and help. GPs will have to decide whether they are going to be in commissioning groups, and then how involved they are going to be. I’m probably going to be trying to help public commissioning support organisations (former PCT staff) in the North East. So I’m trying to make work reforms that I think are entirely the wrong thing to do. I don’t see what else I can do. To mix a metaphor badly, those of us that care about the NHS are put in a position where we try and stop a dog’s dinner turning into a train wreck.
If we get the Bill dropped now, I’m not sure what we have left in terms of the current infrastructure. If we don’t, then we need to all do our best to stop the whole system falling to pieces. We all have difficult decisions before us.