The NHS reforms and the responsibilities of the Secretary of State for Health

It became apparent over the weekend that the legal responsibility of the Secretary of State for the NHS is going to be removed as a consequence of the ‘hands off’ clause within the Bill (http://www.guardian.co.uk/society/2011/aug/29/nhs-bill-lansley-wash-hands?CMP=twt_gu).

The logic goes like this. Lansley is passing commissioning down to groups, and so for them to have autonomy and be responsive to local need, they need to be free from interference from the SoS. Now, if you buy the logic of the reforms, based on trying to achieve bottom-up improvement through more localised commissioning of services and of greater choice and competition within those contracts, then this makes a great deal of sense. If you are going to put in place a competitive marketplace, you don’t want the SoS intervening all the time messing things up, do you? That would distort the market, putting political expediency ahead of market need.

The problem is, of course, that there’s no market for healthcare in any meaningful sense, and the coalition no longer are proposing a decentred, bottom-up market led health service, but a monstrosity that combines the worst elements of private involvement and a huge number of new QUANGOs. The market based elements of the reforms were never going to work because they are based on unrealistic views of how markets do (or don’t) work. This is a market in which neither patients nor GPs know how to choose, where outcomes data isn’t easily summarisable to make care decisions, and where there is no price comparison. A strange market indeed.

Equally, the expansion of the NHS Commissioning Board and the creation of the additional QUANGOs in the compromises the government has made around the Bill, mean that we don’t even have a dysfunctional market to look to anymore – we also have an incoherent bureaucracy.

So we have gone from a situation where we have an dysfunctional market to one where we have a incoherent bureaucracy on top of a dysfunctional market. I have no idea which is better or worse. Both are pretty awful – if the NHS is going to remain on track it is going to depend on the good will of the clinicians, managers and other workers that remain within it. If any improvements occur, it will be despite the reforms, not because of them.

What we need at a time when the reforms looking like they could turn into a train wreck, is for someone to take responsibility for them. And at exactly that time, it looks like Lansley, in the name of market freedom, has written himself out. Presumably he’s done this so that, once the extent of the mess emerges, he won’t have to take responsibility for it, blaming it on the Commissioning Groups and the Commissioning Board, and demanding bottom-up change.

But if you create an incoherent institutional structure, you have to take responsibility for it. It seems crucial that Lansely is not allowed to get away with blaming others when his reforms throw up the problems that his reforms have created.