First it has an immediacy which the other more traditional forms of writing don’t have. An article for the HSJ comes out, at best, a fortnight after you have written it. A pamphlet might be published 10 months after it was begun, and writing a book always feels like a lifetime. So the immediacy of writing a blog was very different and I had to learn how to do that.

Most of my posts have been written at 6 in the morning, or on a train journey on the day before publication. Tweeters will know that I have not engaged with their minute by minute level of immediacy. I have used Twitter mainly to advertise the blog.  The reason I haven’t tweeted more is that I have been afraid that if I did my life might disappear in a welter of tweets.

So I have become sufficiently modern to manage day to day commentary, but minute by minute still feels beyond my capabilities.

The second thing I’ve learned about writing a blog is that you have to write it in such a way as to allow and encourage the reader to complete it with their own ideas and emotions. Most of the ways in which we learn to write teach us to complete our contributions by tying them up with a great big bow to show they are finished. A method that leaves no room at all for argument.

I have come to believe that whilst this approach may make a good article for the BMJ – it makes a lousy blog.

The point of each post in the blog has been to progress my own argument but also to provide room for disagreement – and to raise questions and encourage debate. Above all there should be room in the post for people to think their own thoughts and to agree, or disagree, in their own ways.

Learning to write in this way has been a lot of fun, and very different.

A lot has happened in these past 4 years.

I started the blog when there were still 13 months to go for Gordon Brown’s government and during 2009/10 the numbers reading it moved slowly upwards to about 1000. Then the election campaign in 2010 moved them up to about 3000 a week. Over the summer of 2010, as Andrew Lansley’s White Paper was published, they did not go up so much.

It was only when readers realised that the Coalition Government were really going to carry out their reforms that more people wanted to make sense of what they meant. By the time of the famous ‘pause’ readership had increased to 5000.

The reason for this growth had almost certainly, less to do with my great insight, and was more likely a consequence of people having no idea what on earth was going on.

Then there was the occasion when John Rentoul, in the Independent on Sunday, reprinted my post setting out the words that Lansley and Cameron should have used to apologise for the chaos of the reforms and the ‘pause’.

Through the period of the pause numbers rose again, and as the reformed reforms entered the House of Lords more than 10,000 readers a week were visiting the blog.

As the row about the Bill grew and it finally became an Act the blog readership peaked at 20,000 hits a week and it has stayed around that figure – slipping a little last summer – until recent weeks.

I am advised, by those in the know, that when you reach a certain size there are machines that roam around the blogosphere looking for new material. You, dear readers, will know how many of you are machines.

But now I am now going to wind down the blog. It’s been fun but it’s also been hard work – and I want to reduce that work.

At the height of the politics of reform I was writing four posts a week and in most weeks there have been three. Over its four years of life that’s equated to about 600 posts – which probably means I have written around half a million words. They are all there on the web.

This does not mean I am never going to write another post. There will be times when I just won’t be able to help myself. But from the end of March I will not be writing two or three times a week.

Thanks for reading it. Thanks for all the comments and, above all, thanks to all those who have taken the time and trouble to talk to me about the content.

There will be a couple more posts next week, and whilst this is not ‘goodbye’ it does mean that I won’t be popping round to see you quite so often…

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The Budget comes up this week and for this and the next few budgets the best news for any domestic public spending department will be for the health service. As today’s blog headline suggests, health will have grabbed nearly a quarter of all the increase in spending over that time period.

Cuts in public expenditure are political in nature so the ability of parties to choose to increase spending on some areas of public expenditure – rather than others – is also political. The NHS has strong political friends and can depend upon these increases. So everything is all right then?

Well not really. Think about the long term logic of this. In round one, 2011/12 to 2014/15, spending on all other domestic expenditure is cut – but NHS spending grows.

At the end of this spending round, the NHS will feel that it has less money and will complain loudly that it cannot afford to maintain the same standards of care.

In the next spending round education and equipment for the armed forces joins the ring-fenced group and the cuts now fall upon budgets that have already become smaller because of they will have undergone cuts in the previous round.

This could perhaps work for the rest of the next Parliament, but sooner or later the arithmetic will overcome the politics. If in every spending round the cuts need to fall on a smaller and smaller proportion of public expenditure, sooner or later the numbers will no longer add up.

So if the worse happens and the British economy flat lines for the rest of the decade (and the odds of that are I reckon about one chance in four so it’s worth considering) it means that the NHS probably has at best 7 years to prepare for real time cuts in expenditure (against rising demand).

I wrote last Wednesday about the Nuffield Summit’s opening morning sessions where they brought internationally based economists to talk to the NHS health summiteers. Mark Pearson, Head of Health at the OECD, was there to talk about how different countries had faced their economic problems using a range of different activities.

And given the fact that a number of countries have already experienced real cuts in their health budgets he was able to draw from real experience rather than looking into a crystal ball.

The economic crisis in Europe has meant that there have been real cuts in health budgets in Estonia, Greece, Iceland, Ireland, Portugal and Spain. In all of these countries there were large cuts in salaries.

These are ‘one off’ solutions (or in the case of Greece ‘two offs’) which are the obvious and straightforward way in which a highly labour intensive service can deal with overall cuts in expenditure. Alongside these were cuts in pharmaceutical budgets – again a ‘one off’ solution.

So if we get to the end of the decade without much economic growth and there are real cuts in the health budget, then it is salary cuts that will have to be made.

The alternative would be the NHS recognising that this is coming and preparing for it through radical changes to the way in which we organise health services. In this worst case scenario we have 7 years to prepare.

Or we can have 7 years pretending and hoping that this won’t happen and believing that there is always going to be more money. And hope that in some way, in 2020 when there is nothing else left to cut, the Government will find some more NHS money under the mattress. (But there won’t be any.)

Or as one president of a Royal College put it, “Many of my senior colleagues seem to think that they will discover diamonds in the Cotswolds. They won’t. There is no more money”.

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Throughout my time at the Summit I couldn’t shake off the nagging idea that, here we are in the spring of 2013 – and right now would have been a great time to launch a Government NHS reform programme.

Following Francis there is a growing (if patchy) recognition that something is wrong with our current model of NHS care and that it needs substantial reform. Francis made 290 recommendations all of which surround, and try to change the culture of the NHS. He recognises that structural reform without culture change will achieve little. But equally to change the culture there needs to be many connected changes to the structure.

Following Francis there will, for the next few months, be quite a number of front page stories highlighting particular breaches of safety in different parts of the NHS. (On Sunday March 3^rd the Express carried a main headline saying that 1165 people die of malnutrition in NHS hospitals. There will be much more of this). Over the next few months it may well be the case that a further 5 or 6 hospitals are labelled as ‘failing’ through a combination of public stories and NHS investigation.

At the same time as the Government works through the plans for the next round of cuts in public expenditure, there may also be a dawning recognition that ring fencing the NHS budget, when everything else is being cut, will simply not work forever.

In the spring of 2013 there is a growing case for a substantial reform of the NHS that clearly tackles safety and quality whilst also significantly improving value for money. The narrative for radical change is strong and clear.

Jeremy Hunt’s speech at the Nuffield Summit was a clear example of how a reforming Government could, given these conditions, develop a narrative for radical reform of the NHS. He was attacking mediocrity in the NHS and calling for ambition and improvement. This looked like a good start for a reforming narrative.

The problem is that the Government launched its reform programme 32 months ago when no-one was suggesting that there was any need for NHS reform. Now they are stuck with a set of reforms that don’t really have any bearing on this new and obvious set of issues.

Why Andrew Lansley, at the same time, decided to launch both a programme of NHS reform and the Francis Inquiry – that would, when it reported, require an addditional programme of reform two years hence – was a genuinely weird thing to do. If he had waited two years to launch his reforms not only would he still be Secretary of State for Health but he would also have a narrative upon which to build a reform programme.

This will remain one of the many mysteries about his time as Secretary of State.

Returning to the Nuffield Summit. The first session consisted of a set of talks from economists, most of whom NHS people would never really get the chance to listen to.

Starting with the IMF and going on to the OECD and an ex-member of the Bank of England’s Monetary Policy Committee, there were a series of analyses of the world economy and its impact on the health service that provided a master class in the incontrovertible fact that, however big the NHS might be, the issues surrounding the world economy dwarf it.

The IMF recognises that in the developed countries there will be an increase in fiscal demand caused by an aging population. They reckon that between now and 2030 the cost pressures on GDP caused by increased costs associated with pensions will see an increase of about 1% of GDP. However the cost pressures concerning the aging population associated with increased demand for health will be three times as much. As they said it is difficult to see how, over the next 18 years or so, the population in countries such as the UK will agree to the substantial increases in taxation necessary to meet this increased demand for NHS resources.

Andrew Sentance ex-Bank of England Monetary Policy Committee member (the group that sets interest rates) gave a talk called “The New Normal”. He underlined that it is difficult to see a return to years of growth in the British economy and that the new normal was little growth and very tight money.

And whilst this is not directly relevant to health he showed us one of the most important and counterintuitive slides I have seen. Instead of concentrating on the problems of the UK economy in isolation he looked at the growth in the size of the world economy from what it had been in the year 2000 to what it could be projected to be in the year 2017. This was one of the most significant sets of statistics I have seen in the last decade because it showed that between 2000 and 2017 the world economy will increase in size from 23 trillion dollars to 93 trillion dollars.

I know these are very big numbers, but it means that over those 17 years the annual amount of wealth produced in the world will have increased nearly threefold. This is a fact of massive importance to the world economy. The economic troubles of the UK are put into perspective by this massive growth, although it does make the harsh point that though the world economy is growing very fast, we are standing still. This means that whilst not growing at all is already very very difficult for us, it is in fact much worse than that. The world economy is growing very fast and we are standing still.

And I still don’t know where those people who think there will be more money for the NHS imagine it will come from…

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This has often involved the apparent development of the Government’s NHS reforms, and last Tuesday we saw this year’s example when Lord Howe withdrew secondary legislation for developing the commissioning framework within which CCGs decide to put the healthcare they are commissioning out to tender (or not).

These regulations, so far as some were concerned, were aimed at bringing more private sector health care into commissioning – by introducing European competition law to the NHS. Some have claimed that the Government’s chosen method of achieving this was to write regulations into the secondary legislation to force CCGs – when making decisions about commissioning care – to put more out to tender.

At the moment only a very small proportion of the £65 billion commissioned by local NHS commissioners (whether they be the PCTs of the past or the CCGs of the future) is actually “commissioned”. Most of the money that passes through the hands of commissioners, and is given to organisations to provide care, is given to the same providers as it has been in previous years – for providing the same activity.

This yearly repetition has made commissioning a ‘conservative’ force. It is only rarely that the power of commissioning seeks to ensure that all NHS patients receive the improvements in healthcare that they should be. Mainly it reproduces past practice.

If local commissioners want to try and change the way in which local patients receive care – say through the commissioning of an integrated care pathway – local providers treat this as a very odd way of working.

The regulations, so those critics who wanted them withdrawn claimed, were an attempt to try and get more commissioners actually commissioning – rather than simply handing over last year’s money, plus or minus a bit.

Now it’s true that the idea of providing a regulatory framework where commissioners would actually commission signals change, and those against change are right to notice this.

But there continues to be something wrong with the way in which people talk about this process. They argue that these regulations – and other reform activities – are in some way “introducing EU competition law into the NHS”.

This basically misunderstands the relationship between European Law and the British Parliament. Nearly every aspect of EU Law applies to Britain without any recourse to British Parliament itself. Treaties are ratified and – whoosh! – lots of EU laws apply.

And here is something you won’t hear me say too often – UKIP and the eurosceptics have got it right. On a whole host of issues EU law, once passed, simply applies to the UK. And in the area of competition there have been no ‘big fights in Brussels’ by UK governments seeking opt outs.

The DH is not constructing a set of regulations for CCGs to usher in European Competition Law. Rather it is constructing a system for CCGs which will try and keep them within that law as much as possible.

The only reason EU competition law has not of itself demanded more bite over the NHS is because no one has yet taken a commissioner to court and fought a case to demonstrate how a law that already exists will be applied.

This could happen any day, with any commissioner. The DH was trying to warn them. The fact that that this process has now been stopped is fine – and politically quite interesting – but it does not stop the law from applying. Don’t imagine that a new reality, preventing the application of European competition law to commissioning in the NHS, has been established.

There is one very obvious way of stopping the application of EU law. I suspect it is one which will not have been heard at all at the Liberal Democrat spring conference over the last weekend.

That is to leave the EU. If we leave European Competition Law will not apply to the NHS.

This will be the interesting touchstone for the next few years.

If politicians really want to protect the NHS from competition, they will have to be in favour of leaving the EU. There is no middle way on this. Because at some time between now and the referendum on membership someone is going to take a commissioner to court to demonstrate that EU law applies. After that all CCGs will either have to operate illegally or put most of their commissioning out to tender.

Or we leave the EU.

I look forward to hearing the argument for leaving the EU in order to protect the NHS from the application of EU competition law at a future Liberal Democrat spring conference.

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But even before then there was an obvious problem built into this relationship – from the very beginning of the White Paper in July 2010. And this is straight from Andrew Lansley’s attic during that dangerous period when he was encouraged to think this up all by himself.

He had, for some time, wanted to create a body that was separate from the Department of Health to act as the ‘top’ of the NHS. He wanted this to be separate from the day-to-day powers of Ministers. It became the National Commissioning Board.

He also, for some time, wanted to create local clinically-led commissioning groups that would commission healthcare for localities. It made sense for the former, at the centre, to performance manage the latter.

The NCB would be given a very large sum of money to hand out to the CCGs.

But at the same time the NCB would also be an organisation that carried out some commissioning itself. It’s responsible for commissioning special health services and for commissioning GPs.

And this is where the problem lies. Let’s imagine that the NCB underestimates the amount it needs for one of its own commissioning activities. It has the opportunity to simply recoup that money from that which would have gone to local commissioning. It has the opportunity to pass what is clearly its own problem on to the local commissioners at CCG level.

If, in a national body, you combine both the duty to spend money and the duty to pass it on to localities, it is very likely that the national body will solve its own problems at the expense of the localities.

And, as Tony Hancock might have said, “Stone me!”  - that’s exactly what has happened in the last few weeks.

Having made the allocations to local CCGs, and quite rightly told them to get on with planning how to spend their allocations, the NCB discovered a very large hole in its own specialised commissioning budget.

So the obvious thing to do was not to deal with the problem themselves, but by taxing every CCG by a certain amount – and cutting their allocations. As of last week no-one was very sure how much this would be but its probably nearer £900 million than £500 million.

Only in the NHS can we be blasé about such enormous sums of money.

What does this mean for CCGs?

It means that they were planning, for a few weeks, on spending a certain sum of money next year. Other parts of the NCB were encouraging them to draw up their anticipated accounts for next year to demonstrate how they will spend that money.

As with all budgets things were tight. Let’s not forget that these are new organisations expected to make an impact on local problems of healthcare. The commissioning intentions that the CCGs were assured against by the NCB were ambitious and for many of them involved the creation of integrated care pathways.

So they did their sums and for many of them it looked like a very hard first year, but nonetheless they drew up their accounts…

Now the NCB says that they will have less money. May be a further 1- 1.5% cut in that budget.

And following this another part of the NCB says that they given that they need to submit new budgets within the month.

There is a problem here. Not many CCGs will have submitted their original budget with a slush fund that they had not planned to spend. So they had a good budget which NCB Local Area Teams were agreeing.

Now they have to cut it, and the NCB Local Area Team expect them come up with a new budget.

The problem here is that for most the only way they can do this, in only a few weeks, will be to come up with a ‘pretend’ budget which they know won’t work. This reflects the traditional accounting experience that took place previously with the performance management of the SHAs and PCTs setup.

If the budget doesn’t look good, just bash it with a mallet until it looks OK.

It’s a way of making the numbers stack up but it’s not a way of making something real.

So all around the country in this last month, these brand new organisations of which so much is expected are expected to knock their future accounts about to make them fit a new control total.

For many this will mean constructing a fantasy. And those CCGs that refuse to do it will get into trouble. This means that this brand new regime, that was announced with such high hopes, is actually being born with the expectation of reproducing the very worst economic behaviour of the past.

The best will resist using fantasy economics, but many will acquiesce.

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But first I want to talk a little about one of the biggest losers at Eastleigh – an organisation that was not even standing. The Daily Mail spent the 10 days leading up to the by-election trying its best to get the Eastleigh electorate not to vote for the Liberal Democrats. They ran a media campaign against Lord Rennard in a very clever way – assisted by the failure of the Liberal Democrat leadership to grasp the issue.

And whatever you think about the allegations against Lord Rennard (which I would hope will be publicly much clarified by the various investigations) it’s always a treat to see the Daily Mail fail in an attempt to influence the electorate.

Whatever else happened last Thursday the Eastleigh by-election demonstrated that protest votes are still a very important part of the UK political scene. In the past it was the Liberal Democrats that benefited from protest votes cast by a dissatisfied electorate, but as they are now seen as part of the establishment they are not likely to receive protest votes for the rest of this Parliament.

This time it was UKIP that voters felt were serving of their protest. Of itself this was not too surprising, and may be very important for the Conservatives as they try and secure a majority in 2015. For over 100 years there has not been a serious opportunity for the electorate to vote for a party to the right of the Conservative Party. (The BNP and other fascist parties have consistently taken votes from Labour). Because of this 100 year history we don’t yet know how effective a party to their right might be in hoovering up Conservative votes.

But if UKIP were to win over 10% of the votes at the next election – and most of those votes came from voters that voted Conservative in 2010 – it’s very hard to see David Cameron getting a majority in 2015.

But there is another, more NHS, story from the Eastleigh voters. Despite the apparent existence of about 13,000 protest votes these did not go to the National Health Action Party candidate Dr Iain Maclennan. He received only 392 votes or 0.94% of the total turnout.

Before I provide my analysis, I do not want to belittle the hard work and effort put in by anyone who stands for Parliament. Standing in a parliamentary election is hard and very public work and receiving less than 1% of the vote will feel bad after all that effort.

And I need to admit that I have been in exactly the same place. In May 1979 when Margaret Thatcher was receiving her first majority, I stood for Parliament in Coventry North East. I stood for the Communist cause and received 390 votes. So in 2013 Dr Maclennan did 2 votes better than Dr Corrigan in 1979.

In the 1979 election it was clear that the electorate was going to swing to the right. Did that mean that just because I had no chance at all of winning that I shouldn’t have stood? No of course not. Winning didn’t enter my mind but neither did not standing.

So very genuinely I am not knocking people who stand for Parliament with little hope of winning. It’s important to our democracy and it defines who we are as a nation in the same way that the NHS defines us.

But I do think the NHS Action Party and its hopes are based upon a false political analysis.

Most elected politicians know and fear what happened in the constituency of Kidderminster in 2001 where a local doctor came from nowhere to overturn a Labour majority and win as an independent. MPs now know that a local campaign about a local NHS issue, aimed at a sitting MP could, if it takes place after 24 months of powerful front page campaigning, overturn their seat. If the campaign is galvanised around a local doctor then the possibility of defeat for the incumbent MP is high.

The NHS Action Party has drawn the wrong political conclusions from Kidderminster. The public need to be strongly and consistently up in arms about a local NHS issue.

That is very different from a political party raising the NHS as a national issue and trying to mobilise votes around, for example, the voting record of the incumbent MP on the Health and Social Care Act of 2012.

“Government MP votes for Government Health Bill” is not much of a political story.

“MP agrees to closure of local NHS hospital” is.

These are two very different things with two entirely different politics, and two very different chances of success.

And it is very unlikely that in the absence of a very big local NHS issue, a political party set up to defend the NHS will ever get much more than 1% of the vote.

However as I say there is nothing wrong with that. It’s democracy in action.

But rather like I did in the 1979 election, it wouldn’t be a good idea to go around thinking that you will have any impact on the next general election.

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The heading is a quote from the Francis report which places commissioning firmly in the driving seat for developing NHS services. Some might think that this is a bit of a commonplace since it is obvious that commissioners decisions about what services should be provided should prevail. But in fact in most years and for most resources spent by commissioners this has not been the case. Many providers feel that they are best placed to make decisions about what needs to be provided and have been the leaders of their system.

So in a month’s time will all of this change? Will there be a sudden onset of commissioners driving change and deciding what should be provided?

Systems don’t change that quickly. Many of the people making commissioning decisions in the system will be the same ones as made the decisions this year. Many of the contracts commissioners will be using will be the same as this year.

So don’t expect powerful commissioners commissioning fully integrated pathways left right and centre.

But I think there are signs that there will be change and with the aid of the web I want to make the case for limited local optimism.

My reasons for optimism begin with a real long term alteration in the way in which patient organisations think about service change. I have mentioned the Richmond Group of patients before. Their April 2012 publication “From Vision to Action”, outlines the changes that these patient groups want to see over the next few years. It argues for stronger integrated care based on much greater investment in patients’ capacity for self-managing their conditions.

Of course this won’t happen overnight, but the case for much better investment in self management is being made across the country. There will be an expansion of investment in self-management from this April and the potential for greater growth in the future.

I have also mentioned that many Clinical Commissioning Groups are looking at using different sorts of contracts between themselves and providers. They have recognised that contracts based on episodic payments will not create integrated care, and contracts emphasising payments for inputs will not be able to ensure good outcomes for patients.

That is why, across the country, different CCGs are developing different contracts. Two of these are ‘alliance’ and COBIC.

Many of these new integrated care contracts will be taken on by existing providers – who will then try and develop an overall integrated pathway – but there are others who recognise that there is a need for a different organisation of providers where integrated care demands it. Some of these are looking at the organisational form of an accountable lead provider – where an individual organisation takes the responsibility of holding the single integrated care contract. They then sub-contract with other providers.

A few weeks ago all this stopped being hypothetical. On 25^th January Bedfordshire started the process of letting a single contract for all of its muscular skeletal services.

As I say, this doesn’t mean that everything will change overnight into a set of strong integrated care pathways, but it’s a start.

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Since then the method has been used many times to understand how a policy works its way through giving real clinicians and managers the opportunity to work and behave within the new architecture.

What is interesting about such simulations is how both the small and the big changes work. If we role play from the year 2013 to 2014 we quickly see the big decisions looming for the local NHS.

Inevitably, given the coming demise of SHAs, there are some that feel that the tier of management that developed strategy is going and that the capacity to make strategy will go with it.

But that is to confuse titles with reality. Just because an organisation is called a Strategic Health Authority does not mean that it created strategy. What SHAs mainly did was to pass down actions that were expected by the centre. So given the stock management culture of the NHS this meant that the NHS Management Board raised its voice a little on a Tuesday, the SHAs shouted at the PCTs on a Wednesday and at the NHS providers left – who did not have FT status – on the Thursday.

Whatever this was we should not mistake it for strategy.

And it is at this time of year – towards the end of year closing of accounts – when what passed as strategy took place at highest volume in the NHS. For it is at this time of year that the DH expects the SHAs to ensure that as few NHS organisations as possible end up in deficit.

It was therefore at this time of year that PCTs and their local NHS providers were summoned by the SHA to gather in darkened rooms where the PCTs would be leant on to cough up a few million pounds to providers to make sure that they weren’t in deficit. Never mind the fact that they were in deficit and had economically failed that year. The role of the SHA was to lean on the PCT to cough up a bit more money to make the books balance.

The role of the Strategic Health Authority is effectively to make the PCT steal money from organisations that are succeeding to pay for organisations that are failing.

Again you can call this process whatever you like – ‘bungs’ is quite a good name – but it is definitely not a strategic approach to developing the NHS.

And as I have travelled the country over the last few weeks I have heard this traditional bullying of PCTs to deliver bungs going on as normal. With only 6 weeks to go learnt SHA behaviours are still being carried out to the end.

So who will do this next year? Certainly there are elements in the NCB who think it is still their job. (This is hardly surprising since so many NCB staff have a track record both of running NHS providers and holding senior management positions in the NHS).

But the big difference next year will be that the organisation that needs to organise the bungs – the NHS Trust Development Agency – will be separate from the organisation that can lean on the CCGs – the National Commissioning Board. I am sure there will be elements of the NCB who will see this as their job, but the bungs won’t be able to flow from one part of a single organisation to another.

I am sure the NCB will, over the year, build what they will see as a failed NHS hospital emergency fund but their crisis, the one that matters to their organisation, will be the problems within CCGs. The NCB will be judged over 2013/4 on the success of CCGs and not by the size of the deficits in the remaining non-FT NHS trusts. That will be a separate problem for a completely different organisation.

So the passing of the SHAs will not mean the passing of strategy, but it will mean the passing of a single organisation that could, in the last 6 weeks of every year, move money around to hide those NHS organisations that are failing.

Not sure if that is worth a tear or a cheer?

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One of the long term mistakes has been the failure of policy to clearly develop, publish and use a failure regime for the nation’s hospitals. Whatever else we learn from Mid Staffs, we must recognise that a considerable number of local people felt that this hospital was failing them. Yet I am still not clear if, several years later, Mid Staffs is labelled a falling hospital or not.

That fact it has failed is clear. Whether anyone has had to nerve to categorise it in this way is less clear.

This has been a policy area that has been fraught with political failure. Several governments, including the one for which I worked, have failed the public by failing to develop, publish and use a regime that clearly and consistently uses the label ‘failure’ to describe a hospital.

In 2000 the NHS plan made it clear, not only that there should be a simple red amber and green rating system for the nation’s hospitals, but that there should also be a regime which clearly labelled a hospital as ‘failing’ and had a policy to deal with that.

But in fact the development and application of this policy over more than a decade has been weak.

Compare this to education – where the first school was labelled as failing 20 years ago.

Let’s look at where we are today.  South London Healthcare Trust had the administrators sent in because it had failed economically. But the point made by the Public Accounts Committee was that we don’t know the criteria that determined that administrators should be sent into this hospital – and not to any of the others that can only pay their staff because money is stolen from the rest of the NHS to subsidise them.

In quality and safety terms we don’t really know what the failure regime looks like.

Two weeks ago this led the Prime Minister, in his statement in reply to Francis, to ask Monitor to develop what he described as a ‘unified’ failure regime.

We all know why there has been a decade-long failure to construct a failure regime. It is a collective failure of nerve by the political class (including me in my time in Government).

Most of the public believe that all NHS hospitals provide a similar standard of service. As far as they are concerned the NHS brand is a badge which guarantees both quality and their safety.

ALL of us in the system have long known this is not true.

But it took a catastrophe like Mid Staffs to acknowledge this.

It’s true that some Government policy helped patients at Mid Staffs. In the past they would have had to keep going to the hospital because they had no choice. Developing the policy which gave patients the choice to go to a different hospital was hugely controversial. It took row after row with the various aspects of the NHS to say that the public had the right to choose where to go.

This is one area where I don’t have to apologise because we faced down that opposition and implemented a policy of choice.

What did this mean for people at Mid Staffs?

On February 10^th BBC news carried an interesting report on a Freedom of Information request. This had been published on the BBC Stoke and Staffordshire web site.  This showed that the current CEO of Stafford hospital had found that the number of patients who had chosen to go there through the ‘choose and book’ system had fallen from 15740 in 2007/8 to 6513 in 2012/13.

This is a really significant statistic. Because people could choose two third chose not to go.

It is the case that many outside the NHS may find it very odd that as many people as 6513 are choosing to go to a hospital which has been so systematically labelled as bad.

This is the first time I have seen a set of figures which so powerfully demonstrate the choice of the public not to go to a certain hospital. 2 people out of 3 are choosing not to go to Mid Staffs compared to 5 years earlier.

These choices are costing the hospital £3.7 million a year and will be one of the reasons why Monitor has had to look carefully at whether the hospital has a future.

The policy of choice enshrined in the NHS constitution gave people the right not to go to a certain hospital, but because we did not have the nerve to develop and implement a failure policy, we left it all up to the individual.

I am pleased that we gave people choice. But I am ashamed that we didn’t clearly say that failure was failure and decisively act upon it wherever and wherever it took place.

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A few weeks ago Andy Burnham made an important speech launching a major consultation on Labour’s Health Policy. What he described as “the biggest consultation on health and social care policy by the Labour Party for 20 years” is obviously an important event. My Monday posts are discussing his policy proposals in a particular way.

My chosen point of departure was “Can Andy Burnham’s own policy be defended against the attacks that he has been making on government policy?” – looking at it in this way is raising some interesting questions.

Andy Burnham has strongly attacked the government for carrying out an unnecessary ‘top down’ reorganisation. He has been particularly fierce on the Conservatives for saying, before the election, that there would be no ‘top down reorganisation of the NHS’, and then carrying one out. His point being that it is not a matter for a Conservative politician to decide when a reorganisation is a reorganisation; it is a matter for the NHS – since they endure the turmoil of change.

This is a powerful charge, and one that has had considerable resonance with the NHS where they recognise the upheaval that this reorganisation has brought about. Variously people, including the Labour health team, have said that between 2 and 3 years has been lost to the NHS whilst everyone has had to apply for jobs. People have been anxious for a long time, and have taken ‘their eye off the ball’.

Indeed in his recent King’s Fund speech Andy Burnham said that one of his two principles about the debate on reform is that, “Our fragile NHS has no capacity for further top down reorganisation having been ground down by the current round. I know that any changes must be delivered through the organisations and structures we inherit in 2015”

I don’t think he can be clearer than this in his intent. The problem is that his wish NOT to have a top down reorganisation is overcome by his stronger political wish to attack the Conservatives and repeal the 2012 Health and Social Care Act. To try and square this circle he says, “Where we retain the organisations we will repeal the Health and Social Care Act”  As we shall see if you repeal the Act you will need a new Act and this new Act will actually create a top down reorganisation.

Politically this is a very bad idea. I would go so far as to argue that having a policy which would undoubtedly be experienced by the NHS as a top down reorganisation, whilst claiming that it isn’t (and that you know best), could be the one thing, outside of the economy, that in the year before the next election could lose Labour the most political support.  I’ll explain why later in this post.

Andy Burnham says now that his reorganisation will not be top down since it will be based upon the existing structure of Health and Wellbeing Boards in every major local authority. At the moment these give advice to CCGs on spending the money they receive from the NHS to commission healthcare. The CCG is the statutory organisation, and what Andy Burnham is suggesting is to switch this around so that the CCG gives the advice to the Local Authority Health and Wellbeing Board and that the latter becomes the statutory organisation for commissioning NHS care.

And he says this is not a reorganisation since both organisations currently exist.

This really is disingenuous. One of the major changes in his plan is the rerouting of £65 billion of central government taxation that will have, up until now, been spent through NHS organisations. This will now be moved to local government.

At the moment the CCGs have the staff and authority to spend this money but this will be changed. This will require an extensive piece of legislation involving two major Departments of State – Health and Communities and Local Government. All of the clauses necessary to move this responsibility from PCTs to CCGs in Andrew Lansley’s Act will have to be in this new legislation to move it again, from CCGs to local government.

The staff, working for CCGs at the moment, will have to be transferred to the local authority. This will be a much bigger upheaval because they will move from NHS terms and conditions to local authority terms and conditions.

Whilst at the moment it is not clear what would happen to the National Commissioning Board (NCB), it is difficult to see how an organisation set up to performance manage CCGs could now performance manage local government. So I can’t see it being left untouched, which means the reorganisation of the £12 billion of specialist commissioning as well as the £20+ billion of the commissioning of GP services.  Again, all of the clauses in the Act that created the NCB will be necessary to un-create it and establish elsewhere.  (Where? – the DH perhaps?)

It’s also difficult to see Monitor being left unchanged by Andy Burnham’s policy of “NHS preferred provider”, so there are another few hundred clauses there…

This will be a big Bill. (As big as Andrew Lansley’s.) This is where there is a simple definitional issue of what is (and what is not) a ‘top down’ reorganisation. One of the main definitions must be – yes you’re right – that it is made from the top, downwards. These proposed changes will be made from the top downwards. They will need the Labour Party to win a General Election to bring about national change. It will require extensive Parliamentary legislation to make it happen. Not only will it be from the top down but it will reorganise every aspect of NHS commissioning. That tends to suggest that a) it’s a reorganisation, and b) it comes from the top.

So let’s role play this for a moment. Let’s assume that this remains Labour Party policy and move forward to the spring of 2014 – a year before the election. The Labour Party is saying that it is going to make a few organic changes to the NHS that will not add up to a top down reorganisation. By this stage many people in the NHS will be thinking, “My God they really mean to do this. They are really going to change the whole of commissioning. He we are, in April 2014, just one year after CCGs were created and now the Labour Party is planning to change it all. They can’t be serious? But they are!!”

Andy Burnham will say it isn’t a reorganisation. Many people in the NHS will then be saying, “But that’s exactly what the Conservatives said in 2010! And you Andy quite rightly pointed out that they did not keep their word. Now you are saying the same thing. You’re planning to change everything but claiming it is not a top down reorganisation!”

Someone like Lord Ashcroft will then carry out a poll of nurses in marginal seats with the question. “Do you want the next government to have a top down reorganisation of the NHS?” About 9 out of 10 say no, they don’t. (They really, really, don’t.)

The rest of the spring sees nurses pleading with the Labour Party not to do this.

Later that same spring the GPs, who have spent a year learning how to run CCGs, learn that if the Labour Party wins power they will remove this responsibility leaving them with only an advisory role for local government. Many of them, having been running their CCG and making real decisions for over a year, will not be best pleased with this. They may well say that the time for clinicians advising has passed and now the job of clinicians is to make decisions about commissioning. (More on this next Monday).

A new survey commissioned in the summer of 2014 reports that 90% of doctors do not want a further reconfiguration.

This is the point at which, after 4 years of the politics of health being very tough for the Conservative Party, it starts – for the first time – to get easy. They now have 9 months before the next election during which the Labour Party has to justify turning everything upside down while the coalition parties only have to say that we need a time of quiet for the NHS after the election, not a further organisation.

To win the next election Labour will need to poll between 20 and 25 percentage points better than the Conservatives when the electorate answers the question “Who has the best policies for the NHS?”

If, with a few months to go, the Labour Party policy is one of the total reorganisation of commissioning, this lead will evaporate.

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