This was not a normal summer for news. Journalists not only reported the news but made it, with phone hacking dominating the early part of the summer. Then, tumbling stock markets, looming national defaults and riots have stolen the headlines. Silly season? Not much. Surreal season? Definitely. The impact of all this has been to shift the focus from health, something which Andrew Lansley and Number 10 will be relieved about, even if they will not be so happy with the causes of this shift.
Yet, as the autumn political season gets into full swing there are plenty of issues which will put health back on the front pages. The NHS reforms may have come through the listening exercise basically intact, albeit with some extensive nip and tucks. Likewise the carefully constructed detoxification of the Conservative brand on health just about survived and a fragile peace between Coalition partners was at least superficially restored on the issue. However, there is plenty of scope for mishap before the year is out. What will be the major health flashpoints? And what potential do they have to damage the prospects of the reforms, or indeed those of their architect or his party?
Legislation, legislation, legislation
A primary objective of the pause was to secure sufficient support – both within Parliament and from stakeholders – to enable the Health and Social Care Bill to pass. The number of government amendments tabled to a bill can be misleading – all legislation gets extensively tidied up as it makes its way through Parliament and the majority of the 1,000 or so amendments that have been tabled are simply name changes – but there is no doubt that there has been significant change to the Health and Social Care Bill. However, it is equally clear that the changes have failed to quell opposition. Despite many of the leading professional bodies making more positive noises after the pause – and in spite of the Prime Minister’s recent claims – several retain significant concerns about the Bill.
Perhaps more worrying for the Government is the continuing disquiet amongst Liberal Democrats. Nick Clegg’s ‘scorecard’, which he used to proclaim “victory” for his party, looked a little hollow as many of his own backbenchers failed to back the reforms during their remaining stages in the Commons. With those on the left of the Party seeking support for an emergency motion setting out demands for 13 additional far-reaching changes to be made and, unless they are, calling for “Liberal Democrat parliamentarians to reject the Health and Social Care Bill in its entirety.”
The truth is that the Liberal Democrats were never going to be able to unite behind a Bill which retained Conservative support. As I have written before, there are no concessions which Nick Clegg can extract from the Conservatives that will appeal to all of his party. Liberal Democrat opinion spans those who believe in the Blairite model of competition to those who reject any role for competition within the NHS. Indeed the draft text of Dr Charles West’s emergency motion states that “a competitive market is not an appropriate model for delivering healthcare in the UK.” A position which would not be shared by many in his party, let alone the Conservatives.
So the Government is in for a rough ride in the Lords on the Bill. Peers from all sides have watched with some frustration as their counterparts in the Commons have scrutinised (or perhaps failed to scrutinise) the reforms and they will be eager to sink their teeth into it. Large areas of the Bill (particularly latter parts) have yet to receive substantial scrutiny and the Lords can be expected to go to work on these, as well as on the broader ideological questions. Simply because some parts of the Bill cause less ideological friction, does not mean that they will be straightforward in the upper chamber.
QIPP or cuts?
There are also difficult decisions to be made about the future of some hospital services, particularly those in organisations which are struggling financially and may not make it to the promised land of foundation trust status. I have written before about the case of Chase Farm, a hospital perennially under threat and which will now lose its 24 hour A&E unit. There are many more like it, particularly in marginal constituencies in the south east. There may be sound clinical (as well as financial) reasons for change, but this will be difficult to explain to communities – and parliamentarians – wedded to their local hospital.
We are now well into the delivery period for the Quality, Innovation, Productivity and Prevention programme and there are examples of how pathways are being redesigned in such a way that improves quality whilst also reducing costs. However, in a febrile climate of public opinion which is conditioned to the concept of large scale reductions in public service expenditure, it is easy to confuse QIPP with cuts. In any case, stories of PCT red lists, referral rationing and longer waiting lists all combine to create significant political difficulties for the Government, undermining the argument that it is protecting NHS budgets. The political danger is that perceived cuts (which always feel worse as the weather gets colder) become conflated with controversies over reform, with the Government’s reform agenda – rather than the slowdown in spending – being seen as the cause of unpopular reductions in servic
Incentives for GPs
The Bill won’t be the only cause of testy conversations with the BMA. The Department of Health also needs to negotiate annual changes to the Quality and Outcomes Framework (QOF) of the GP contract and, at a time when public sector pay is being squeezed, it is unlikely that GPs will readily agree to do more for the same (or less), something which the Government will be keen to demonstrate it is achieving.
As well as provider incentives, the Department of Health needs to begin designing the system of commissioner incentives for GPs – the Commissioning Outcomes Framework (COF) and the Quality Premium. Establishing financial incentives to GPs as commissioners has already proved controversial. Anyone who follows Clare Gerada on Twitter will know that the Chairman of the Royal College of General Practitioners has concerns about whether it is a conflict of interest for GPs to be both providers and rationers of care (others would argue that they already have this dual role). Introducing financial incentives merely heightens this worry.
There is also the practical issue of finding the money to resource the Commissioning Outcomes Framework at a time when budgets are tight. Efforts to shift resources from GP provider budgets would not prove popular, but expect the Daily Mail to have something to say if it is perceived that even more resources are being directed towards ‘fat cat’ GPs.
Either way, the detailed work on QOF and COF needs to begin soon and it will be fraught with complexity and controversy.
Launching the Information Revolution (again)
That the Department of Health’s information strategy has been delayed (again) is now almost a running joke in health policy and, in itself, a document about information policy is hardly going to make the headlines. Yet market theorists – and we know that Andrew Lansley puts a great deal of stock in their advice – argue that information is fundamental to making every aspect of the reforms work. Markets fail when there is information asymmetry: if different actors in the system don’t have the right information, then they cannot make the right decisions. Without access to high quality, timely, relevant and usable information, commissioners will not be able to make decisions on the basis of quality or cost, providers will not be able to introduce timely improvements and certainly patients will not be able to make informed choices. So getting this right matters. The Department of Health has actually made fairly good progress in releasing data, but it now needs to ensure this is put to use.
As well as acting as an enabler for the reforms, the information strategy also needs to ensure that a number of things that could go wrong don’t. Releasing information is all good and well in theory, but steps need to be taken to ensure that data are not identifiable and that their release do not hinder – rather than stimulate – research. Those who remember the MTAS debacle will need no reminding about the political consequences of releasing the wrong data into the public domain.
Sorting out social care
The publication of the Dilnot Review seems a long time ago, yet the issues it raised – and the political challenges it poses – have yet to be resolved. Remember, there was no more vitriolic fight than the ‘death tax’ row before the last election – a row which certainly soured relations between the now Secretary of State and his then Liberal Democrat opposite number, Norman Lamb.
The social care landscape has actually moved on significantly since Dilnot was commissioned, with the problems of Southern Cross and the Winterbourne View scandal demonstrating that the challenges of social care go well beyond funding. This might dilute the focus on Dilnot (helpful from a political perspective), but it also raises the stakes. Social care – as ever – will not be an easy issue to sort out.
In doing so, the Government will have to balance Treasury nervousness about the costs of reform and its own natural instinct to stimulate a market in social care insurance with the desire of stakeholders and many Liberal Democrats to significantly limit the cost exposure of individuals. This will not be an easy balancing act, and has the potential to become another major Coalition flashpoint.
The political temptation to delay action is clear and Downing Street sources have stated they are happy to kick the proposals into “the medium term grass,” but there is significant Coalition and stakeholder pressure for action to happen sooner rather than later. A social care white paper has been promised for the ‘spring’ (although it should be noted that Department of Health seasons are somewhat more flexible than those on the calendar). Expect fraught discussions to begin in earnest in the coming months. One way in which the Government may seek to take the heat out of these discussions is to launch a listening exercise to mirror that which occurred for NHS reform. After all, it is clear that reform will have to be far wider than the funding issues that Dilnot was asked to consider. Watch this space.
Will flu infect NHS reform?
Finally, anyone who has worked in the Department of Health will be aware that events can always derail any secretary of state. Last year provided a sharp reminder of the threat that a nasty winter virus outbreak can still pose to the NHS, as well as the reputations of its political leaders for competence. A&E units and hospital beds come under severe strain during the best of winters. An outbreak of flu, noro virus or something similar, combined with a cold snap, can easily create a sense of crisis.
It was flu last winter, remember, that provided Andrew Lansley with his first brush with events-driven negative publicity and day after day of ‘crisis’ coverage in the Mail (for what was actually a relatively mild outbreak) proved to be particularly wounding.
The political danger this autumn and winter is that a serious outbreak of flu will inevitably be conflated with – and unreasonably blamed on – the reform process, further contaminating public perceptions. Recent comments by the Chief Medical Officer show that the threat remains real and concern remains high. The Secretary of State may actually be helped by heightened public awareness (and he will hope preparedness) created by one of this autumn’s blockbusters, Contagion, a fictional account of a severe flu pandemic. Ironically, this may prove far more effective in preparing the public than the awareness campaign Andrew Lansley memorably failed to fund last winter.
A fall this autumn?
Following a frenetic and noisy pause, the summer provided some respite from the spotlight for health. The prominence of market crashes, hackling and riots has been reflected in the polls, with the salience of health declining slightly. Yet there is still plenty for the Government to be concerned about, and many potential flashpoints which could see health catapulted back to the top of the public’s agenda. The Department of Health will need to manage these at the same time as the NHS continues to navigate a complex transition. From the vagaries of legislation, to industrial relations, detailed policy implementation or simply events, there will be plenty of headaches for the Department of Health this autumn. It will be a busy time for all those involved in health policy.