Permissive, but not prescriptive
The recently passed NHS reforms will not break a beloved system, argues The Independent’s Health Editor, but the details of their implementation present clear dangers
Image above: London News Pictures / Rex Features
After the sound and the fury, time for some cool reflection. The Health and Social Care Bill is the most contentious piece of legislation to have passed through Parliament in living memory – but it does not mark the end of the NHS. Care will still be available to all, free, on the basis of need. The NHS will not be broken up overnight, nor is it about to be privatised. For most patients, things will carry on much as they are now – for as long as the money lasts. That is the most significant challenge the NHS faces in the coming years – making the money last. How to do more for less as demand rises and revenue remains unchanged will be the new refrain.
The Bill accrued more than 1,000 amendments, adding layers of complexity that have made it impenetrable to all but a few. The central plan was to hand control of the bulk of the £106 billion annual budget for England to GPs, who would be encouraged to go outside the NHS to buy services to stimulate innovation. At the same time, layers of management were to be removed and power devolved to the front line, freeing doctors and nurses to deliver better care. But the plans were so badly sold, they united opposition groups and professional organisations against them. Andrew Lansley, the technocratic Health Secretary, was a master of the details, but struggled to fuse them into a single message. As no one could explain what the changes were about, the view grew that there was a secret plan to privatise the NHS.
Key amendments to the Bill during its tortuous passage through Parliament include the provision for hospital doctors and nurses to be involved alongside GPs in deciding how the money is spent. Hospitals feared losing power to GPs. But this change will limit the scope for moving care into the community – one of the Bill’s chief original aims. Competition will be restricted to quality, not price, and will be introduced in a more managed and balanced way. This will reduce the risk of turbulence, and of ‘cream-skimming’ – picking off the easy cases – by the private sector. But it will also cut the scope for savings.
Shifting the blame
One change the Bill will usher in, which has attracted little attention, is that for the first time in the NHS’s history the people making decisions on treatment (the clinicians) will also hold the purse strings. When problems with long waiting lists or shortage of resources arise, the buck will stop with the GPs. In the past, doctors have been able to blame managers for the ills of the NHS. No longer. They will have to ration resources, and take the rap for unpopular decisions as the resources tighten. It is a politician’s dream.
The Bill is permissive, not prescriptive. It says what could or should happen – not what must happen. Much will therefore depend on how it is implemented. Lansley’s hope is that more care will be provided locally and by private organisations. Will Monitor, the independent economic regulator, press GPs to do so – or will it leave them to commission as they see fit?
Lansley’s critics claim that increased competition will lead to privatisation and the end of the NHS. Similar predictions were made at the time of Margaret Thatcher’s 1991 reforms, which, for the first time, split the health authority purchasers of care from the hospital providers and ushered in the ‘internal market’. Yet the NHS is stronger today than it has ever been, waiting lists are smaller, and the private sector’s share of the NHS market is low and has hardly changed in a decade.
The biggest worry is that the opposition to the Bill will translate into resistance to change. If that happens, the £20 billion productivity improvements needed by 2015 to meet increased demand will be at risk. Further savings will be required beyond that. It is often easier to continue with the status quo than to seek ways of making the NHS more effective. The complexity of the relationships between the bodies in the new, reformed NHS makes that a greater risk. But unless ways of doing more with the same resources can be found, the NHS’s future will indeed be under threat.
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