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Turning up the heat


22 July 2011

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A core aim of the Health and Social Care Bill was to remove the politics from the NHS. However since March the Bill itself has become the proverbial political football, kicked about by all parties for months only to be booted out of shape in recent weeks by the government itself. Having survived months of opposition from almost every health organisation, union or charity out there, the government finally admitted – under pressure from the Liberal Democrats – that the reforms had to be reviewed, and eventually, changed. So, will the 'reformed reforms' be an improvement on the original ones? Or has coalition politics killed the Bill?

Prime minister David Cameron told his Tory MPs the recent rethink of the Health Bill is "not about party politics", amid concerns too many concessions were made simply to appease the Lib Dems. But a recap of recent events would suggest otherwise.

As recently as March, Health Secretary Andrew Lansley and the government were still pressing ahead with their ambitious reforms at a rapid pace, unfazed by months of criticism. The Lib Dems and Deputy Prime Minister Nick Clegg ensured the Health Bill passed easily through its first two readings in the House of Commons, and NHS Chief Executive David Nicholson set the reforms in motion on the ground. GPs formed pathfinder pilot consortia quicker than anyone expected and primary care trusts (PCTs) were collapsing into clusters and preparing to switch off the lights.

Then the Lib Dems flexed their muscles at their spring conference in Sheffield. Party members decided they wanted the reforms thrown out, and their leader Nick Clegg agreed to take action. Only at this point did opposition to the reforms go truly mainstream – the British Medical Association (BMA) rejected the proposals at its special representative meeting, and a derogatory rap video attacking Andrew Lansley went viral.

Increasingly, Clegg painted himself as a martyr and reduced Lansley's complicated legislative framework (longer than the Bill that established the NHS in 1946) to some kind of corporate takeover of the NHS. Clegg told his party he would not let the "profit motive drive a coach and horses through the NHS".

In April, the Bill had become a political liability and the government launched its listening exercise to review the reforms.

Dr Paul Charlson, Chairman of the Conservative Medical Society, says the government's decision to hold a review was partly down to overwhelming opposition from the medical profession, but also simply because "they realised they would never get the Bill through the Lords". But at this point, many critics, including the BMA, still felt the listening exercise would be "a political exercise" and little would change.

Then came May's local elections and the referendum on the alternative vote (AV) – two political events seemingly irrelevant to the ongoing NHS debate. But the result for the Lib Dems was disastrous; support for the party had been blown to smithereens by Clegg's failure to stop Tory policies on tuition fees, spending cuts and, yes, the NHS. In an attempt to save his party, Clegg simply declared Monitor would encourage collaboration, not competition, effectively ripping the heart out of Lansley's reforms.

This was the beginning of the end for the Bill and the start of a period of infighting involving leaked emails and name-calling. The BBC's political correspondent Nick Robinson described how he witnessed "the curious spectacle" of Nick Clegg and David Cameron "competing publicly for the credit in undoing the reforms that they themselves proposed".

So, are the resulting concessions a response to the expert opinions of the NHS Future Forum? Reports that Lib Dems were toasting 'victory' and ticking off a checklist of changes they have achieved for party members suggest they are.

Nick Seddon, Deputy Director of Reform, says there has been "so much bartering behind close doors" that no one knows what the thinking is behind the latest reforms.

"Nothing in the Future Forum's response has surprised us given that the prime minster had been announcing very similar changes over the previous few weeks," he said. "It suggests the Future Forum was responding to what the government was suggesting. It's a huge fudge."

While it seems clear that the changes to the Bill are Lib-Dem influenced, it is arguable how much has really changed. Dr Charlson says the changes really are about "softening how their intentions are articulated" – and the way the policy works on the ground may change very little.

But David Worskett, Director of the NHS Partner's Network, says competition has been offered as a "concession" because "the public couldn't or didn't want to understand it."

He believes the work of the NHS Future Forum on the whole was "an honourable attempt to improve the reforms." But the debate became "horribly ill-informed" as it widened, he says. "Myths" over the use of the private sector have dominated where detailed discussions about contracting are needed for all within the NHS to get on with commissioning, he says.

Dr Charlson agrees that the debate became "frequently facile" as politicians took the debate public. "Most of the public don't understand how the NHS works. Some clinicians don't even understand the NHS, because they've never looked outside their own environment at what Germany or Spain do. It's been a very ill-informed debate."

Seddon, meanwhile, blames the prime minister himself for bringing misconceptions and fear mongering to the forefront. "The politicians have made it ill-informed," he says. "And it is the prime minister who has led on this. Joe Bloggs didn't know what cherry-picking was until David Cameron started warning against it."

Others think the changes are actually a fairly shrewd way of progressing the reforms unchanged. Nick Bosanquet, Professor of Health Policy at Imperial College, said the government's proposed changes are "cosmetic", yet will appease the Bill's critics.

"If you look at the Future Forum's report, it has actually been a ringing endorsement of the principles of the plans," he says. "The government can move forward now saying they've made some changes and 'let's move on.' The changes are relatively minor, and essentially cosmetic – but cosmetics are important." Bosanquet believes that, regardless of the government's shifting rhetoric on competition, pressure on local GPs to spend less will lead them to consider alternative providers.

Dr Charlson is also confident that GPs, as commissioners, will survive the political turbulence and get on with the job. "A lot of GPs will be ready in consortia in 2013. There are always leading-edge people. It won't have delayed progress in the long term because this will hopefully speed up the parliamentary process – the Bill won't be toing and froing between the House of Commons and House of Lords, hopefully."

Seddon is not so sure, and is firmly in the camp that believes the ideological uncertainty introduced by the review will mire GPs in bureaucracy. "I think GP commissioning will continue, but at the same pace as practice-based commissioning," he says.

The listening exercise may or may not have been intended as a political exercise. But what is clear is that the Future Forum's recommendations largely accord with how Cameron had suggested the Bill might change. That, in turn, was what Nick Clegg decided to speak up for just as his party was on the verge of imploding.

The Health Bill still has a long and torturous journey through parliament to come. Plus, a series of crucial frameworks clarifying how the most contentious aspects of the Bill work in practice are still to be published. But given what has happened so far, nobody can claim to know what the final bill will look like when it becomes law – least of all Andrew Lansley.

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