Cameron’s Conflict

Why has David Cameron decided to go to war with the NHS? With just about every professional organization and journal opposing the Health and Social Care Bill, public support for it at 18% and Downing Street briefing the Times that the Health Secretary should be ‘taken out and shot’, Cameron has decided to be ‘at one with Andrew Lansley.’ In turning the Health Bill into a confidence vote, with the Lib Dems driving the getaway car, it’s extremely unlikely to fail. But it will hand Ed Milliband so many open goals in the run up to the next election, even he can’t fail to score.

It’s doubtful Cameron has read the Bill in its entirety –  it was unintelligible even before the 300 amendments – but Lansley does a very convincing line in whispered one-liners. The Bill will apparently ‘safeguard the NHS for the future’, ‘put patients first’ and ‘give frontline staff the right to determine how the NHS budget is spent.’ Lansley insists that to achieve this vision, the NHS needs a lot more legislation and a lot more competition, but there is no evidence-base for these reforms so  it’s a huge leap of faith getting staff and patients to trust him. Politicians rarely have jobs outside management consultancy or law, so it’s not surprising that the only professions lining up to make sense of chaotic legislation at £200 an hour are…. management consultants and lawyers. And many MPs have links with private companies that could benefit from the Bill. The potential vested interests in the NHS are about to be notched up by several orders of magnitude.

Support from GPs has fallen as Lansley’s promises haven’t stacked up. The fantasy that GP commissioning groups could be the size of bridge-clubs has been stamped on by the Department of Health. Small groups have been forced to merge into larger ones and forced again to have the same boundaries as the local authority. And the promise of less bureaucracy is laughable. The Bill has replaced three levels of management (DH, Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs)) with up to eight (DH, National Commissioning Board, 4 Clustered SHAs, 50 Commissioning Support Groups, 300+ Clinical Commissioning Groups, Clinical Senates, Healthwatch and Health and Wellbeing Boards.) Nobody has a clear understanding of what these organizations will do or how they’ll work together. They’re unlikely to liberate the NHS but the opportunities for tax avoidance are huge.

Even if frontline staff do get to play at deciding how the money should be spent, there is no evidence that they’ll do it well or have the time and energy to do it in-between patients. Labour’s massive drive for ‘world class commissioning’ was a big belly flop, not because frontline staff were excluded, but because the NHS doesn’t measure and compare outcomes to allow meaningful choices. If you buy a suit, you can feel the width and take it back if it falls apart. It’s harder to do that with a breast implant. So the NHS just buys the cheapest and hopes it doesn’t burst. The PIP scandal is an extreme example of what happens when you compete on cost (PIP implants were a fifth the price of competitors) without paying any attention to quality.

The one bit of Lansley’s reforms that makes sense is the Outcomes Framework. Until we have robust data comparing the harms and benefits of different treatments, clinical teams, hospitals and GP surgeries, commissioning will remain a confusing, wasteful mess. At the moment, there is very little hard evidence that patients benefit from their care in the long term. We cut them open or dose them up with pills but have no idea whether we do more harm than good. MD has argued for published outcomes since exposing the Bristol heart scandal in 1992. Twenty years on, and adult heart surgeons are the only profession putting their results on show to allow commissioners and patients to choose. If the NHS is going to compete, it has to compete on getting patients better, not balancing the books by fobbing breast cancer patients off with cheap silicon meant for mattresses.

Measuring is not the only solution. An open, transparent culture that ensures management act on poor outcomes rather than deny it as in Mid Staffs, is equally vital. At present, the best smoke alarm in the NHS is patients, relatives and staff speaking up when they encounter appalling care, and yet the brutal suppression of whistleblowers (Eyes passim ad nauseum) shows how much NHS culture needs to change. Alas, when a Prime Minister stakes his reputation on reform, the NHS nearly always becomes more brutal and bullying, and buries bad news. Cameron is about to repeat Blair’s mistake.

David Cameron has made the Health and Social Care Bill into a confidence vote, just as Blair did, which if history repeats will lead to a brutal suppression of dissent, the silencing of whistleblowers and more buried scandals. The Lib Dems should be deeply concerned about this, but they’ve been briefed to give a positive spin on their contribution to the Bill’s improvements, to mask driving the getaway car.  See below – and please comment!

The first point is obviously bollocks, given that Andrew Lansely has just given an exclusive interview to the Health Service Journal on ‘Why Competition is Crucial for NHS reform.’

Health and Social Care Bill: Top Lines for Lib Dems to Remember when doing Media Interviews:

 No more competition:

Liberal Democrats were clear that the NHS mustn’t be treated in the same way as the gas, electricity or utilities markets. That’s why there’s no longer any mention of promoting competition in this Bill. Instead, the number one priority hardwired above everything else is the interests of patients.

No favours for the private sector:

Labour rigged the market in favour of the private sector by giving them ‘gold plated’ contracts and paying them £250million for operations they didn’t even perform. We’ve made sure there won’t be any more special favours for the private sector by making it illegal for any future government to deliberately favour the private sector.

Secretary of State still accountable:

Liberal Democrat peers have secured changes to the Bill that ensures the buck still stops with the Secretary of State.  These changes mean the Secretary of State will remain politically and legally accountable for a comprehensive national health service. 

No decisions behind closed doors:

GPs and other doctors shouldn’t be allowed to spend public money without being required to tell us how they’re going to use it.  Changes pushed for by Liberal Democrats mean that commissioning groups will now be open, accountable bodies required to meet in public and subject to FOI laws.

Evolution not revolution: The pace of change has been slowed down to ensure changes are not rushed into. There are no more arbitrary deadlines so people only take on extra responsibilities when they are ready and able to.

Substantial change and scrutiny:

This Bill has undergone substantial change and unprecedented level of scrutiny. The Government have put down over 1,000 amendments, dedicated over 200hours to parliamentary scrutiny, and –for the first time in 9 years recommitted the Bill to committee stage.  No one can argue that this Bill hasn’t undergone substantial changes.

 Lansley goes over the top

You’ve got to admire Health Secretary Andrew Lansley’s lack of insight. Having united every Royal College bar the surgeons against his reforms, his website insists: ‘Andrew frequently visits hospitals and GPs across the country, listening to clinicians and NHS professionals and is well respected across the medical profession for his knowledge fo (sic) the NHS.’ And there’s more: ‘Aside from being appointed as the Secretary of State for health, Andrew’s proudest career achievements thus far include transforming the public’s view of the Conservative Party’s commitment to the NHS.’

This detachment from reality is not entirely Lansley’s fault. He tours the NHS tirelessly on largely pre-announced visits where the bad bits are hidden and the staff are too polite or frightened to blow the whistle. Even the collective chorus of dissent over his Health Bill coming from nurses, midwives and doctors hasn’t thrown him off his stride. This, Lansley claims, is just payback for the government downsizing their pensions.

Only 1% of doctors responding to a BMA survey thought the pension proposals are ‘fair and acceptable’ and two thirds said they would be prepared to take some form of industrial action. But Lansley knows doctors won’t strike and that the public aren’t bothered by the issue. Never mind that doctors renegotiated their pension agreements three years ago to ensure they were ‘affordable and fair’. In a recession, junior doctors aren’t going to win much sympathy by saying their annual pension will be slashed to £68,000.

More of an issue is making doctors work until 68. MD finds general practice tough enough at the age of 50. The thought of another 18 years trying to safely treat someone of 86 with seven diagnoses in under ten minutes is daunting. Or it would be if his job wasn’t disappearing at the end of March. The big threat to doctors is not their pensions, but that the NHS can no longer afford to employ all of them.  Many clinical staff are facing the axe, alongside managers, and it’s impossible to make such cuts without affecting the quality of care. Ask anyone at Mid Staffs hospital, past or present.

Lansley believes his Health Bill will keep up the quality in the face of cuts. He immodestly compares himself to Nye Bevan, fighting for vital reforms in the face of self-interested professional opposition. Those who are against him just don’t understand the Bill. Even Malcolm Grant, the chair of the NHS  Commissioning Board (NHS CB) finds it ‘unintelligible.’ The NHS needs to keep improving and clamp down on poor care but overall, survival rates for cancer and heart disease have risen dramatically. So why the need for such massive reform?

Anyone hoping for answers from the NHS CB – the unelected uber-quango that’ll run the NHS – may be disappointed. Last week, it published details of its ‘design’. 63 pages of wonk including such gems as: ‘The NHS CB will deliver improved outcomes through matrix working, by hard-wiring into the ways of working’  and ‘The NHS CB will have a consistent approach to leading change and transformation running through the matrix working approach. The change model will have two components:  massive improvement approach; and having clear principles for the application of that approach.’ All that disruption for this?

Lansley has at least set up a Whistleblower hotline, curiously run by Mencap, for those who wish to raise awkward questions (Eye 1305.). MD called  08000 724 725 and was told: ‘The number you have called will be charged at a rate of 14p a minute and will appear on any itemised bill. If you do not wish to continue, please end the call now….. Thank you for calling the whistleblowing helpline for health and social care. A Customer Service Adviser with you shortly… MENCAP is now closed.’ The line then went dead.

The NHS has to make 4% savings and, as the Health Select Committee pointed out, the chaos of Health Bill is making this harder. Patients will suffer and whistleblowers won’t be heard. But at least the hotline is bringing in money, even when it’s closed. Genius.