For anyone wishing to understand the latest bizarre twists and turns in the Health and Social Care Bill, the Guardian and Observer have been indispensible reading this week. Sunday’s leak of the Health Select Committee report on NHS expenditure may have been highly partial, giving a rather unrepresentative version of what was actually a far more nuanced report, but it set the media agenda on health for the week.Equally, today’s article on Richmond House’s latest travails provides a unique insight into the continuing dance between ministers and the royal colleges.
The accuracy of today’s article is not in doubt: what is clear is that at some point on Tuesday the royal colleges determined that they would issue a joint statement declaring that they ‘were not in support of the Bill’ (note the negative support rather than positive opposition – a turn of phrase which possibly meant something to the colleges but would have been taken as outright opposition to the Bill by everyone else). Ministers, having got wind of it and sensing the febrility of the media, determined to ensure the statement was never issued and spent most of yesterday on the end of the phone to the great and the good of England’s medical community. Tuesday’s draft of the statement was promptly leaked to the Guardian, leading to a rushed statement from the Academy of Medical Royal Colleges denying the existence of a united position.
The story illustrates how the sands are shifting, even as ministers mount one last push to get the Health and Social Care Bill passed into law. Why have the sands started to shift again? The story behind the story is important here, and it reveals how the medical politics of NHS reform are every bit as bizarre as Westminster politics.
There are a range of possible explanations for this latest bout of uncertainty. One possibility is that the royal colleges, sensing that the Government will need to make further concessions in the Lords, are considering making one last push to get new amendments put into the Bill. This can be discounted for a multitude of reasons.
First, Andrew Lansley – a man whose early politics was forged under the tutelage of Norman Tebbit and Margaret Thatcher – has simply never been in the mood to make further concessions. In taking this view, he appears to have the support of the Prime Minister, who described continuing opposition to the Bill yesterday as simple trade unionism. He also appears to have the support of the Deputy Prime Minister, something which has come and gone and reappeared over the past year. For Nick Clegg, having declared victory in his plan to get the Bill watered down a few months ago, it would be difficult to now say that he has (again) signed off on a plan he didn’t really agree with. The Bill may be tweaked, but it is not going to fundamentally change.
Second, it is not abundantly clear what amendments the royal colleges are asking for. The concerns people have with the Bill are largely unspecific now – worries about ‘competition’, ‘integration’ and the like, all of which are difficult to address in legislation. As the Future Forum noted, much of the change will need to be cultural, which is difficult to legislate for. For example, there is precious little consensus behind a specific amendment of the sort which was made when nurses demanded they should be included on what became clinical commissioning groups. Without specific amendments being suggested, the Government can do little to offer legislative concessions.
Third, the Bill has been in the House of Lords. The Lords know precisely what concessions they are going to extract from the Government. As a revising chamber, digging around in the weeds for five months, the concessions they want to extract are on things like the Secretary of State’s accountability over the health service, the extent of the margins of competition in the NHS and the relative independence of HealthWatch. The Lords have spent months poring over the legislation. As an institution which has to pay less attention to democracy than most, it is less likely to feel swayed by the prevailing media mood. The amendments that peers suggest will be the amendments they want to make – not the royal colleges.
So, if a growing consensus behind a belief that the policy needs to be changed is not behind the royal colleges’ wobbles, what is?
Experience tells healthwatchers that when doctors move en masse, there is only one organisation behind it. The British Medical Association.
One day, I hope a study will be written into the BMA’s approach to the Health and Social Care Bill. I am not sure anyone has yet written the first draft of history, so this is it.
The leadership of the BMA are predominantly GPs. In their heart of hearts, they support the thrust of the Health and Social Care Bill. Their initial reaction to the White Paper, lest we forget, was broadly welcoming.
But BMA activists hate it. These are the people who are still virulently opposed to the purchaser-provider split. That is a debate which was first fought a quarter of a century ago. They have expressed grave reservations about moves to further embed the split – whichever party proposed them – ever since.
The disconnect between the members and leadership of the BMA has been a recurring theme in health policy. From medical training to staff contracts, change has often exposed the fact that the medical profession is not at one within its union.
A speedy passage of the Health and Social Care Bill was in the interests of – nay, was needed by – the BMA’s leadership to avoid their becoming dangerously exposed. But a combination of political cackhandedness and Coalition tensions put paid to this. Precisely the opposite happened. The Government became so bogged down in the legislative process that they had to stop it.
Notwithstanding that delay, the head of the BMA, Hamish Meldrum, could just about have argued his case internally had he managed to extract concessions on other issues which affected his members, such as pension reform. But this was always a difficult ask: the public are not remotely sympathetic to the idea that they should pay for doctors’ pensions – which are three times average earnings – and the media are more hostile still. Then the Government took the decision everyone knew they were going to make in December.
So, in order to shore up his position and avoid the fate that has befallen many of his predecessors, Meldrum has needed to move towards his activists on NHS reform, becoming resolutely anti-Bill. And he is doing just that, moving behind the scenes to orchestrate a combined movement by the BMA and the royal colleges.
The role of the royal colleges and that of the BMA have always been different. The former are meant to promote professional standards, training and address issues of quality, the latter to represent the interests of doctors, but in recent weeks the two roles have converged. This places the leaders of the royal colleges in a position to which they are unaccustomed.
Last night I spoke at a meeting of the British Thoracic Oncology Group in Dublin, to a group of about sixty surgeons, oncologists, radiographers and nurses. The subject was NHS reform and how it might apply to lung cancer. Their mood was interesting. Many were bewildered by the way in which the Government had introduced and explained the reforms. As one put it, “I had assumed that politicians would be good at politics.” Apparently not. However, most of all, they were tired of the uncertainty. They now want to get on with it and make the best of the reforms for patients. The last thing they want is to prolong the agony. Their position was very different from the medical-political debate currently consuming their leaders.
The heads of royal colleges speak of receiving hundreds of emails in the last couple of weeks from their members urging them to speak out against the Bill. In private, they appear slightly bewildered. They do not understand what has made their members suddenly so agitated. And now, understandably, they fear for their own positions.
The truth is that there is no reason for this sudden agitation. Nothing substantial has happened on policy terms since the Government’s response to the NHS Future Forum last summer (and it is highly questionable whether anything substantial happened then). However, members of the royal colleges are also members of the BMA, which – as a trade union – is orchestrating an effective campaign of opposition. My bet is the emails received by the leaders of the royal colleges are sent by the BMA’s most ardent activists.
An eleventh-hour campaign spearheaded by Hamish Meldrum with the royal colleges in tow would almost definitely solidify the position of Hamish Meldrum. And that is what we are seeing being played out this week. We will find out sooner rather than later whether the leaders of the royal colleges extricate themselves from a political position to which they are unaccustomed, or whether the roles of the medical trade union and the royal colleges further converge.
It is hard to believe that anything could match the high political drama (or farce) of the pause, recommittal of the Bill and then non-committal debates in the Lords, where peers have still, to formally agree on the primary duties of the Secretary of State. Yet medical politics are proving to be every bit as bizarre as Westminster politics.