The political theatre surrounding the listening exercise has kept health policy geeks on their toes, and has been an eye-opener in terms of the way in which coalitions (or at least this coalition) work. However, as Steve Field wrote in the Future Forum’s report, it “has…been a destabilising period for the NHS and an unsettling time for staff and for patients. It is time for the pause to end.” The pause is now over and those at the top of the Coalition will be fervently hoping that this week’s announcements have succeeded in re-establishing some form of collective responsibility on health – something which has clearly been lacking. They will also hope that this newfound ‘unity’ will translate into a quieter media environment for the health reforms, as well as a greater degree of public support. It remains to be seen whether this hope is justified by the reality.
It is nearly a year since the Equity and excellence: Liberating the NHS was published. At the time, I wrote that the White Paper hoped for “a great transformation” in the NHS but that the reforms consisted of many moving parts, all of which would have to work in the right way and at the right time if this transformation was to be achieved. I wrote about the political risk that this entailed – and that risk has certainly been borne out by the reality of the last year.
In truth, few – if any – of the changes made by the Government yesterday are surprises. The listening exercise has been a relatively open one and, in any case, there has been a regular trickle of leaks and briefings to the media. Nonetheless we still don’t know whether the agreement will succeed in quelling opposition, or in re-establishing Coalition unity. It will only be when the amendments to the Bill are published that we will get a better sense of the extent to which the political objectives of this exercise will be met. Remember, Downing Street only became uncomfortable about the initial reforms when it felt the political heat following the publication of the Bill.
Although the mood music from key stakeholders has changed, there are still rumblings of discontent from both sides of the debate. The British Medical Association has said that it hopes that its “missing concerns”, over issues such as excessive power of the NHS Commissioning Board over clinical commissioning groups, will be addressed as more detail emerges. This is echoed by the NHS Alliance which argues that, irrespective of the Bill, the success or otherwise of the reforms will be in implementation, particularly the “balance of power” between the NHS Commissioning Board and clinical commissioning groups. The Royal College of GPs, responding to the Future Forum’s recommendations, said that it was worried that proposals may lead to “additional levels of complexity and bureaucracy” which could stand in the way of commissioners being able to develop appropriate services with, and for, their patients.
That the reforms have undergone significant surgery is beyond question. Yet surgery can take many different forms, from radical to minimally invasive. What matters, beyond the political posturing, is the extent to which the moving parts have survived. Is the Government’s creation still alive and well, or has a fundamentally different beast been created? Even critics of the original White Paper concede that it is philosophically coherent (even if they don’t like the philosophy). So it matters whether the constituent parts still work (or even exist). It is worth examining each of these parts in turn.
Commissioning: from GP to clinically-led?
Much of the initial concern about the reforms was focused on the development of GP-led commissioning. Perhaps scarred by memories of fundholding, many stakeholders – particularly for conditions involving high levels of specialist care – expressed fears that GPs would not be up to the job. Those close to the Secretary of State would argue that it was always Lansley’s intention that GPs should seek specialist expertise to support them in commissioning, but this is besides the point. The views of some of the more hawkish GPs only served to exacerbate these fears, and – in the spirit of permissiveness – little was done to reassure them.
Rebranding GP consortia as clinical commissioning groups is cosmetic in the extreme and the other steps – such as requiring them to use NHS branding – will have little practical impact (given the strength of the NHS brand, why would an organisation not use it when it had the opportunity to do so?). PCGs, then PCTs, then GPCCs and now CCGs. The NHS alphabet soup continues.
An irony for Andrew Lansley is that, because of his desire not to focus on structures (“function over form” is an expression that many civil servants will have heard him utter), much of the debate became fixated on exactly that. PCTs, unloved by most, found themselves in a position where they were being defended by many. These changes will reassure stakeholders that the NHS is not being signed over to GPs and they should help refocus the discussion on how the quality of clinical commissioning can be improved, rather than what the structure should be. However, they do not fundamentally alter the vision of clinically-led commissioning. And GPs remain firmly in the commissioning driving seat.
Similarly the renewed and very welcome emphasis on clinical networks (such as cancer networks) is not a fundamental departure from the White Paper vision. In truth, there was always a role for clinical networks (as demonstrated by the fact that the new cancer strategy offered them some protection from cuts, long before the pause was announced) but – again – this was never articulated due to the desire not to tie the hands of the new generation of commissioners. The biggest winner from this concession could be those conditions – such as musculoskeletal disorders or liver disease – which do not currently have networks but which could usefully benefit from them. Networks are back in favour and expect the NHS Commissioning Board to use them as a key mechanism for ensuring an orderly transition.
Choice: based on competition or cooperation?
The debate on competition is an exemplar of the unnecessary political risk created by the reforms. A poorly understood and frankly arcane issue exploded into a political row based on a hypothetical debate about the extent to which European law may or may not apply to an issue which had not been tested in the courts. The way in which this issue has been communicated and described in proposed legislation may have made sense to competition theorists, but comparing the NHS to unloved privatised utilities was hardly a communications masterstroke. As I have blogged before, removing competition as the primary purpose of Monitor makes a good deal of sense, not least in that it makes clear that requiring coordination or integration is a perfectly reasonable (and in fact desirable) position for a commissioner to take.
Retaining the Co-operation and Competition Panel on a statutory footing and within Monitor means that the competition regime will look much as it does today. This, however, does nothing to remove the threat of EU competition intervention. Monitor, in effect, remains an economic regulator (which is what a sector regulator is), albeit with an amended primary purpose and a more patient-friendly aura.
The commitment to delay the introduction of Any Qualified Provider and then to restrict its scope to those services for which there is a national or local tariff is a more significant deviation. The biggest threat of price competition comes from the fact that so few NHS services are covered by tariffs and the block to addressing this is practical and not political. For those wishing to see an extension of Any Qualified Provider, the focus will need to be on finding ways to establish more tariffs – and fast. The commitment to outlaw any policy to encourage changes in market share is not much of a safeguard against privatisation as it precludes the Secretary of State from intervening to promote NHS delivery (remember “the NHS as the preferred provider?”) as well as greater private provision.
The proposed ‘choice mandate’ – now the key mechanism for encouraging diversity of provision – is not too dissimilar from the choice strategy initially promised in the White Paper and it will presumably lead to the promised ‘choice guarantees’ to patients, setting out the choices which will be available (and by implication those that will not) to patients. This, combined with the proposed integration pilots, could be a new frontier for health reform in the second half of this Parliament. Expect some of the same battles to be played out again.
Incentives: from activity to quality?
One area in which the Government’s response is conspicuous by its silence is in that on quality incentives for providers. CQUINs – and other quality incentives – are popular, although their actual impact remains unproven. If the Government now wishes to move forward with its vision of competition between (mainly NHS) providers, then it should urgently spell out how it will expand the use of such quality incentives. This should not wait for the NHS Commissioning Board to finally crank into gear.
With regards to incentives for commissioners, the proposed Commissioning Outcomes Framework (or quality premium) has attracted controversy, with critics arguing that it could be tantamount to incentivising GPs to provide less effective, but cheaper, care. The commitment to clarify that this should be about delivering quality improvements and to restrict the way in which any payments can be used will be welcomed by many, but it will be important that progress in developing the system is not unnecessarily delayed. Again, focusing commissioners on securing quality improvements is popular and the fact that the initial concept was never explained should not be used as an excuse to sacrifice this.
Information: consensus, but where next?
One area where there has been broad agreement is about the need to use information to empower patients. However, beneath the broad consensus that the Information Revolution is a good thing, there remain serious concerns about the practical impact of some changes, particularly in relation to patient confidentiality. The Government has heard these concerns, but has yet to come up with answers as to how they will be addressed.
Beyond this, it is not clear how the aspirations of the Information Revolution will be translated into reality. As I wrote last week, this will require a demand side revolution as well as one on the supply side, and achieving this is likely to cost money. Putative information revolutionaries await the much-delayed Information Strategy with baited breath.
Democratic involvement: commissioning or oversight?
Differing views on the role of democratically-elected representatives in commissioning is a tension at the heart of the Coalition. Put simply, the Conservatives support commissioning by technocrat (with democratic oversight) whereas the Liberal Democrats believe in commissioning by democrat (with technocratic input). On this one, the Conservatives have won, albeit with a stronger role for health and wellbeing boards and a clarified right of referral for local commissioning plans (although no veto).
There is also a clearer role for HealthWatch at both a national and a local level, which will be welcomed by charities who feared a repeat of the fiascos on community health councils and the Commission for Public and Patient Involvement in Health. The details of HealthWatch now need to be fleshed out.
Accountability: a more responsive NHS?
There is a range of symbolic but important changes in the way in which the Secretary of State will be held accountable for the performance of the NHS. Clarifying the responsibilities of the Secretary of State – including making clear that he has the ultimate responsibility for securing the provision of services – may have little practical impact, but is an important statement of intent. In fact, although the intention may be to ‘liberate’ the NHS, these reforms reserve significant powers for the Secretary of State – powers which those seeking to influence health policy would do well to bear in mind.
The reaffirmation of the NHS Constitution is also important, although in truth its powers were never withdrawn. The commitment to retain the right to drugs and treatments recommended by NICE after the introduction of value-based pricing in 2014 is significant and will be welcomed by those who feared its withdrawal could lead to an exacerbation of postcode lotteries. The commitment not to introduce any new charges during this Parliament is not unexpected, but is a clear signal to those on the right who may be clamouring for charges that this is off the table.
Agreeing to establish Public Health England as an executive agency of the Department of Health is a significant signal about the importance of independent advice, which could be highly relevant given the controversies about the Responsibility Deal and the so-called ‘ladder of interventions’ in public health (what happens if Public Health England recommends legislation on, say, alcohol pricing?).
Sir David Nicholson described the reform proposals as ‘a revolution.’ What was revolutionary was the scale and timing of the changes. Many of the proposed reforms were actually a logical extension of previous initiatives.
Had all the conditions on the fabled Liberal Democrat ‘scorecard’ been met then we may have witnessed a counter-revolution. I wrote on Monday that the briefings about a total ‘victory’ for Nick Clegg were overdone and that has become clear. The Liberal Democrats have every right to feel pleased with the changes made to the reforms, but this is far from a total victory, even on those demands which they have claimed as being secured. For example, on point 4 (“the complete ruling out of any competition based on price”), EU procurement law states that price has to be a factor in tendering. As Nick Clegg’s policy is to remain within the EU, it is difficult to see how adopting best value principles in procurement achieves this.
That Andrew Lansley hoped to achieve a great transformation in the way in which health services are commissioned and delivered is undeniable. Despite significant changes, and a bruising experience for the Secretary of State, his broad vision remains intact. And, despite much speculation to the contrary, the architect of the reforms remains in his job.
However, the belief that there won’t be further challenges to the reforms is misplaced. As Paul Corrigan wrote yesterday, “defenders of the status quo, having been thrown much of what they wanted, will now smell weakness and want more. [They] will want everything…The Government are wrong if they think they have had their fight with reaction. It is only just starting.” It will be interesting to see, having re-established collective responsibility, how strong the will of the different parts of the Coalition is in this respect.
Perhaps the most counter-revolutionary aspect of the changes has been the delay in transition, firstly as a result of the pause itself and then as a result of the relaxation of the timescales associated with authorising both clinical commissioning groups and foundation trusts. In the House of Commons yesterday Andrew Lansley was adamant that this would not lead to a two tier NHS. Yet if authorisation is to mean anything, then this must be a substantial risk. The political danger associated with this is significant: do the Coalition parties really want to fight the next election with a two pace system in place and accusations of a two tier NHS?
The other casualty of the pause may be the enthusiasm of GPs, many of whom were eager to assume commissioning responsibilities. Yesterday I met a couple of leading figures in pathfinder consortia, both of whom expressed dismay at what they felt has been an exercise in politicians marching them up the hill, only to march them back down again. Recovering the momentum and clinical enthusiasm which was driving the transition may be the Coalition’s biggest short term challenge. Without this, the great transformation will not be achieved.