Thursday, 8 September 2011

The NHS reforms: Not bad

I find myself surprised at the surprise in the actions of most Lib Dem MPs with regards to the NHS Health and Social Care Bill, passed for consideration by the House of Lords yesterday by a narrowish margin of 65 votes. Obviously this figure of 65 gives fuel to the ire because it's a number that could have been reversed by a strong Lib Dem rebellion.

It also would have spelled the end of a coalition at a time when the country least needs it, with the Tories the only party that can truly afford an election right now (if "the word on the tweet" is true), and Labour completely unprepared for taking the reigns as they rediscover what they actually bring to the table.

But I find myself more surprised at the Lib Dem supporters themselves that are aghast at the actions of their MPs doing what they agreed to do when they signed the coalition agreement in 2010; not least because this is a very "Lib Dem" bill, and, if you believe that it can be achieved, is actually better for providing a progressive and improving health service than our current legislation.

Profit driven decision making

A possible hangover from the bill before it was paused and rewritten, there was a real fear that we would be continuing down the path that the Blair administration set us down which is privatisation of public services to the lowest bidder. It's clearly a system with huge risks, doesn't deliver adequate results, and leaves devastation in it's wake as we are unable to reclaim the standard we knew before.

Thankfully the new version of the bill specifically veers away from such plans. (Section 23 14Q)

The whole point of the bill as amended is that the commissioning consortia have to improve standards in care. It's common sense really...the people that are tasked with running a good health service are legally required to ensure the service is good. They aren't, as councils and similar have been in the past, mandated to go with the lowest offer and so it is not in the interest of private bodies to put in a low ball offer, the evidence has to be there that they can do as good a job as what is currently provided, or better, and that the service is value for money on top of that.

It's decision making with the needs of the public's health put first, not how much money can be saved.

Lack of public interaction

Not all concerns are so baseless, this concern is one that is centered on a lack of real information or clarity within the bill. The bill fairly loosely talks about involving patients in their own care...the intent for this is that patients will have options presented to them of how to achieve their care, and to be part of the decision making process for the journey ahead.

It also talks of a "Health and Wellbeing" board, that operates with the overarching commissioning board that oversees and regulates the numerous, yet all that the bill talks about is these bodies giving "advice" to the various commissioning bodies.

There is also a requirement for commissioning consortia to consult those affected by any changes that they make to healthcare provisions. (Section 23 14Z).

However the trouble with all three of these things is that without further embellishment they could let lazy elements within the NHS off with doing very little to engage with the public. Indeed the wording of consultation is right along side "provide information", and if commissioning bodies are able to get away with "consultation" simply by putting leaflets on a desk in GP offices then the spirit of the legislation isn't being followed.

Inequality of care

There are concerns voiced about two tier systems of care, the charge of "cherry-picking" of profitable services by the private sector while others languish. However it is not as simple as to say that, as the GPC deputy chair Dr Richard Vautrey claims, that old and vulnerable people will be treated differently.

It would be a breach of the law if there was an active decision made by commissioning bodies to split the same service in terms of profitability, and hand some patients to a superior care provider, and retain others on lesser conditions. For example, there could never be a situation where it was actively sustained to have elderly cancer patients dealt with by one service, and young cancer patients by another, without there being a clear comparability between the two in terms of quality and effectiveness. (Section 23 14S)

There is a problem with the differences between services. Will mental health patients get a comparative level of funding and care to those treated for cancer? The truth is that the situation on that front is not equitable right now, nor is there any framework to try to ensure that it becomes more equitable. If people want better standards of mental health care right now it appears there is no route they can rely on to try and force the matter...aside from lobbying politicians.

Under the new system there is a duty for the new commissioning consortia to try to improve standards year on year, obviously it is not a requirement to always improve as sometimes that will be impossible even with the greatest of wills behind it. If this duty is not followed, then the consortium can be told to act differently, members of the consortium removed or added, and even the consortium itself dissolved in cases of severely abandoning that duty.

If we're looking for more equal patient care then we have a much more robust framework to discuss that issue with in the Lords. Before there was nothing to stop ministers actively "running down" areas of healthcare for whatever reason, now there is.

Privatisation of healthcare

An obviously big concern is that of private companies taking over our hospitals and services, at least where there is no need, with no consultation and with no patient choice. This has been, I believe unfairly, highlighted by recent reports of considerations made for a German company to run 10-20 hospitals.

Yet the reports have no bearing on the future of the NHS, as strange as that may sound. The idea of ministers contracting in private companies to deal with healthcare would actually be impossible under new reforms, where local autonomy of commissioning bodies is paramount.

It helps to be more specific about what we mean by the dangers of privatisation, as surely it cannot be argued that if the best value for money (note: I didn't say cheapest) provider happens to be a private organisation, then that organisation should seriously be considered for provision. The downside comes when that choice is made without the patient in mind, when it is done purely on cost, and when the structure of any agreements are such that we risk running down an avenue where we lose all ability to provide services as a state because expertise is lost to these private organisation...all of which have long term effects of *not* being value for money.

Simply throwing out scare stories isn't an argument of why the reforms are wrong, or dangerous. In fact part of the reforms is to extend the scope of the body "Monitor", who will take on the task of being an economic regulator for providers of health and social care in England, and in doing so will be responsible for dealing with anti-competitive behavior. (Section 57)

What's interesting though is the that language talks not only about anti-competitive behaviour, but in the sense of behaviour "which is against the interests of people who use such services". Does this mean that there is a loop hole for the co-operation of GPs with established local bodies even if such co-operation were to be "anti-competitive" as long as it can be shown that it is for the benefit the public?

This is another area that needs to better clarified; adequate provisions must be made to stop businesses following the anti-competitive behaviours that could lead to a lack of choice further down the line. This bill is essentially about competition, and about choice, so to allow any chance of the opposite occurring but for the benefit of private companies instead of the public sector must be shut out.

In the end we should accept that privatisation can, in some cases, improve our NHS; not privatisation as Tony Blair helped push through while Labour were in power, but a new way of approaching it where the contract cost isn't king.

"Free" NHS on the way out

Put simply, there are no provisions in this bill for charging for services that aren't already being charged for (Dentistry, for example). However there is the wording that leaves such an option on the table. There's not much to read in to this, it's the kind of catch all "Just in case" wording to make legislating easier in the future. (Section 1(3))

I don't see this as a threat for the now, if there were a time in the future where additional charges were intended to be made then that is an argument for that particular time, and it isn't responsible to oppose this bill on decisions that would have to be democratically taken in the future.

Lack of accountability of government

Slightly more abstract is this issue of "accountability". Accountability comes in many shapes and forms, however it seems a lot of people just don't care about accountability unless it's via an election. It's, in my opinion, a terrible stance to take when talking about having decisions made correctly, not decisions made in the most popular manner.

The Health Secretary will no longer have responsibility for providing a health service in the UK, in a sense we're turning from a National Health Service to a National Health Franchise. But this isn't necessarily a problem. When I say above that this is very "Lib Dem", the very nature of taking decision making out of the power of the central governing body of the country and devolving/distributing it to local cells is a natural Lib Dem position for most issues.

And so accountability doesn't disappear, though it does change. Gone is the rather blunt force manner of changing the direction of the NHS, i.e. electing a whole new government with all the various OTHER changes in direction that comes with, and instead comes much more local (regional at least) bodies that take over from where Primary Care Trusts left off with better regulation but also more local autonomy.

Of course the reality is also that the Health Secretary hasn't had the direct legal duty to provide services since 2002 anyway, when Labour decided that those PCTs should be the ones that carry the duty. Sure, the Health Secretary could call back his legal duty, but in practical terms the authority and accountability of decision making with the NHS isn't really going to change.

The change the bill provides on this is only a problem if you believe that you need to elect everything in order to make them accountable. I, on the other hand, don't believe that we get better decision making through elected officials, nor do I think areas like policing or health benefit from the public having ultimate control over strategic direction. Quite frankly very few of us are crime, safety and health experts, and it's not our place to interact with those areas in such a direct manner.

Freedom of information

A concern across all areas of outsourcing and privatisation is that of lack of transparency within the organisations contracted to do the work. Freedom of information is a tool that is supposed to ensure that the public can see what is going on behind the scenes of public bodies, but some are concerned that not enough is being done to ensure private bodies would also be accountable to relevant freedom of information requests.

A lot of new approaches to how competition is approached are taken in this bill, it would also be the perfect time to quash this concern and start a new trend of telling companies that wish to get involved in public sector work that they have to accept public sector responsibilities too.

...

The ultimate question that should always be asked of reforms is "are they necessary?" and "How does it benefit us?"

It seems to me that the bill isn't quite selling itself as "necessary", but it does have interesting ideas on how to help make the health service more relevant to patients, to embed a culture in strategic direction that drives improvement and progress. These are ideas that, if they do work, could seriously benefit us and our healthcare; and given the practicalities of the duties are very similar to what we already have with regards to Primary Care Trusts and Foundation Hospitals there's a certain element of not taking a huge leap to get there.

I am not going to say I think that these changes will definitely work in improving our health service, I have deep reservations any time that the issue of privatisation and competition come up in areas that need such consistent and improving service. However I also can't take many of the criticisms leveled at the bill seriously, some seemingly out of date accusations of a bill that was clearly much worse before Lib Dem interventions on rewriting it to what it is today, as some of these criticisms simply do not stack up against the reality of what is being proposed.

The Tories were always going to reform the NHS, and the Lib Dems have come in and saved the country from a continuation of Blairite privatisation methodologies that have lead to tensions and problems where such a model has been applied. They've developed a robust framework for checks and balances, and as long as some more elements are improved through the passage through the House of Lords, there is a strong argument to be made that these reforms will help make the health service in this country more relevant and more progressive for patients.

Quite frankly, the reforms aren't bad, they have great potential...and I'm happy to "blame" the Lib Dems for that fact.

Edit:

Been made aware of this motion for Lib Dem conference that goes quite a way to dealing with most of the concerns that are legitimate above, and is worth a read.