The NHS Bill is a dog’s dinner but we may be stuck with making the best of it

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.

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5 Responses to “The NHS Bill is a dog’s dinner but we may be stuck with making the best of it”

  1. Dr. Carolyn John Says:

    Still early days in dismantling infrastructure so I think have aato stem this ASAP and focus on killing the bill to prevent the venture capitalists getting a foot in the door which wld b much hardesr to reverse. Once bill rejected we can then focus on rebuilding PCT’s with wider GP and other health providers’ representation to end up with a more robust and publicly owned NHS.

  2. Ian Greener Says:

    Thanks Carolyn, I’m glad you think there might be potential to rebuild. My worry is that the PCTs and SHAs I speak to have already lost loads of staff, with the latter including redundancies, and many are being encouraged to set up social enterprises. Buildings are being sold and leases not renewed. I agree entirely we should try and stop the Bill, But not sure what we do then…..some serious reconstruction thinking needed.

    • Dr. Carolyn John Says:

      I agree need the best minds on this one. Does anyone know the law arounding tryng to sue the Govt for the redundancy monies as a first step? Seems unprecedented that directives to dismantle encted before bill becomes law…..? Might be a useful marker for public and professional standpoint on this issue?

  3. Carl May Says:

    Good post Ian – I think this is exactly the dilemma that many of us face. But here’s the thing: you could actually be describing the structures that were put together to implement the National Programme for IT in the NHS back at the beginning of the 2000s. That did turn into a train wreck, despite the efforts of many very talented NHS managers, clinicians, and IT professionals. It also did immense damage to some of the IT companies involved in trying to meet those contracts. What looked like a great deal at the outset gradually decayed into a morass for both taxpayers and shareholders, because the State maintained a rigid (but arms length) control over the governance of contacts and the delivery processes themselves. Similar things have happened in other public sector domains (HMRC, DWP, Prisons/Criminal Justice etc). There’s no reason to suppose that they will not happen again – and you describe the practical reasons why.

    The question is, why do these problems in service delivery continue to come around, and why are they so similar when they do? Why do both of the main political parties suffer from them? Simple lack of experience may be part of the answer – it’s very unusual now for a senior politician to have had real experience of strategic management in a large organization. Stephen Dorrell, who had been MD of a large retail company before becoming a minister, may well have been the last Secretary of State for Health who had that kind of life experience. His brief tenure was marked by a signal lack of grandiose projects and by a sensible and cautious approach to policy delivery.

  4. Ian Greener Says:

    Thanks Carl. I agree about IT. I think the difference this time around is that the changes may be irreversible – once we have extended the role of the private sector it will be very different to go back on it. It is possible still to pull the IT plug, what what do we do when 10-15% of NHS provision is from private companies who will fight any kind of public-style accountability every step of the way?

    Your second question is a key one. No SoS for Health has ever gone on to be PM (Ken Clarke arguably came closest) – if we love the NHS so much makes you wonder why it’s usually the dead-end for political careers. Mix of hubris and overambition in believing that there is some kind of technical fix to the NHS?

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