The Prime Minister is a good communicator. He spent several years in opposition trying to ’detoxify’ the public image of the Conservative Party; and he carried out this process with particular attention to the NHS.
He spent a lot of time and effort arguing that the Conservatives were the ‘Party of the NHS’. He was good at this but, importantly for him, not quite good enough to secure a Conservative majority in the 2010 election.
He has carried those communication skills through from opposition to Government. A review of the history of communications regarding the Health and Social Care Bill reveals that he has had to come to the rescue of his Secretary of State for Health on two strategic occasions.
Last April he first called for a pause in the development of the Bill and then developed a narrative to explain why the Government were having a pause. His argument that the Government needed to listen to voices from outside was persuasive. Unfortunately, at the end of this suspension of progress two different explanations about what had gone on during the pause emerged.
The Prime Minister claimed that there had been significant changes made to the Bill while his Secretary of State claimed that the changes were minimal.
His second strategic intervention has come in the final stages of the Bill. He has, once more, developed a narrative to explain why the reforms are so important and has written an important article for the Sunday Times of 12 February.
In this article the Prime Minister says that there are three sets of reasons why the Bill and its reforms are so important.
“First our Bill gives power to doctors and nurses.
Second the Bill will cut bureaucracy.
Third the bill identifies the public health challenge, funds it transparently, and gives councils the powers they need.”
These are worthwhile goals for any legislation. Taken together they could create a persuasive narrative for the reform that the Bill brings about.
But the problem he has is that developing a narrative as Prime Minister is very different from doing so in opposition. In opposition there is no reality which your narrative has to encompass. In opposition you can write a narrative about a promise rather than about a reality.
In Government the unfortunate difficulty for the Prime Minister is that his Health and Social Care Bill narrative must be judged against both what the Bill actually says, and what the reforms will actually achieve.
So whilst the storyline may be that “our Bill gives power to doctors and nurses”, as a Government statement we can judge this against what the Bill will actually achieve.
Let’s look at that reality and compare it with the narrative.
The Bill sets up two kinds of commissioning organisations.
One is the National Commissioning Board where the Chair and the CEO have already been appointed (neither are a doctor or a nurse). The health care that this commissions will not give the power to doctors and nurses.
I have mentioned before that the NCB will commission 10% of the whole of NHS commissioning with specialist commissioning of rare diseases. They will commission a further 27% for general practice across the country, and 2.2% for public health. Added together that comes to 40% of all NHS Commissioning.
The other commissioning organisations that the Bill sets up are the local Clinical Commissioning Groups. Where CCGs have not been authorised by April 2013, managers from the NCB will be commissioning NHS care in those localities.
Michael Dixon, one of the GPs in favour of reforms, believes that only 50% of CCGs will be authorised by April 2013.
So let’s do the maths.
All this means that half of the remaining 60% of NHS care not already commissioned by the NCB will then also be commissioned by managers from the NCB.
Which in turn means that in April 2013 70% of all NHS Commissioning will be carried out by managers in the NCB.
It may be a good story to say that this Bill gives power to doctors and nurses but the reality is that NHS Commissioning will be largely nationalised and run by managers -and not doctors and nurses.
The second claim in the Prime Minister’s narrative is that the Bill will cut bureaucracy.
The Bill sets up a plethora of new bureaucratic organisations. We are just beginning to get a flavour of how this will work. Last week the coalition of GP commissioners – an organisation that is in favour of the Bill, published the following statement,
“In the Department of Health’s original guidance Developing the NHS Commissioning Board (July 2011), Sir David Nicholson said: “CCGs will be the engine of the new system and things will only be done at a different level of the system where there is evidence that this produces better results.”
Fast forward a few months and the Government’s document Design of the NHS Commissioning Board, released on 2 February, seems to be telling a completely different story. What we see are layers of bureaucracy and management, with complex guidelines. The old ‘footprint’, i.e. 50 local offices, remains there, plus four sector outposts, all using a single operating model.
There is a risk that the NCB will replicate ‘more of the same’, not least because many of the people involved in all of the ‘layers’ of the NCB, at sector and local office level, will be the same people – risking the same behaviours. This then adds to clinical commissioners’ concerns and perceptions that they will be suffocated, instead of liberated, which in our view, is fundamental to the success of clinically-led commissioning.
Dr Michael Dixon, a senior member of the NHS Clinical Commissioning Coalition, said: “The Clinical Commissioning Coalition takes the view that, with most CCGs seeing the National Commissioning Board itself as their greatest risk at present, the NHSCB will now need to work much harder to convince primary care clinicians, clinical commissioners and CCGs and their leaders that they are not simply pawns in strategy of implementation or largely see ‘business as usual’.”
Dr Charles Alessi, also a senior member of the NHS Clinical Commissioning Coalition, commented: “What we are hearing and seeing are the same old messages and the same old structures, albeit with new nomenclatures. If we put the same ingredients into the mix, the likelihood is that we shall deliver the same inefficient environment and outcomes. This is insupportable in an economy of tight financial restraint. Something will have to give. The Coalition will exert all its energies to bring about an environment in which clinical commissioning can thrive. This is our raison d’être and we shall be tireless in our efforts to liberate our members.”
The Prime Minister says that the Bill will cut bureaucracy. But what do the people representing GPs that are trying to develop GP-led commissioning think about that part of his narrative? They say that clinical commissioners feel they will be suffocated instead of liberated, and that rather than bureaucracy being cut,
“what we see are layers of bureaucracy and management, with complex guidelines. The old ‘footprint’, i.e. 50 local offices, remains there, plus four sector outposts, all using a single operating model.”
Last Thursday Charles Alessi was on Newsnight supporting the reforms.
In this statement he says,
“What we are hearing and seeing are the same old messages and the same old structures, albeit with new nomenclatures. If we put the same ingredients into the mix, the likelihood is that we shall deliver the same inefficient environment and outcomes.”
The Prime Minister’s narrative – that provides his rationale for the Bill – says that the Bill will cut bureaucracy. The GPs who are in favour of the Bill say there are the “same old structures”.
The Prime Minister’s third narrative strand is that,
“the bill identifies the public health challenge, funds it transparently, and gives councils the powers they need.”
A few weeks ago the Department of Health announced the distribution of the funds that are at the moment spent on public health by the NHS. This amounts to 5.2% of the whole NHS budget. 2.2% of the budget will be spent on commissioning public health by the NCB. Another 2.2% will be spent by local Government, and the rest by other national bodies.
So if we look at the entire NHS budget to be spent on public health 42% of it will be spent by local government on public health – 58% by central bodies.
This distribution of the resources for public health cannot be said to “give local government the powers they need.”
Late in the day, it’s true that the Prime Minister is starting to develop a good narrative that explains the rationale behind the Health and Social Care Bill.
The problem is that his narrative does not reflect what the Bill is really enacting.
Does any of this matter?
In the long run, for the Prime Minister, it looks as if it does.
In the same edition of the Sunday Times that the Prime Minister’s article outlining his narrative for reform appeared there was an article by commentator Martin Ivens. He said,
“A vast polling exercise undertaken by Michael Ashcroft the former Conservative Treasurer into the attitude of those who were tempted to vote for Cameron in 2010 but spurned him at the last moment shows that the health policy is toxic for Conservative prospects in 2015”
(Martin Ivens Sunday Times 12/02/2012)
This considerably raises the stakes for the Prime Minister.
The narrative that the PM developed in opposition – aimed at detoxifying the relationship between the NHS and the Conservative party – nearly won him a majority at the last election.
In government his new narrative – about the NHS – will be measured against the reality of his reforms.
It seems likely that reality will cause him some problems in gaining those extra seats at the next election.
Narratives work best when they describe reality.