In many ways this is a typical winter. Health is in the news and the headlines don’t make entirely comfortable reading for the Government – for years this has been the usual pattern, although the bitterly cold weather and the number of winter bugs and viruses have made this winter more challenging than most. Yet in others, it is unique. Rarely, if ever, has the NHS faced winter challenges at a time of significant structural and systemic reform – and at a time when budgets are being squeezed and some services are being halted or postponed. For the Government, this is politically dangerous: there is a risk that the challenges of winter become confused with the implications of reform. This risk has been heightened by the decision not to proceed with the publicity campaign for flu jabs. Whether or not you think this criticism is fair is irrelevant. It has heightened the political stakes.
In this environment, it is hardly surprising that news of Treasury and Cabinet Office scrutiny of the pace and detail of reform has been interpreted as evidence of concern and second thoughts. The truth may be more prosaic. The Cabinet Office and Treasury are probably just doing their job by scrutinising policy delivery and expenditure respectively but, nonetheless, when combined with ongoing scepticism (and in some cases outright opposition) about the reforms from the professions and unions, it is clear that the Department of Health is in for a politically difficult winter. For a Secretary of State who in opposition spent many years seeking to neutralise health as a political issue (and with some success), this will be quite a change.
The big picture and the detail
The lines of attack on the reforms are increasingly well-defined and the purpose of this article is not to rehearse them. Suffice to say that criticisms of the Coalition Government’s health reforms tend to come in three forms: ideological opposition, concerns about the detail (or sometimes lack of it) and worries about the narrative supporting them. Ideological concerns tend to be intractable and in any case are a core part of politics. Worries about the narrative behind the reforms and the detail underpinning them are perhaps therefore the most important to address from the Secretary of State’s perspective.
Concerns over the minutiae of the proposals and about the bigger picture narrative are, of course, sometimes contradictory but nonetheless do highlight Andrew Lansley’s fundamental challenge: the far-reaching reforms being undertaken in public health, NHS and social care are difficult to translate into practical differences for patients, healthcare professionals and the public. Whereas previous health reformers could point to new hospitals or polyclinics, shorter waiting times or new services, with the exception of the Cancer Drugs Fund there is precious little that the Secretary of State can use at this stage to demonstrate the tangible difference the reforms are making. Herein lies the political challenge for the Government. Although ‘setting free’ the NHS is a politically compelling idea, it does make it harder to set out at a national level, in practical terms, what will be different.
So, as Andrew Lansley embarks on his first full year as Secretary of State for Health, he knows that 2011 will be critical to his reform programme. He used his first six months in Richmond House to set out the theory – at length – in a blizzard of white papers and consultations. Yet, until the theory is translated into practice, it will be difficult for otherwise informed health stakeholders to understand the implications for them. Politics – like nature – abhors a vacuum and, in the absence of this understanding, it is inevitable that the debate on health has been shaped by concerns over the transition, funding shortfalls and worries over NHS redundancies, rather than on the benefits Mr Lansley argues will result from the Government’s reforms. Given this, it is easy to see why some who are close to the Secretary of State are arguing that, far from slowing down, the pace of change should be increased, fast forwarding the period of uncertainty and hopefully, from the Government’s perspective, bringing closer the date when widespread benefits will become evident.
The task for 2011
Yet the New Year also presents significant opportunities, enabling the NHS to begin translating white paper theory into practice. The last couple of weeks of December and the early days of January have already seen the Government take the first practical steps towards implementation and we can expect many more to come.
The appointment of David Nicholson – the doyen of NHS managers – as Chief Executive of the shadow NHS Commissioning Board will be a reassuring sign to many in the service even if, as Paul Corrigan points out, he has little experience of commissioning health services, as opposed to managing health systems. We now know more about the level of resource which will be available to develop GP consortia, as well as the money they will be able to spend on the process of commissioning. The way in which PCTs will step back, forming clusters under a unified management, delegating responsibilities to shadow consortia before eventually dissolving, also offers reassurance to those on both sides of the PCT:GP fence, and particularly to those employees who will hope to cross it. Freed from the legal shackles of the consultation period on the White Paper, Andrew Lansley himself has been far more explicit about the support that GP consortia will receive in commissioning complex services such as cancer, confirming that funding will be available for cancer networks next year and that, in the longer term, consortia, “will get all the support they need” in commissioning cancer services.
Importantly, we also now know which GP consortia will be ‘pathfinders’ for the new system. These groups of enthusiasts will not only be tasked with spending 2011 translating the theory of GP commissioning into practice, but will have Richmond House looking eagerly to them for examples of how GP-led commissioning can result in more effective, efficient and patient-centred services. Although many GPs remain unpersuaded about, or even hostile to, the reforms, this somewhat misses the point. Consortia will not need every GP to be involved in making commissioning decisions. MHP Health Mandate is already working with some GP commissioners who have a clear commitment to improving services and tackling health inequalities. The challenge will be to translate their enthusiasm into action, communicate the benefits their activities bring and also ensure that they do not take on too much too soon.
2011 will also see the development of the Commissioning Outcomes Framework (COF), which will incentivise consortia for delivering improvements in particular outcomes. Given the experience with the Quality and Outcomes Framework (QOF), expect the COF to be a powerful determinant of where consortia place their focus and attention.
We now also have more flesh on the bones about the role and resources for HealthWatch, the scope, structure and processes of local health and wellbeing boards, the library of quality standards which will be produced by NICE and the way in which outcomes will be measured in the NHS (even if we don’t yet know the level of improvement which will be demanded).
From theory to practice
So what else for 2011? Although the reforms will ultimately be made or broken far away from Westminster in consortium and provider land, there is the small matter of the Health and Social Care Bill to be published and piloted through Parliament first. The Bill will not be without controversy – expect fierce debates on Foundation Trust borrowing powers, the consortia failure regime, the powers of HealthWatch, public health ring-fencing and the scope and powers of the economic regulator to name but a few. A Bill of this length and complexity will also have unforeseen pitfalls and will inevitably take longer to pass through Parliament than the Department of Health might wish. Irrespective, by the end of January we will know much more about the detail of the new system and the rules that commissioners, providers and the Secretary of State himself will have to abide by. The Bill will also be important in framing the political debate on health in this Parliament.
We will also see the first of a new wave of disease-specific strategies, setting out how the reforms will be applied to improve outcomes for particular conditions. This will be an important step, providing examples about how sometimes esoteric reforms will be translated into practice in a way – and at a level – that patients and stakeholders will be able to relate to. Cancer and mental health will be first out of the gate, with others to follow. The impact of these early strategies should be felt far beyond the conditions they relate to. Stakeholders interested in other conditions should study how the reforms can be applied to improve outcomes and seek to initiate similar changes in their area of interest.
The true impact of reforms cannot be understood until they have been tried and tested. The scale and nature of the reforms means that it will not be possible to reach a comprehensive verdict on their impact until well beyond 2015, something the Department of Health freely acknowledges. This only serves to heighten the political challenge facing the Government. Advocates of the reforms are of course correct to point out that many, if not all, of the constituent parts have been tried before and, in theory, they are all effective levers for improving services. What is new is applying all the reforms together. For Andrew Lansley, 2011 must be about demonstrating that theory can indeed be put into practice and that benefits can be realised in the short and medium, as well as longer political term.