Tuesday, 13 March 2012

I break my silence on the NHS Bill

I appreciate that I’ve said nothing to date on the Health and Social Care Bill (referred to almost universally as the NHS Bill) – something that has been commented on by some readers.

There are a number of reasons for my apparent silence. The first is that this Bill will not have much of an effect on the Scottish NHS, concerned at is it with the reorganisation of the NHS in England. Secondly, I actually continue to work in the NHS and it is therefore appropriate that I am more careful than usual regarding what I say in relation to the Bill. Thirdly, as a former director of a national pressure group for health improvement I appreciate that it is almost possible to have a sober, non-emotive and pragmatic discussion about the future of the NHS. And, finally, I realised at an early stage how easily, if not managed effectively, this Bill could threaten to divide and potentially destroy the Liberal Democrats. I foresaw these divisions and decided I didn’t want to be pinning my colours to any particular mast.

When it comes to issues affecting the NHS, I always favour approaches that depoliticise as much as is possible, rather than attempt to turn it into a partisan party-political football. The NHS is far more important that that - at its heart are human problems, not exclusively political ones. The NHS is not the preserve of any politial party and collaborative working generally is far more effective in delivering NHS improvement than the tribal arrogance of politicians.

Let’s start off with some fundamental truths. The NHS’s 64 year history (65 in the case of Scotland, whose separate NHS was founded in 1947) is not as glorious as some would suggest and has for decades been a canvas onto which successive politicians have chosen to paint their very different and sometimes contradictory portraits of the future. It has been pulled one way and then another by health ministers with more interest in their careers, reputations or ideologies than in ensuring the health service is fit-for-purpose. In spite of the esteem in which the public seem determined to hold it, the NHS’s often credible successes cannot conceal the reality that, too often, it fails its most vulnerable service users – particularly in regards mental health care and services for elderly people. We don’t, as some naively insist, have “the best healthcare system in the world” - but I for one would settle for a system that at least cares for its patients and their families. Given that I work in mental health services, I’m sure you can appreciate that on many occasions my belief that the NHS should work in the interests of its service users has been utterly shaken to the point of destruction.

Let’s also take a look at the “p” word – privatisation. This is not a new phenomenon, or even a new feature of government policy. Ever since the Griffith Report of 1983 every successive government’s attempts at NHS reform have met with cries of “privatisation” as if public ownership in and of itself guaranteed a quality of service. Of course, the public backlash was often based on something more than an irrational fear of the private sector; the Thatcher government’s ideological obsession with the private market would undoubtedly have undermined both the service delivery and the ethos of the NHS itself. But the Conservatives did indeed introduce the internal market and this marketisation of the NHS was, contrary to the hypocritical howls of objection from Labour whenever any suggestion of private sector involvement is concerned, actually extended under Tony Blair.

I can remember as a health campaigner being at a meeting with then Secretary of State for Health Patricia Hewitt and having my objections to the economics of PFI practically ridiculed. Hewitt, lest we forget, was a health minister who oversaw job cuts and service closures as part an ambitious and poorly-considered plan to increase efficiency, while at the same time being determined to secure a place for the private sector in delivering primary care – New Labour had an almost obsessive belief that greater use of private hospitals for elective surgery was a necessary part of “patient choice”. That most people would “choose” a good, local NHS hospital providing as a full a range of services as possible didn’t seem to occur to Labour.

Labour’s thirteen years in power were not marked by a rolling back of the privatisation agenda, whatever they might be saying now. Some people clearly have very short memories. I’m not suggesting that Labour got everything wrong, but let’s not pretend that the Blair-Brown governments were anything other than friendly towards increased private sector involvement in frontline NHS services.

And there has historically always been a role for the private sector in the NHS – in the shape of the GP practices we all love. It’s not private services that are in themselves dangerous but the power of private providers to dictate terms to the NHS, to steer its direction or cherry-pick the more lucrative services.

Thirdly, the NHS needs reform. It doesn’t, as some seem to insist, need saving – at least not yet. What it does need is rethinking. Services should be constantly evolving and adapting to changing needs, but change must be carefully considered and clinically driven. If the NHS is to be an effective service and meet the demands of 21st century Britain, it cannot afford to behave as if it’s still 1948.

What the NHS does not need is permanent revolution – this, as we saw during Hewitt’s disastrous time in office – proved to be seriously destabilising. And so, when Andrew Lansley suggested before the 2010 election that NHS reconfiguration would be more considered and less kamikaze-style than his predecessors he seemed reassuring. He promised a moratorium on hospital closures, and that “all service changes...must be led by clinicians and patients and not from the top down.” This was something which, as a liberal, it was easy to identify with and while his insistence that patient choice should include “new independent and voluntary sector providers that meet NHS standards" was more than a little concerning, he was – effectively – only reiterating what Patricia Hewitt and other Labour ministers had several times before.

Within weeks of becoming Health Secretary, Lansley committed a significant u-turn. No longer did he support a softly-softly approach to NHS reconfiguration with policy direction being informed by clinical evidence. In addition to the broad and undefined pledges in the Conservatives’ manifesto (such as enabling patients to rate services, linking GP pay to results and providing opportunities for voluntary and independent sector providers) Lansley now promoted an unashamedly pro-competition Bill for NHS reconfiguration that was the product of neither coalition party’s manifesto nor a feature of the coalition agreement.

The rest, as we now know, is history. I do not wish to spend an inordinate amount of time discussing the evolution of the Bill during the previous 20 months. What I think is evident is that Lansley and Cameron have a greater interest in ensuring this Bill is passed than we do, and that had it not been for the intervention of Lib Dem conference last spring it is likely that our parliamentarians would have passed this without giving it much of a thought. Certainly many who have expressed criticisms in the last year, since concessions have been made, were making more positive statements about a much worse draft Bill prior to the wider party making its voice and concerns heard. While this underlines the influence of conference, it also suggests a certain lack of scrutiny of legislation on the part of our MPs.

And so we come to another federal Conference, in Gateshead, at which the party membership apparently wished to discuss nothing other than the NHS – not even Syria. That’s the view taken by the press of course; not having actually been there it is difficult to gauge the mood of delegates. The Independent was eager to describe how “the party’s unruly tendency…embarrassed Mr Clegg, reinforcing a perception that the Liberal Democrats’ leadership are doggedly pursuing a piece of unpopular legislation for the sake of showing political strength rather than being fully signed up to the merits of the changes”.

I have written in the past in support of the principles of coalition. I still believe in those principles. We are not in government to obstruct, but to imbue government policy with a strong liberal identity. It would be wrong to wish to drop this Bill simply because it would make us unpopular. What should ideally have happened at the outset is for the Liberal Democrats to have forced Lansley to drop the Bill as it stood, to rethink his vision for the NHS with input from clinical expertise and to redraw a new fit-for-purpose Bill. That has not happened and instead we’ve had a number of concessions, a fair bit of tinkering at the edges, plenty of hysteria and misinformation peddled on all sides and Dr Evan Harris given the opportunity to enthuse Conference and irritate the Tories. While the concessions are welcome and progress has meant that the Bill is certainly less toxic than it once was, there can be little escaping the fact that the government’s determination to push through the Bill is simply an exercising in saving face. Lansley’s position depends on a successful outcome which is why the Tories are willing to apparently offer any concessions in order to ensure this Bill finds its way onto the statute books.

Now, is Andrew Lansley’s political future something that we should have risked dividing our party for? Something we should risk our own values and principles for? Something we’re willing to pay the inevitable electoral price for?

Not everything in this Bill is bad. In fact, there’s a lot that is positive. But that does not mean that it’s a good Bill and it’s also true that many of the positive changes outlined within it do not require new legislation. What this Bill has not been is – to quote Lansley – “led by clinicians and patients” and is most definitely of the “top down” approach he claims to dislike. The various concessions that have been made to date, welcome as they are (especially in relation to the role of Monitor), do not obscure the inescapable reality that this is still a badly constructed piece of potential legislation, based on assumptions rather than evidence and political ideology rather than clinical practice.

The Bill has represented something of a triumph for Lansley – no previous Health Secretary has managed so successfully to secure opposition from practically every union, health pressure group and Royal College. That in itself is a telling statistic. Reaction from the likes of Unison, Unite, the RCN and the BMA was as predictable as it was inevitable. But when the Royal College of Psychiatrists claims that patient services will worsen as a result of the Bill and other usually silent, intellectually respected and more conservative voices such as the British Psychological Society make a similar case the government should realise it has problems.

What is the point in the government imposing its will on medical and health professions that are unwilling to accept the Bill or are even hostile to it? So much for the “hearts and minds” concept - it is setting itself up for inevitable confrontation with potentially damaging ramifications for both the government and the NHS. It would be an arrogance beyond belief that insists on kicking against the collective resistance of health professionals. At least Nye Bevan was able to fill the BMA’s mouth with gold – Lansley doesn’t have very much of that at his disposal and lacks the required skill or appetite for constructive negotiation.

Fellow blogger Andrew Emmerson fears that the issue has so divided that party that it has been “ the point of civil war”. I hope that is not true. But there can be no avoiding that this is a problem of the leadership’s making, that that issue has been badly handled by the party and that tensions within the party are now strained as a result. It isn’t helpful to see words like “traitor”, “Judas” or “hypocrite” being used by Lib Dems to describe fellow Lib Dems.

Where should the party go from here? As a believer in coalition, and the principle of collective responsibility, I’m not one for suggesting that we turn this into a war with the Tories. Many party members have the appetite for that sort of thing: Lib Dems such as Liberal Left who can see no scope for any relationship with the Conservatives or those who naively believe we will be rewarded in future elections for making the Tories a little less obnoxious. The truth is that we’re not in government to be a moderating force on the Tories – that is simply a by-product of our effectiveness, not our raison d’etre. We’re in government to work collaboratively to take the country forward and to ensure there is a liberal thrust to government policy.

If the Health and Social Care Bill was a product of the coalition agreement then I’d be encouraging our MPs to fight for whatever concessions we can achieve but not to reject the Bill outright. As it stands, the Bill is not even the product of Conservative policy, but of the disjointed and untested political ideology of one man – Andrew Lansley. No number of concessions can alter that. It is not being untrue to the responsibilities of coalition to tell our Conservative partners that the Bill in its current form cannot be supported – as Andrew George, John Pugh, Adrian Sanders, Greg Mulholland and David Ward have done. While Shirley Williams is no doubt correct when she insists that the Bill is very much better for its many changes, that in itself is no reason for accepting it.

I have sympathies with those who want the Bill to be dropped and never revisited. However, a more “grown-up” and constructive move would be to shelve it, consult with professional bodies such as the Royal Colleges and service users’ organisations while negotiating with our Conservative partners a new draft Bill based on our respective manifestos, the coalition agreement and the recommendations of professional experts.

It might not be a bad idea to establish an independent commission to report back within a year, which would base its findings on a range of clinically-driven and professionally respected evidence. This approach would go some way towards reassuring the public as well as taking some of the wind out of Labour’s sails. It would be difficult to accuse the Liberal Democrats of deliberate and direct sabotage, while providing a means of maintaining positive working relations around the cabinet table.

It may well be too late for this idea to prove workable. I suspect that irrespective of our Conference vote and the well-publicised concerns of many Lib Dem parliamentarians the Bill will become law. But that can by no means be guaranteed and I think a “shelve, consult, revisit” approach is likely to be more fruitful than either dropping outright or voting for a Bill for reasons of ensuring the stability of government. There is, of course, no immediacy or urgency and therefore no sound political or clinical reason for rushing the Bill through. There is still time for sober reflection, reconsideration and input from expert advisors.

Did I use the words “sober” and “reflection” together in a piece about the NHS? I am beginning to fear for my sanity.

As indeed Nick Clegg must also be doing. This debacle is largely of his creation and could arguably have been avoided if he had been less dispassionate and more obviously uncomfortable with the Bill from the outset. While very few people have come out of this with much credibility intact (including Shirley Williams who has unfairly been victimised by petulant individuals with little realisation of how hard she has worked to improve the Bill) Clegg looks as if he’s just received an important lesson in taking members’ opinions and expectations for granted. Let’s hope that he learns from the experience.


PrueBray said...

cracking piece and exactly right.

Amy said...

I hope this doesnt go through :/ Damn Nhs/government..

John Lyons said...

you might want to reconsider the statement

"The first is that this Bill will not have much of an effect on the Scottish NHS, concerned at is it with the reorganisation of the NHS in England."

Whilst this is essentially true, any savings made on expenditure in England due to privitisation of the NHS will result in a significant reduction in the money granted to Scotland under the Barnett formula.

That may very well result in the Scottish government running out of money and being forced down the privatisation route also.

Andrew said...

John - I'm aware of that, which is why I used the word "much of an effect". It will have an effect, just an indirect one and largely in relation to funding rather than reorganising the NHS.

I can't see the Scottish government going down the privatisation route - or at least I hope not. Hopefully the impact these changes will have on the Scottish NHS will be minimal, but at the moment this hasn't been examined in any detail and it's hard to make precise predictions.

Perhaps the effect this misplaced legislation will have on the Scottish NHS will be the subject of a future blog post...