The NHS bill as a failure of democracy

My overwhelming feeling about the NHS bill now is how it represents a comprehensive failure of democracy.

We didn’t vote for either the Conservatives or the Lib Dems to reorganise the NHS in this way. It wasn’t in their manifestos, and this wasn’t a part of the 2010 election debate or even the coalition agreement. There is no democratic mandate for this reorganisation.

The government have still failed to tell us what the reorganisation is for. They present claims about making the NHS less bureaucratic, but this simply isn’t the case – the bureaucracy that has built up around commissioning is now far greater than that of the PCTs. Equally, GPs won’t be in charge of commissioning as they will be heavily controlled because of the bureaucracy I’ve just mentioned, but also because they will be increasingly outsourcing their commissioning to private companies – why ask a highly-paid and highly-trained GP to make these decisions? Their skills and expertise lie elsewhere. Finally, there are arguments about making the NHS sustainable into the future. I have no idea how this bill does that. I would argue that the NHS has for the vast majority of its history, been relative to any comparative country’s healthcare, been starved of resources. We have only just now got up to about the OECD average spend on healthcare. If there is a healthcare spending crisis, then other countries have a much bigger problem, and that actually we have some years of under-investment to catch up on first. In sum, there has been no sensible reason given for this reorganisation – the government are not being open and clear about their motives.

Third, the bill has now been amended so many times that confusion reigns about what is in it, and what not. In the last couple of days there have been angry exchanges in the media between Polly Toynbee and Shirley Williams about private patient caps. The question this raises for me is that, when you get to a point where serious figures actually disagree what is even in the bill because it has been so amended (well over 1,000 changes and counting), then you have failed to go through a democratic system of making a bill law. The bill is a mess, an undemocratic mess. The bill as it is now is very different from the bill that the commons originally voted on. I don’t doubt it would get through a commons vote again as the Lib Dems don’t seem to have grasped how the bill, in my view (and other’s) has the potential to transform English healthcare, but it should be voted on again as it is now so different. And if legislation can be changed this much through amendment, it no longer carries any legitimacy.

Then we had the nonsense this weekend at the Liberal Democrat conference, where one of the political parties in the coalition government voted against offering its delegates the right to vote against the bill in favour of a motion supporting it, and then voted against the motion asking Liberal Democrats in the Lords to vote in favour of the bill. Is this really the best they can do? It seems to me that the Liberal Democrats have lost any right to be taken seriously on this issue – it is too important to be this obfuscatory and weak, hiding behind your own nebulous bureaucracy rather than allowing an open discussion and free vote on something that clearly matters a great deal to your party.

The next point is the farce of the risk register. The last time we got into such a mess over releasing information was over Iraq under the Blair government. There seem to me to be few grounds for not making the register public, but the government have repeatedly refused, even in the face of the information commissioner demanding it be published. Now I don’t know what’s in the risk register, but had it just been made a public document last year we’d all be better informed. Surely that’s what democracy is meant to be about?

Next there are confusions over the research evidence base of the bill. John Rentoul, for example, in the Independent, keeps presenting the LSE research on competition which supports competition as straight fact when it is rather contested. This isn’t just my view (or Allyson Pollock’s). Bevan and Skellern reviewed this work in the BMJ last year and found significant gaps in it. To present this work as ‘proving’ competition works is premature, and even if you do still believe the work shows competition works, rather ironically, it actually shows Labour’s policies of the 2000s work, not that the NHS bill will work.

Then there are confusions over the implications of the bill. Allyson Pollock and her co-authors have argued it provides a basis for charging (or at least doesn’t preclude it). Others are more skeptical about this. But again, the problem here is that these matters haven’t been openly and democratically discussed – we are stuck with a heavily amended bill that makes little sense and which is no longer coherent. It is hard to debate a 450 page bill amended over 1,000 times which simply has not been adequately scrutinised in its current form.

We also have a distinctive democratic gap in terms of support for the bill. Opinion polls suggest the public don’t support it, and we know that just about every clinical representative group (with the exception of the Royal College of Surgeons and a couple of very small bodies) have now called for its withdrawal. This despite both Cameron and Lansley claiming until relatively recently that the bill had the support of those working in the NHS.

The NHS bill does not represent informed, evidence-based policymaking. The bill is now so amended it is a mess, and it puts in place a range of competitive dynamics and private commissioning support which may be irreversible, and over which we may have little democratic control in the future – I see huge problems over claims of commercial confidentiality, as we have had with PFIs.

The NHS bill represents a failure of democracy.


4 Responses to “The NHS bill as a failure of democracy”

  1. Dave Neary (@DaveNeary1) Says:

    I can’t think of a Bill that has gone through Parliament in such a fashion in post-war British politics,,,maybe Nick Timmins or another historian of the welfare state could think of a parallel but I can’t. This may be a product of coalltion politics but I don’t think so, I think it really is a case of this being Lansley’s Bill with Cameron trusting his former boss and Clegg not really grasping it. It would certainly make a fascinating case study in the policy making process with plenty of lessons on how not to do the politics of health care reform.

    A while ago I looked at Conservative plans for the NHS when they were in opposition and you could see a developing line of thought that has lead to this Bill. However, I really think the most important factor is that Lansley has been on the front bench with the health brief for so long that he almost felt compelled to get this major re-organisation on the statute book rather than being a Secretary of State who managed the NHS during a period of constraint. The fact that this Bill lacks democratic and political legitimacy doesn’t seem to matter to coalition politics at the moment because both partners are probably reluctant to break the pact.

    The role of evidence certainly seem to be quite peripheral to this policy process – ideology has been far more important with Lansley as the key individual with Simon Burns at his side in DH – and I’m rather doubtful that robust academic research would have made much of a difference. This is especially true when the evidence base on the impact of competition and empowering clinicians as commissioners is developing and highly contested. My reading of it is that competition might have some influence on hospital perfromance but it is likely to be pretty marginal and you’re basically better off leaving health care services to be organised and regulated in a collaborative and collective framework rather than seeking to impose the atomisation of the market on to it.

    Still, Lansley will have his legacy as SoS…

  2. EdinburghEye Says:

    I am so thoroughly depressed by the whole thing that I fell into TV Tropes and didn’t come out.

    (Seriously. I was asking myself, Self, how on earth can the Lib Dems think they can recover from this as a party? And I think the answer is, they just don’t recognise the narrative.)

  3. How Do We Reverse the Health and Social Care Bill? « beyondclicktivism Says:

    […] As Professor Ian Greener notes, the Health and Social care bills “represents a comprehensive failure of democracy.” […]

  4. Tony Finch Says:

    It was part of the conservative manifesto:

    * We are putting patients in charge of making decisions about their care.
    * We are giving every patient the power to choose any healthcare provider that meets NHS standards, within NHS prices.
    * We are strengthening the power of doctors and nurses as patients’ expert guides through the health system by enabling them to commission care on their patients’ behalf.

    I think those are the key points. They are in the coalition agreement too, as is a lot more of the NHS bill.

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