Health Matters | Paul Corrigan's blog

Two months ago, on April 4^th, the Prime Minister called for a pause for a bit of a think about his NHS reforms. That same day the chair of the Health Select Committee, Stephen Dorrell, noted that the Government had ‘lost control of its health policy’ and the last two months have witnessed some very machinations as various other groups of people and vested interest groups have set about trying to take over that control.

Yesterday the Prime Minister made a speech that, by going into much greater detail than had been trailed, sought to regain control of his health policy. Over the next few weeks we will see, as the story unfolds, whether he has been successful.

There are two main strategies which he has deployed to regain control of his NHS reforms.

Firstly he has sidelined his current Secretary of State from the strategic narrative of NHS reform. Let’s not forget that this is a Prime Minister who came into office not wanting to be chief executive of his Government but wanting to be its chair. He deliberately had no health policy expertise in Number 10 – instead trusting his Secretary of State for Health to take charge of policy.

By April 2011 he saw politically where this laissez-faire attitude had got him and decided that if the NHS reform policy was to survive at all he would have to take control.

This lack of trust in his current Secretary of State for Health has now reached such a low point that he now announces changes in policy himself – sidelining the Cabinet member who is meant to hold that responsibility.

So the PM has now regained responsibility for his NHS reforms but it is not clear how and when the Secretary of State for Health will be allowed to take back control (if ever).

His second strategy for regaining control of his health policy is to change it radically. He announced in his speech that there would be “real changes” to his plans for NHS reforms in England.

As a result, he said he would support a number of important changes to the proposals:

1. Doctors and nurses will be involved in new consortia planning and buying care, not just GPs
2. These groups will only take responsibility when they are ready – not by April 2013 as previously envisaged
3. New “clinical senates” consisting of senior medical professionals will oversee integration of NHS services across local areas
4. The NHS watchdog, Monitor, will have a duty to promote integration of care across an area
5. Greater competition will only be introduced when it benefits patient care and choice

Going through these five changes…

Firstly the Bill will now almost certainly enforce on GP Commissioning Consortia additional and specified people to sit on Consortia Boards. The promise made in the Bill – that has gone through its House of Commons committee stage – was that this matter would be left up to GPs in their consortium and that it was not the business of Parliament to lay down the detailed governance structure of the Consortium.

However it now looks as if this will indeed become the business of Parliament, and whilst we will have to wait until the Bill leaves Parliament to be sure, I suspect that, in the end, the boards of GP Commissioning Consortia will look a lot like the Boards of PCTs.

Secondly, there will be no deadline for the implementation of GP Commissioning Consortia (and by implication there can therefore be no date for the abolition of PCTs). This is a very important concession. The whole emphasis on speed and deadlines which has so characterised the behaviour of the PM and the current Secretary of State for Health has now stalled. It was always daft to think you could tell GPs across the country to do something everywhere from a certain date. So we are now going to get a two-tier approach to commissioning. In those places where the NHS Commissioning Board decides they are ready, GPs will take responsibility from April 2013. In those places where they are not ready the PCTs, that in almost every place have been abolished into clusters, will continue with the role that Government plans had previously wanted to terminate.

Thirdly a brand new tier of NHS bureaucracy is being created above GP Commissioning Consortia called “Clinical Senates” whose task it will be to create integration. I think this certainly means that the Government’s original intention to slim down the number of NHS state organisations will not be realised. By the end of this process they will have got rid of 152 PCTs and 10 SHAs and created over 200 GP Commissioning organisations and an unspecified number of clinical senates. It will be interesting to see how the Secretary of State defends the additional number of state bureaucracies in what was to have been a “liberated” NHS.

Fourthly, Monitor will get additional powers. On top of what I am sure will be a reworked relationship with competition, when compared to the task in the original Bill, Monitor will now have a duty to ensure that there are more integrated services in the NHS. The creation of integrated care, something that the existing NHS has failed to achieve in nearly every patient pathway, will be a massive new task for Monitor. It will be interesting to see if these additional powers for the new system regulator get through Parliament.

Fifthly, the Government will only introduce competition when it will create benefits for patient care or increase patient choice. What is interesting about this statement is that the only way you can make sense of this as being a change in policy is if there was a serious belief in the Government that previously they were going to introduce competition in areas where it would NOT improve benefits for patient care.

These headlines from his speech are a little bit premature as policy announcements. Apparently the Cabinet receives the report from the listening exercise next Tuesday and then will announce the policy changes to the Bill that follow on from that. One might have thought that the best time to relaunch the policy would have been then – when Cabinet and perhaps even the Secretary of State for Health had been involved.

But no. The Prime Minister is so determined that his Government should regain control of his health policy that he wanted to announce these changes in his reforms before any of the constitutional niceties have been completed.

Over the next few weeks we will see whether he has in fact succeeded in regaining control of NHS policy or whether this new strategy has given that control to his opponents – who will no doubt continue to exercise it.