Double dichotomy on the rocks

There are obvious dichotomies in the coalition health policy. While health secretary Andrew Lansley promised ‘no major top down reorganization of the NHS’, his chief executive David Nicholson has been busy telling anyone who’ll listen that ‘the reorganization of the NHS will be so huge you can see it from space.’ Lansley has now admitted that his changes amount to ‘a significant reorganisation of the management of the NHS’, and Nicholson has been rewarded for his impertinence by becoming surprise chief executive of the new NHS Commissioning Board. He will now take the rap if the NHS doesn’t come up with £20 billion of productivity savings by March 2015, an impossible task the Tories have labelled ‘the Nicholson challenge’ to ensure the buck knows where to stop.

GPs were supposed to hold the purse strings in Lansley’s NHS, but the government’s response to its White Paper consultation – helpfully released just before Christmas – has deemed that the ‘accountable officer’ in the new GP consortia doesn’t have to be a GP. This is good news for GPs, many of who were wary of taking on the top jobs knowing they could well be sacked in a few years when the debts mount up and Nicholson looks for someone to pass his buck on to. Some Primary Care Trust chief executives are now moving back into their old PCT buildings as the new chief executives of the GP Pathfinder Consortia, and Nicholson will still be pulling their strings. It’s a change so small you couldn’t spot it from the other side of the desk.

Lansley is hoping to distance himself from the front-line carnage of a cash-starved NHS by becoming the Secretary of State for Public Health. This at least recognises that no health service can cope with the current levels of alcohol abuse, smoking and obesity. Labour’s biggest health improvement was to ban smoking in public places, but only after sustained lobbying defeated John Reid’s ludicrous compromise of allowing smoking pubs in poor areas where people had nothing better to do than die prematurely.

Lansley’s Public Health White Paper couldn’t fail to recognise the impact of alcohol misuse. It costs the economy over £25 billion a year, the NHS almost £3 billion and is a major cause of violence, family breakdown and premature death. There is strong evidence that a minimum price of 40-50p for a unit of alcohol would significantly reduce future harm all round, but the Treasury review of alcohol taxation has come up with another toxic fudge by merely recommended a higher tax on high strength beer and lager. This leaves strong cider taxed at only 7p a unit and 9% wine attracting the same tax as a 14% wine. Alcohol is alcohol, and there are still far too many cheap routes to liver failure.

The UK is the European leader for alcohol-related disease and while the treatment and life expectancy for just about every other chronic disease and cancer has improved markedly over the last forty years, premature death from alcoholic liver disease has increased nearly six fold. For the millions already affected, the NHS offers a very disjointed service, with no quality standards, precious few dedicated alcohol care teams in district general hospitals and very little co-operation and co-ordination between hospitals, GPs, social and public health services. Too many staff are disinterested and judgmental, perhaps unsurprisingly given the widespread denial of alcohol problems amongst NHS workers. For every eight people who receive simple alcohol advice, one will reduce their drinking to within lower risk levels. This alone could have a huge impact if more staff saw it as their responsibility.

The British Society of Gastroenterology has already produced an excellent action plan to help the NHS sort out its alcohol problem, if only it could stop obsessing about reorganizing itself. If Lansley does nothing else in his five years but reduce the availability of cheap alcohol and increase the availability of a joined-up service for those with alcohol problems, he will do more for the NHS, and the health of the nation, than any amount of vainglorious structural reform. Happy New Year.