Health Matters | Paul Corrigan's blog

One of the main arguments currently being used by those in favour of the Health and Social Care Bill getting through its last stages in Parliament is that most of the changes it would bring about have already started to happen. Those arguing for the Bill say that to stop it now would cause greater disruption than if the changes go ahead.

This is a good, practical argument. It makes sense to people who intuitively know that in their own lives when they are halfway through something – even if they know it was a mistake to have started it – that sometimes it’s better to finish it – and then have a think about what to do next.

Those arguing for the passing of the Bill do so for this very pragmatic, common sense reason.

The only problem with this argument is that in this context it completely undermines the sovereignty of Parliament.

The Bill to abolish PCTs has yet to pass through Parliament, but they have already been abolished.

The Bill to set up the National Commissioning Board is yet to pass through Parliament, but this illegal body already has a Chief Executive and Chair – and last week outlined its structure, where the staff are going to sit, and what they will do.

The Bill that will move public health functions to local authorities has not passed through Parliament, but most Directors of Public Health are already spending a lot of their time arguing about to whom within the local authority they should report.

I know there are all sorts of good reasons why the implementation of a Bill has to start before it is passed, but the speed with which these NHS reforms have been implemented – without legal certainty – is an exceptional example of the ‘need for speed’ that has characterised this Government.

But this is a very, very high risk argument to use. People have only to link the idea that we are half-way through implementation with the unfortunate fact that the Bill has not yet been passed and some will raise some constitutional issues.

The Government appear to be daring Parliament to assert itself against those who seem to see its agreement as a minor issue.

Last week I posted on the necessity for the Labour opposition to construct a set of medium to long term policies for the NHS which would clearly see them work with it over a period of time that I think of as ‘the long austerity’.

I received a number of comments from people who felt that the reforms in which as special adviser to Alan Milburn, John Reid and Tony Blair I was involved from 2001 – 2007 had laid the ground for the current reforms and that I should take some of the blame for the current Government. Read the rest of this entry »

The government finds itself in a really odd position when it comes to good news about the NHS. In the last month two prestigious organisations operating in the field of comparative international work have said that compared with other health systems, the NHS does between ‘pretty well’ and ‘very well’. Read the rest of this entry »

I know I shouldn’t go on about this.

This quote – about “constancy of purpose” – jumped out at me from last year’s Government Executive Summary document on the NHS. Words can of course mean all sorts of things but it’s difficult to recall a period of NHS reform which has had such inconstancy and such little purpose …… Read the rest of this entry »

Armies and governments can get used to retreating. In becoming expert at doing so they may forget that they are giving ground all the time, and when reviewing their week’s work, think it good – because they retreated well.

When the strategy is to give ground, the tactics are to do it well. Read the rest of this entry »

Yesterday I was hypothesising about how Number 10 would be thinking about the politics of the NHS in its overall political strategy for the next election. I suggested that given the failure of the last year it will now not be able to do as well in comparison with the Labour opposition on the issue of the NHS as it did at the last election. If it were wise it would try and discount the extent to which it could neutralise the NHS as an issue and get used to the fact that at the next election it would be 15 points behind the Labour Party in answer to the question, “Which Party has the best policy on the NHS?”. Read the rest of this entry »

The 11 page Government document published yesterday Government Changes in Response to the Future Forum does contain a considerable set of changes to the Government reform programme. This is a genuine reform of the reforms.

Going through each paragraph, most of them contain significant amendments to last July’s White Paper and will require extensive changes to the Bill. (This is why the Government is correct to ensure that the Bill has to go through the Commons Committee stage again. You can’t politically say that the Bill is being radically changed and at the same time procedurally say that it doesn’t need a completely new Commons Committee stage)

But what I am unclear about is where this leaves the NHS reform programme. The Future Forum was asked to think through a set of reforms to the original reforms. It was not, nor should it be, their responsibility to ensure that the entire package of reformed reforms is coherent.

But that is the problem for the Government.

I think there are three  problems that are likely to emerge.

First, nearly all of the amendments to the original proposals are a softening of those proposals. I can understand politically why this was necessary to get the reforms through not only Parliament but also ‘through’ the NHS. For the last few months however we have been told that the strength of the original programme was necessary to achieve significant improvements in value for money within the NHS. Commissioning for example, was being strengthened by putting GPs in charge…

But using that example, every additional check and balance on GP commissioners will limit the effectiveness of GP Commissioning in creating value for money and bringing about strategic change.

Most commissioners, for example, want to restrict the number of emergency admissions into hospital. Commissioners have wanted to do this for the last 5 years or so but few have managed to achieve it.

Two of yesterday’s new checks on GP commissioning power will limit their capacity to reduce hospital admissions. First, having a hospital doctor on their board will not make it easier to lower the number of hospital admissions. Second, since GP Commissioners now have to have their plans agreed by the local authority Health and Wellbeing Board, the likelihood of moving care away from a politically iconic hospital will diminish.

At the very least this will make it harder to implement the very changes that the Government have identified that the NHS needs.

The second problem with the new reform programme is that there are now two very different authorial voices creating this single reform programme and the Bill. The phrase “authorial voice” is one that novelists use – it lets readers know who is telling the story. If you have a strong authorial voice the story, characters and dialogue all fit together. If you have two different voices, especially if the second has been introduced to criticise the first, it can lead to much greater incoherence.

And that will become clear for the reform programme as it progresses. There are very different ideas here that will clash and murmur against each other.

The third problem is the completely new idea that has become important to the new reform of the reforms – the integrated care programme. The Government are right to single this out since their problem is not a general increase in demand for health care but a very specific increase in the numbers of people with long term conditions. They are right in believing that we need integrated care to provide a new and more “joined up” approach.

Whilst nearly everyone agrees with this view, there are very very different ways of bringing about such integration. There are those who believe that it is this new idea about competition that is preventing the NHS from collaborating in building integrated pathways. Then there are those who believe that without competition the NHS has failed to collaborate to create integrated pathways – and that we need competition to bring it about.

If integration is as important as it seems to be (and it is) then sorting out this difficulty must also be important.

Sunday’s Andrew Marr programme contained the best public discussion I have heard about this issue so far – between Clare Gerada of the Royal College of GPs and Stephen Dorrell, Chair of the Select Committee on Health. I will post about this tomorrow.

One of the more interesting consequences of the Government’s outsourcing of their NHS reform policy is that those now under attack for wanting change are not the Government but the leaders of the Future Forum.

Today’s Times contains an article arguing for greater choice in the NHS. For me it makes a better common sense argument for choice than anything that the Government has tried to stitch together in the last 12 months. Read the rest of this entry »

My immediate response to the report that has been produced by the Future Forum is that if only the Government could learn from the care that has gone into its narrative for change, they would find themselves in a very different position. Read the rest of this entry »

Earlier today I suggested that the Government’s main task on NHS reform this week was to get the public to believe that the Government are 100% committed to a policy that will protect the NHS from the policy that the same Government were 100% committed to in July 2010. Read the rest of this entry »