I practically cut my academic teeth reading Chris Ham’s wonderful work, but I was a little confused by his piece in today’s Guardian (http://www.guardian.co.uk/commentisfree/2012/jan/27/polarised-debate-nhs-bill?CMP=twt_gu) calling for people to move on from opposing the NHS Bill, and instead to find ways of implementing it as well as possible. I’m afraid I think he’s wrong.
I’ve argued elsewhere in this blog that we may be stuck with the Bill – but that’s not at all the same thing as moving on from the debate, or from working out the best way forward. Before I work through that muddle however, I want to look at Ham’s argument more closely.
Ham starts by saying what a mess the government has got itself into over the NHS, and that it has made a major strategic error in putting in place a lengthy and complex piece of legislation rather than an evolutionary change. He suggests, however, that critics of the Bill are mistaken in claiming that the Bill heralds the end of the NHS ‘as we know it’.
He goes on to claim that competition can bring benefits in elective care ‘where may patients welcome the opportunity to choose which hospital to use’, but also notes the need for integrated care for older people and those with long-term conditions, which require closer working between GPs and hospitals, and between health and social care.
Ham then says that there should not be a complete halt to change because of the financial pressures on the NHS, and so it is time to move on and ‘focus on what really matters to patients’, which he takes to be maintaining the quality of services in the face of the £20bn in productivity requirements required. This will mean it will be difficult to hold onto already established gains, and that there is a danger, especially as we cut managerial posts, of us having major organisational failures such as those at Mid-Staffordshire.
He concludes that the ‘time for grandstanding about the bill has passed’ and that the challenge now is ‘to carve out a path to implementing the reforms that beings about necessary improvements in patient care at a realistic pace’ and that if ‘this means modifying the direction and speed of change in response to legitimate concerns, then it will be a small price to pay to deliver an outcome that is good for patients’
So, to summarise – the government have made a significant error in proceeding with the reforms in ‘big bang’ legislative fashion (as Rudolf Klein once described this kind of effort), and that they risk causing problems with respect to integrated care (even if competition in elective care will improve things). However, the productivity savings required risk causing organisational failures, and the gains of the last few years risk being lost, so we must get on with trying to prevent this from happening.
What is odd is that Ham’s article is almost entirely negative about the reforms – he talks them being introduced terribly through cumbersome legislation, about dangers to integrated care, productivity savings (let’s stop calling them that shall we – they are cuts) leading an increased risk of organisational failings. The one thing he is positive about is patient choice – and if you look at the entries here you’ll see I think that is a mistake as well (I’m not alone in this – Steve Harrison, who is far cleverer than me agrees http://www.sochealth.co.uk/news/7fallacies.html)
So if Ham is so negative, why should we get on with it? Well there’s an argument for saying we need to accept the reforms because otherwise patients will suffer. But that supposes that clinicians will behave less professionally if they get reforms they don’t like. I don’t think that is the case – but I do think that the reforms risk making their jobs a great deal harder. Why ask GPs to commission services when they are trained to look after people – that’s like asking airline pilots to buy aeroplanes – it makes superficial sense but not with much scrutiny. We are presently throwing out all the expertise we’ve acquired about commissioning services as PCT staff are made redundant or find their views less valued than those of consultancy firms who know less than nothing of value about the realities of buying care services.
Ham is right in saying that we need to make improvements to the Bill, but perhaps the right time to do that is before it becomes law rather than trying to implement really crap legislation (take a look at the nonsense of the failure regime, for example, if you think that word is too strong) now. We need to oppose this Bill to have any chance of making the government see sense.
The more noise we make now, the greater the scope we have of pointing to the government and holding accountable for the mess it makes later on.
Finally, I think Ham is wrong in saying that this is just one example, over the years, where scaremongers have pointed to the imminent demise of the NHS, and so we should not take this seriously. This time is different – the increased role of the private sector is unprecedented, and probably irreversible. The scale of involvement planned will undermine publicly provided healthcare right into the future – with potentially dire consequences as I’ve written elsewhere in this blog. We are playing for much higher stakes this time.
So I’m sorry, but I think Chris Ham is wrong. I will continue to admire his work, but in this case I think he’s making a considerable error.