Tuesday, 20 March 2012

The NHS just entered a whole new era

With last night's passage of the Health and Social Care Bill through the House of Lords, and today's probable final passage of the Bill through the Commons, the largest single change in the history of the National Health Service is now all ready to be enshrined in law.

The largest single change? Really? Without ever mentioning that in the two governing parties' manifestos, or even in the Coalition Agreement?

Yes. And here's why. The Bill and the Act transfer most of the NHS budget to groups of General Practice commissioners - on the basis of extremely slight and extremely controversial evidence that this might drive up standards. Such a sudden, dramatic and far-reaching upheaval finds its justification in Scandianvian and French systems that contain a far grater plurality of providers. But moving to this system, from a rather more command-and-control system, in just a few short months and years, is nothing short of a huge leap in the dark.

The Bill will also allow up to 49.9 per cent of hospitals' work to be in the private sector, as against the two per cent or so cap that the previous administration effectively used to hold down the amount of private work that NHS hospitals could do. Despite Liberal Democrat protestations to the contrary, there will be a slow and gradual climb in the amount of private work that NHS hospitals bring in. It's constrained to five per cent a year increases before the regulator will start to take an interest, but those numbers will mount up quite quickly over a Parliament or two.

We've been here before in some ways. The NHS was reorganised in 1972-73 (disastrously), and in the late 1980s (not quite so disastrously), before a torturous and labyrinthine set of acronyms and changes were flung at hospitals and doctors by New Labour. Each time great wails of complaint went up, but the NHS continued to provide so-so care, quite cheaply, and free at the point of use. Note, however, how different things are this time - the Royal Colleges didn't usually oppose those previous changes; those 'reforms' didn't fundamentally (and without testing and piloting) alter the whole position of family doctors in the system; and they didn't come at a time when the Service was about to face the biggest cash squeeze in its history.

As I've written elsewhere, what we're looking at is risky. And these changes are not just shunting around common-or-garden general, indiscriminate risk either. What they do is take us back to the 'patchwork quilt' of provision that preceded the inception of the NHS, and under which charities, local authorities and others provided care under a whole range of funding options. What that meant was the unpopular 'postcode lottery' we hear so much about was a daily fact of life; that each city and even each surgery could provide very different services; and that the sharp-elbowed and the loudly-complaining were even more powerful than they are today.

It's a huge leap in the dark - from managed commissioning to a much more decentralised system; from a public service to a far greater role for the private sector; and from a national NHS to a decentralised group of individual purchasing impulses.

Will it work? Er, your guess is as good as mine. And about as good as the Secretary of State's. He's unlikely to be in his job for that much longer, so someone else will have to pick up the political tab. Watch this space.

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