The Health Bill Balls

Should you feel sorry for Andrew Lansley? The Health Secretary has been polishing ideas for his Health and Social Care Bill for seven years and has spent nine months travelling around England explaining the changes to NHS staff, patients and MPs. But in the last few weeks the BMA has voted for the Bill to be withdrawn and reconsidered, the Lib Dems have voted overwhelmingly in favour of amendments, a study by the Nuffield Trust has found that only 23 per cent of GPs believe the reforms will improve the level of care already provided to patients, and 220,000 people have signed an on-line petition opposing it.

The headline concepts of the Health Bill are hard to argue against – get staff involved in designing and commissioning services, give power to patients and focus on better clinical outcomes. Lord Darzi, the Labour health minister, proposed just that and by the time Labour left office clinical outcomes were improving and patient satisfaction was at an all time high.

Labour’s good fortune was to invest heavily in the NHS without having to pick up the tab for the debt. Despite improvements in services, overall productivity hardly budged and Lansley is right to focus on this. But instead of laying waste to two tiers of NHS management in one sentence, he could have kept the best of the Primary Care Trusts, ditched or merged the bad ones and put more clinical staff and patients on the boards.

Lansley’s biggest error has been to downplay what effect the debt-reduction program will have on the NHS. The Tories made a big song and dance of securing a tiny increase in funding, year on year, but high inflation may wipe that out. The NHS has always swallowed up money at a rate far above inflation, so even if Lansley kept Labour’s NHS structure, the service would still be facing massive problems in the next few years. But because the focus of the debate is so heavily on his reforms, he’s likely to be blamed rather than the recession.
Lansley is desperate for clinical staff to take more responsibility for determining how limited resources are spent, and many would be happy to be involved in redesigning services if they weren’t already working eighty hours a week. Most major reforms need pump priming money to get them started, to pay for training and locum cover, but there’s little of that about. And although GPs are very adept at running small cottage industry practices, it’s a big step up for them to work together in commissioning groups and make the kind of instant productivity improvements that the NHS needs to stay afloat.

But it’s the labyrinthine complexity of the Health Bill that may sink it. The Outcomes Framework starts very well. There are only five of them 1. Preventing People from Dying Prematurely 2. Enhancing quality of life for people with Long Term Conditions 3. Helping people recover from episodes of ill-health or following injury. 4. Ensuring people have a positive experience of care 5. Treating and caring for people in a safe environment and protecting them from avoidable harm.

If the reforms focussed on those five outcomes, everyone would understand them. But they’re being translated into 150 quality standards and then they’ll be ‘fed into’ the Commissioning Outcomes Framework, the Commissioning Guidance and the Provider Payment Mechanisms of tariff, standard contract, CQUIN and QOF. Finally, the division of commissioning labour is split between the NHS Commissioning Board and GP Consortia, and the 60% of management costs that Lansley was so keen to save have been neatly reinvented.