Filed Under (Coalition Government, Health and Social Care Bill, Narrative of reform, Reform of the NHS) by Paul on 06-02-2012
The problem with the Health and Social Care Bill is that it moves reform backwards.
Over the weekend I had several conversations with journalists questioning whether the Government really needed a Bill to achieve the main themes of the NHS reforms that they want.
The short answer is no – and I will elaborate on that tomorrow.
But each discussion began with the realisation of something even more alarming for the Government – that was also a bit of a surprise for the journalists.
Here is this enormous Bill, requiring the expenditure of huge amounts of political capital to get it through parliament, and the outcome, even if it passes, will be a worse platform for NHS reform than before.
How did that happen?
The Government chose a blockbuster Bill as its preferred method of changing the NHS. It did not have to do it this way.
It could have chosen to change it through regulation, change management, financial incentives – there are a wide range of change mechanisms at its disposal.
But they chose a Bill. They chose legislation.
In 2010, with both Bill and White Paper, the Government decided to move NHS reform forward by fighting a war of position. Major legislation fought through both houses of Parliament was a mechanism for change that appeared suited to a new Government that had just assembled a large majority in the House of Commons.
They believed that a Coalition Government, enjoying a majority in both Houses of Parliament, was well placed to bring about a major reform by using the political arena where it was clearly in control – Parliament. Bring about change in the place where you are strongest.
The Government was pretty weak in, for example, the ranks of NHS senior managers. It would have had few supporters there. So it made sense for the Government to fight the battle for change where it was strongest – in Parliament.
Win the battle in Parliament and you change the terms of trade in all the other arenas where the battle needs to be fought. If you can’t win your case for reforming SHAs and PCTs – abolish them and replace them with new organisations.
The political theory goes that whilst Government may be weak in changing the nuts and bolts of PCTs – and of putting GPs in charge of that structure – they believe they are strong in creating legislation.
This is one of the reasons why the Government did not bother with a wider narrative for NHS reform in the country. It did not need that narrative in Parliament.
The Prime Minister changed all this in April. It was then that he discovered just how bad an idea it was to depend upon legislation without a wider campaign for the reforms. It was then he discovered that 60% of the public believed that Conservatives had a secret plan to privatise the NHS.
He could have called a halt then (and I suspect he now wishes that he had) but instead he stuck to the political strategy – we are strong in Parliament and we won’t lose a vote there. To maintain the strategy of winning through legislation it had to depart from its original concept.
So three times – in June, October 2011 and February 2012 – the Bill was substantially amended by the Government – in the opposite direction from the original. In December 2010 it aimed to ‘liberate’ the NHS from the centre. In June and October 2011, and again in February 2012 the amendments provided the NHS with much greater national control.
For the Government it doesn’t actually matter what the Bill says any more. They think it’s still their Bill and they won’t be defeated on it. They won’t be defeated because they will amend the Bill to ensure that we can get a majority.
If this Bill is passed it will in fact move reform backwards – leaving the NHS much more firmly nationalised than it was before it the Bill was introduced.
After the Bill more NHS services will be commissioned nationally than before
After the Bill more NHS public health will be commissioned nationally than before.
So whilst choosing the option of bringing about change solely through legislation may ensure the Bill is passed, the problem for the Government is that it won’t bring about the change that it was intended to.
If you are interested in effecting change, choosing to bring it about through legislation alone has its costs.