A piece of advice that is often given to organisations that want to comment on government consultations is not to start “We welcome the opportunity to comment...”
No matter how long and significant the “but” that invariably follows, civil servants will take those six words and add the response to the ‘support’ pile.
Such, at least, is the suspicion. And the Department of Health’s response to the consultation on the July white paper, ‘Equity and excellence: Liberating the NHS’, does little to dispel it.
Over the past six months, the clamour of alarm about both the direction and speed of the reforms closely associated with health secretary Andrew Lansley has grown louder and louder.
This week alone, the House of Commons health committee, the NHS Confederation and the think-tank Civitas published reports urging caution. Yet the DH response reflects none of this.
It insists “there was widespread enthusiasm for the vision and principles of ‘Liberating the NHS’” and the “more than 6,000 responses” received contained “a broad mix of support, suggestions for improvement and critical challenge” that have resulted, at most, in a few tweaks to specific proposals.
Hazy days of summer
‘Liberating the NHS’ set out plans for a wholesale reorganisation of the NHS. Strategic health authorities and primary care trusts were to be swept away.
An NHS Commissioning Board and GP commissioning consortia were to take over commissioning. All trusts were to become or to be taken over by foundation trusts, while Monitor would ensure competition by taking on a new role as market regulator.
The white paper also promised a new focus on improving outcomes and said there would be an “information revolution” to empower patients and to drive quality by enabling them to make informed choices about their treatment.
The first notes of concern were sounded by the unions. Unison pointed out that the white paper’s proposals had not been part of the Conservative or Liberal Democrat manifestos or the two parties’ agreement for government.
It sought a judicial review on the grounds that Lansley’s decision to consult on the implementation of the plans rather than on the plans themselves breached several legal commitments to consultation.
Meanwhile, the British Medical Association, whose GP membership should have been enthusiastic about the proposals, said only that they were “good in parts”. And managers fretted about the risk of running a reform programme while trying to find £20 billion of ‘efficiency savings’.
By the autumn, the think-tanks were ready to weigh in. At the start of October, the King’s Fund questioned the need for a full-scale reorganisation of the health service and argued that one could distract from the need to find savings while maintaining quality.
It argued that GPs who really wanted to get involved in commissioning could be given ‘real’ budgets; and their participation widened over time. It also raised concerns about whether patients would really be able to use information to make choices about their care; and whether this would have the desired impact on quality.
A week later, the NHS Confederation warned there was an urgent need to preserve organisational memory and the jobs of skilled staff working in PCTs; both of which would be need by GP commissioners.
Acting chief executive Nigel Edwards urged the Department of Health to act quickly to clarify what management functions it wanted to preserve and what it wanted to maintain. He also raised similar concerns to the King’s Fund about patients’ capacity to use information to bring about change.
Raising the alarm
The latest set of reports follow the same refrain. On Wednesday, Civitas issued ‘A risky business: the white paper and the NHS’, fretting about the government’s focus on patient choice rather than commissioning and about its commissioning reforms.
In particular, it added, the government’s plans failed to address the reasons that PCTs had failed to be effective commissioners, and failed to explain what a more competitive market might look like so GPs could support it.
Civitas suggested that the government would be better freeing PCTs from SHA influence, giving GPs more statutory influence over them, and introducing a rules-based failure regime so GPs or other organisations could take over failing commissioners.
Meanwhile, the House of Commons Health Committee warned that the “tough” financial settlement on health and social care represented a “significant challenge” to the NHS and one that would require savings to be made on an “unprecedented scale.”
Unfortunately, the committee, which is chaired by Conservative former health secretary Stephen Dorrell, said: “We do not believe that the government is providing a clear enough narrative on its vision of how these savings are to be made.”
In addition, it added, those savings would have to be made “in the uncertain landscape of [an] NHS reorganisation” that would “have its own costs” – although the government had, again unfortunately, “failed to provide even a broad estimate” of what they might be.
Nigel Edwards agreed wholeheartedly, saying “we need the government to show it understands these issues when it announces the next stage of its programme.”
Deaf to all concerns
The government’s response to the white paper consultation does address the broad points made by unions, think-tanks and even Parliamentarians; but only to say in no uncertain terms that they are wrong.
So ‘Liberating the NHS: legislative framework and next steps’ says: “Some respondents, particularly many of the unions, were concerned that the white paper reforms might weaken the core principles of the NHS or undermine its future.”
But: “The government believes that these concerns are wholly unfounded... By promoting shared-decision making between patients and professionals, backed by clinically led commissioning and greater freedoms for providers, our reforms will strengthen the NHS as a universal, tax-funded resource.”
Or: “Many respondents supported parts of the white paper, but argued that major structural reforms were unnecessary or disruptive.” But: “The government disagrees.
“Our proposals build on the extensive evidence base from the reforms of the previous administration and the NHS reforms of the 1990s... what is new is this government’s determination to introduce a coherent, institutional framework underpinned in legislation... that will put the NHS on the best possible footing to cope with the twin challenges of tighter funding and making services more responsive to patients.”
It’s necessary to move quickly, the document adds: “not just to create a sustainable system for the long-term but because this is the only credible way for the NHS to deliver the productivity improvements that are needed in the short term... to achieve QIPP savings.”
The government has made some concessions. The Operating Framework for the NHS in England 2011-12 that came on the same day as the ‘next steps’ document says more pathfinder GP consortia will be introduced and that elements of joint working and oversight with and by councils will be strengthened.
Otherwise, it not only makes it clear that the government is pushing ahead but that the centre will play a strong role in bringing ‘decentralisation’ about.
So, the Department of Health / NHS Commissioning Board and strategic health authorities will performance manage the creation of the new data structures that they will need to monitor the performance of commissioners through the new NHS Outcomes Framework.
They will drive the consolidation of PCTs into “clusters” with “single chief executives” ahead of the emergence of consortia; not least to try and retain a core of required staff. They will also keep a tight rein on NHS finances.
As the reforms begin to happen, the BMA remains non-committal. BMA council chairman Hamish Meldrum told the union’s north east regional council that its policy was one of “critical engagement.”
“We are not supporting, we are not completely opposing [the white paper] but we are saying which bits we like and which bits we don’t like,” he said; urging members to stay involved to support the bits they like and to try and control the bits they don’t.
Managers seem similarly ambivalent. In response to the ‘next steps’ document, Nigel Edwards said: “We now seem to have come too far for there to be a practical way of turning back [but] no-one should be in any doubt that these reforms are both radical and high risk.
“One danger of predicting major problems in the NHS is its ability, against the odds, to rescue the situation. But much of the machinery the NHS has traditionally used to achieve such change is being dismantled, devalued or suffering from reductions in capacity.”
Yet the health secretary has no doubts. “The consultation process has strengthened the government’s belief that these reforms are necessary and our resolve to follow them through,” ‘next steps’ concludes. If it all goes wrong, he cannot say he was not warned.