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Wednesday, 15 June 2011

Lansley’s NHS plan ditched as Health Bill reworked

As a Liberal Democrat, you might expect me to be ecstatic following the announced changes to the Health Bill. Well, I’m certainly pleased that the worst elements of the Tory plans have been either scrapped or significantly diluted, but I’m not willing to get too carried away. While the new draft Health Bill is an enormous improvement on what was previously being proposed, I still have some concerns about what it will mean in practice. I also see little reason for elation or triumphalism from our MPs or our leadership (who allowed the Bill through its first two readings without any opposition) – although I would excuse party members their moment of celebration given the role of Conference in holding the government to account in a far more effective way than our parliamentarians did.

Andrew Lansley’s controversial Health and Social Care Bill has undergone significant and substantive changes. This is a welcome development but, in the circumstances, not entirely unexpected. Since the Liberal Democrats’ spring conference in March – during which party members tabled demands to slow the pace of change, increase accountability and avoid giving preference to the private sector – the Liberal Democrat parliamentary party have been more aggressive in opposing the ill-conceived Bill. But they’ve not been on their own: the BMA, health unions, patient groups and NHS staff have also expressed opposition, and the public similarly have shown little appetite for it.

Eight weeks ago, in the face of growing opposition, the government announced that the independent Future Forum, chaired by Professor Steve Field, would be commissioned to make recommendations on the original Bill. Yesterday, the government responded to these recommendations, effectively accepting Future Forum’s findings. Among these are stipulations that private providers will not be allowed to “cherry-pick” patients, and that the government “should not seek to increase the role of the private sector as an end in itself”. The Health Secretary will remain “ultimately accountable” for the NHS (Lansley had hoped to reduce the responsibilities of the health Secretary to merely the promotion of public health) and there will be increased scope for local accountability. The arbitrary 2013 deadline for completing the reforms is done away with, while GP-led consortia – which will be responsible for commissioning services and taking responsibility of a sizeable proportion of the NHS budget – will be made up of health professionals from across the various disciplines. Monitor, the Health Service regulator, will no longer be allowed to “promote competition” but to instead promote “choice, competition and collaboration”. All this is good news. Even the unions are cautiously welcoming the changes.

The Daily Telegraph reported, with apparent regret, that vital NHS reforms will be “watered down”. “The role of private companies in the NHS is likely to be restrained while patients’ rights are bolstered under plans to rescue the Government’s health reforms” it opined. Quite why strengthening patient rights should be seen as a negative development is a mystery to me. As someone who has campaigned for such improvements for many years, I am naturally pleased that the NHS should become more patient-led and driven by need rather than the interests of the private sector. Unfortunately, there will always be those who feel the NHS can only move forward if the C-word is made super-significant: many Tories are deeply unhappy that the central principle of introducing competition has been scrapped and are now arguing that the changes necessary for the sustenance of the NHS have been rejected. This is utterly wrong. The NHS does need to be reformed. The status quo is neither sustainable nor desirable. But change must be responsible and it must also be evidence-based, tailored to address the nation’s health needs and driven by the public interest – not those of private companies. I have never been convinced by suggestions that competition in itself would be a catalyst for NHS improvement. But even accepting this, I would be concerned about the context in which competition takes place in Lansley’s vision which would simply have allowed private providers to take from the NHS without giving anything back.

Paul Burstow yesterday rejoiced that “competition has been put back in its box”. This didn’t go down too well with Conservative MPs. I’m sure it went down a bit better with those who work in the NHS, the unions and patients’ groups.

Labour leader Ed Miliband issued a statement yesterday in which he failed to discuss the amendments to the Health and Social Care Bill and argued that “David Cameron is undermining the NHS with an incompetent and bureaucratic reorganisation which puts profit before patients. Cameron made a solemn promise before the general election: no more top-down reorganisations. Yet that is exactly what he rushed in to with an ideological plan which he confirmed today is going ahead. The consequences will be billions of pounds that should be being spent on patients instead being spent on making people redundant in the health service. Patients are losing out with higher waiting times and a worse NHS. The best thing the Government could do is go back to the drawing board and scrap this Bill.” I’m not going to disagree entirely with his analysis of the Conservative default position, but it’s a shame Miliband didn’t feel able to recognise the far-reaching changes to Lansley’s original blueprint that have reversed the position in which patients were secondary to profits. I think it would have been more constructive to have examined the detail of the new proposals, which while positive are perhaps not everything they could be. Given his statement last week, in which he proposed increased cross-party collaboration on the NHS, it is more than regrettable that he already seems to have ditched this high-minded idea – preferring instead the easy politics of tribalism and oppositionalism.

In the House of Commons debate yesterday afternoon, the worst sides of many MPs were on display. Many Labour MPs followed their leader’s example of failing to respond to the actual changes to the Bill being discussed and opting instead to make misinformed and near-apocalyptic predictions of “privatisation” – something that has never been entirely absent in the NHS and was certainly encouraged by the previous Labour government. Dennis Skinner, his usual abrasive self, seemed furious that the NHS Bill had only been changed to satisfy “tinpot liberals", which I have to interpret as the ultimate backhanded compliment. Thanks for giving us so much credit, Dennis! John Redwood was on hand to insist that the changes were not as a result of Liberal Democrat involvement – but if that is the case, where else did they come from?

In truth, these welcome changes would not have come about without Liberal Democrat Conference putting pressure on our MPs to take a firmer line. For our leadership to spin this as their victory is therefore more than a little disingenuous; prior to conference our MPs had expressed little or no concern about the direction of Health policy, despite it so blatantly contravening the policy platform set out in the Coalition Agreement. And so, if it is a Liberal Democrat victory, it is a victory of democratic process: a victory for the members and activists, not for the leadership. But, similarly, such a victory was only possible because of widespread opposition from the unions, the BMA, charities, patients’ groups, NHS staff and the public. It’s surprising that Miliband and Skinner don’t want to give credit to the unions’ role in shaping more progressive legislation. Some credit should also go to George Osborne, who realised early on that Lansley’s unpopular proposals risked damaging the Tory brand and urged a rethink.

Many people come out of this with some credit, but Lansley himself emerges battered and bruised. He is more than humiliated; he has been completely undermined. In the last few days he has had to listen to Nick Clegg –and, more tellingly, David Cameron – prove that his plans were in some respects fundamentally wrong. No-one believed the Health Secretary when he said “I am delighted about having to make these amendments to my Bill”. While some of the principles of the original Bill have been retained, such as clinician-led commissioning, integrating health and social care, tackling bureaucracy and increasing engagement with patients, the heart of his ambitious plans have been ripped out of the Bill. It is questionable whether Lansley can survive: the latest developments do not obscure the fact that only 20% believe that the NHS is safe in Cameron’s hands, according to Conservative Home.

There are some lessons we should take from this debacle. Firstly, we should deal with policies before they're launched, making clear where they have originated from and what their objectives are. Policy must be examined and scrutinised more thoroughly in future; had conference not empowered our MPs to make a stand the consequences of allowing Lansley’s Bill to pass would have been catastrophic. Secondly, as Lansley has found to his cost, rigid thinking and digging yourself into entrenched positions can be fatal, especially when it comes to promoting radical changes. Such changes should be done gradually, not imposed from the top, and should always be organic. Thirdly, listening exercises should ideally be done prior to embarking on a course of action, not once a discredited policy looks set to be defeated. Fourthly, and perhaps most importantly, this saga has demonstrated the significance of internal democracy. The influence of Liberal Democrat Conference can not be underestimated.

While I applaud the changes, I have some concerns. Firstly, I dislike the NHS being used as a political football. It’s bad enough that some Labour MPs feel the need to opportunistically and dishonestly use this for their own ends, but that is to be expected. We’re also seeing some Conservatives, like John Redwood, who are claiming that the Bill is still essentially the same, while other Tories argue that Downing Street has caved in to a weak Liberal Democrat partner. Neither of these perceptions are accurate, but both suggest an unhealthy pre-occupation with the political rather than the health needs of the nation. Redwood’s interest is with saving face, rather than patient care. Other Tories, quick to berate their leadership for a u-turn (especially where promoting completion is concerned) show themselves to possess that obsession for privatisation so characteristic of the Thatcher era. More pertinently, such attitudes suggest a straining of relations between the coalition partners and it is highly possible that partisan perspectives will re-emerge to create a crisis in the future.

From a Liberal Democrat perspective, I’m not going to play down the victory. You know it’s a victory when the Daily Mail complains that the Lib Dem tail is wagging the Tory dog. But it is a victory for commonsense over ideology, of social justice over big-business interests and of internal democracy over party leadership. It’s a victory for Conference, not Nick Clegg. Admittedly, I’m sure this will help restore both the party’s and our leader’s standings, and it’s becoming clear that we can operate effectively as an independent party within government. But I dislike the misplaced triumphalism. The BBC reported that, on Monday evening, Nick Clegg waved around a scorecard of Tory U-Turns at a meeting of his parliamentary party. It is disturbing on two levels: firstly, the NHS isn’t a political football and I don’t care for even Nick Clegg playing this shameful game, especially as it was conference that allowed him to save some face on the issue. Secondly, this incident suggests an approach to government that is unhelpful and I think unwise.

Our role in government is not simply to curb Tory excesses, although I hope we will do that. We’re also not in government to continue acting as if we’re in opposition. Liberal Democrats can be proud of what we have achieved, but it is an achievement because government policy is more progressive, and more inherently liberal, than it would have been without us. That is positive. But I dislike the notion that somehow achievements are measured by the degree to which we can score points at our coalition partner’s expense. Coalition government is about co-operative and pluralistic approaches to politics, which are hardly suggested by obsessive one-upmanship. This is important, because if the Liberal Democrats are to ensure more progressive policy in relation to welfare reform, we’re going to have to work collaboratively with the Tories to achieve it. And while it’s no bad thing to play up our distinctiveness, it’s also in our interests to make the coalition work.

The NHS does not exist for the sake of politicians. Like other Lib Dems – in fact, like any other person who believes in a patient-focused NHS – I am delighted at yesterday’s announcement. I am, however, less pleased at politicians of all parties playing their political games with the NHS. There are challenges lying ahead that need to be risen to; challenges that I believe have been regrettably overlooked.

The real question is not whether the new draft Health Bill represents an improvement on Lansley’s original plans, but on whether it actually improves upon the status quo. I am cautiously optimistic that it does, but I am not entirely convinced and the wording of the new Health Bill has set some alarm bells ringing. For example, while it is obviously an improvement that Monitor can no longer “promote competition” as its sole objective, what exactly does it mean to “promote choice, collaboration and integration” in addition to “competition”? These aims conflict, and inevitably while “increasing the role of the private sector” can no longer be an end in itself it appears that it can be justified as a means of promoting choice. Also, while private providers can not “cherry-pick patients” there are no stipulations in regards cherry-picking services which might effectively amount to the same eventuality. There are also further questions to be answered in regards how consortia will work in practice, what exactly is meant by empowering patients (a section that is notably weak) and how specifically the new NHS Commissioning Board is to help save £20billion.

In short, this victory is to be welcomed. But it is the first battle. Greater battles lie ahead if we are to ensure that our NHS continues to evolve and reform in the public interest. Shirley Williams wrote in The Independent that “Liberal Democrats can comfort themselves with the realisation that one of England's most trusted and best loved public services will now survive as the framework for our health care”. That is not disputed. However, the spectre of preferential privatisation remains and there is much even in the new draft Health and Social Care Bill that needs considering in greater detail. Liberal Democrats must ensure that what is on the table represents a marked improvement on the status quo, as well as a means of taking our Health Service forward. This is not a time for self-congratulation or making political capital from Lansley's incompetence, but for working to ensure the best possible outcome for the NHS. In that respect there is still work to do.

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