Andrew Lansley- Man in a hurry runs risk of losing control
A policymaker’s dream. A pragmatist’s nightmare. That has to be the verdict on Andrew Lansley’s white paper “Liberating the NHS”, published on Monday.
In one sense it aims to complete the work of the last Conservative government – and much that the Blairites also wanted for the health service. The last Tory government tried to free NHS hospitals from direct management by health authorities.
It aimed to get GPs to buy patient care. And it briefly attempted to absolve ministers from responsibility for the day-to-day management of the NHS by creating a short-lived ministerial supervisory board with an NHS executive beneath it.
But it rapidly got cold feet over the likely impact of the quasi-market it had created, fearing the destruction it would cause would be anything but creative.
Labour, having first ditched much of this, recreated it earlier in the decade in a far more sophisticated form – with independent regulation and inspection and a tariff for NHS care that, in theory at least, encouraged purchasers to put quality above price.
It never quite sorted out who should do the purchasing – primary care trusts or GPs, who have been running a form of practice-based commissioning that, in most places, has been severely constrained.
But had the Blairite plans come to fruition, the purchasing of care would by now have been separated from its provision. All hospitals by 2008 would have been self-governing institutions, positioned part way between the public and private sectors.
Primary care trusts would have been solely commissioners, while their district nursing teams and therapists and community hospitals would now be independently run, either on a foundation trust model, or as social enterprises, or contracted out to the private and voluntary sectors.
There would also have been a more vibrant public/private/voluntary market from which purchasers could buy all sorts of care, with patients being able to choose between them.
What Labour – or more accurately Tony Blair and Alan Milburn, then health secretary – wanted is what Mr Lansley now aspires to create: a self-improving system run as a regulated market of competing providers driven by patient choice and commissioning in a way that no longer needs direct management from politicians and the health department.
From there, the step to an independent commissioning board, with ministers doing little other than continuing to raise the money for the NHS, setting its broad priorities, and then holding the board to account, would have been seen as an interesting evolution, not a revolution.
But the NHS is a long way from that. The Blairite reforms first slowed, then under Gordon Brown, pretty much stalled.
Half of hospitals are still directly managed and a chunk will never pass the financial viability test to become foundation trusts. PCT provider arms have still to be sorted out. Social enterprise in the NHS barely exists. Private suppliers have yet to demonstrate convincingly that they can consistently do things better and more cheaply than the NHS. And the best GP commissioners are still relative beginners.
Yet in a dirigiste decision that smacks more of old Labour central direction than anything else, the Conservative health secretary has decided not to allow GP commissioning to evolve into something demonstrably strong and effective but to require that all GPs – whether willing or not – do the job or acquiesce in their colleagues doing it for them. All in one big bang.
Mr Lansley’s plans amount to an NHS revolution. Virtually no part of the service will be untouched by his announcements on Monday, which aim, in barely three years, not just to complete Labour’s unfinished business but to go much further.
Issues Labour grappled with unsuccessfully, however, remain unanswered.
What, for instance, are the failure regimes for the new arrangements? And thousands of managers whose jobs are to go are expected to retain financial control throughout the upheaval while helping GPs take on their new role. The odds are many will bail out while they have the chance.
As Sir David Nicholson, the NHS chief executive, said on Monday: “The clarity of the vision is all very well. The big issue is how do we manage the transition.” With immense difficulty, is the answer. Mr Lansley, a man with a plan in a hurry, risks losing both financial control and performance.
Tags: Andrew Lansley, Doctors, GPs, labour, Labour shambles, National Health Service, NHS, red tape