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.