More Chaos theory
When MD asked health secretary Andrew Lansley to reduce his unintelligible 358 page health bill to 140 characters or less, he wrote: ‘Putting patients and their doctors and nurses in charge, accountable for the results they achieve.’ Some staff were initially won over by the promise of liberation from political meddling, less bureaucracy and more control over how the money is spent. But while most now long to be liberated from Lansley, they’ve now realised there is no freedom if you’re shackled to an unelected economic regulator, Monitor, and an unelected National Commissioning Board. Worse still, the complexities of competition law and competitive tendering are likely to make the NHS more bureaucratic, not less. And it’s the economists who’ll be in charge, stupid.
If Lansley had wanted evolution, rather than revolution, he would simply have slimmed down the existing Primary Care Trusts, put clinical staff on the board alongside the best of the NHS managers and let them figure out how best to spend the money and focus on the quality and safety of care. By throwing all the cards up in the air, he’s created chaos, uncertainty and the perfect storm for another Mid Staffordshire scandal. The fact that even the more moderate health unions – the Royal College of Nurses and the Royal College of Midwives – now oppose the Bill outright and are calling for its withdrawal should make the Government reconsider. But it won’t.
Equally alarming is the confusion at the very top. Monitor is the make or break organization of the government’s reforms. David Bennett – an ex-McKinsey Blair adviser – is both chair and chief executive. Monitor was set up by Labour to be the independent regulator and assessor of NHS Foundation Trusts but under the Bill it becomes the sole economic regulator for the whole of healthcare – including the independent sector – in England. It has to regulate prices, licence providers, integrate care, prevent anti-competitive behaviour and support the continuity of services.
So Monitor has a special and long-standing relationship with NHS Foundation Trusts and yet also has to regulate the entire health sector. It sets the exam for everyone but has a vested and conflicting interest in ensuring Foundation Trusts pass it with flying colours. In an article in the Health Service Journal, Bennett warns that Monitor may face “numerous” allegations of improper conduct unless it can clearly separate its future healthcare regulatory role from its responsibility for Foundation Trusts. The revamped Monitor is hardly up and running in its new role and it looks as if the quango may have to split in two, or at least have two chief executives.
Given the financial climate, Monitor is going to have to make tough decisions and if it is perceived to have favoured Foundation Trusts over, say, the private sector than the NHS will be submerged in a succession of legal challenges. If a quango stuffed full of competition economists hasn’t got a handle on how competition law will affect the NHS, spare a thought for the virgin clinical commissioners. The bureaucratic complexity of having to make local decisions in the interests of patients while obeying national guidelines, regulatory rules and competition law will either make them panic and put everything out to competitive tender. Or they’ll spend a fortune on ‘commissioning support services.’ Or both.
The Scottish and Welsh NHS eschew a competitive market because there is insufficient evidence that it delivers better healthcare. In England, forty one ‘commissioning support organisations’ have already been proposed to help GPs make sense of the Health Bill. The only certainty in this chaos is that lawyers and management consultants will do rather well out of it. As for patients, Lansley’s promise of ‘no decision about me without me’ is beyond satire.