First published on Oct 11th 2011
As the Health Bill returns to the House of Lords for its second reading, what are peers expected to make of the increasingly vociferous messages directed at them?
I have written before about how most of the reporting sits at one or other end of a polarised debate, often showing limited understanding of either the NHS or this entire sector of our economy.
Andy Burnham, the new shadow secretary, says scrap the bill and we will work with you. But this is to deny the fact that the fabric of decision-making structures has already been dismantled beyond the point of no return. Going back is not an option. Too much has already changed for that to happen. Stopping mid change, leaving a vacuum within which confusion and indecision reigns is arguably even worse – possibly the surest way to seal the very demise of the NHS that people are clamouring to avoid.
It is therefore incumbent on the Lords to avoid the temptation for filibustering, scoring points from each other, and other parliamentary devices, so that the debate can be shifted onto a more worthy plane. Such a debate would pivot around what it takes to secure a sustainable future for health services:
- that are better at adopting innovation,
- in which all elements of the system drive together towards best possible outcomes for available resources,
- that ensure we continue to drive up the health of the nation, whilst also reducing the unacceptable inequity – both in terms of health (mortality /morbidity), but also in access to quality care when needed.
Many improvements have been made to the Bill through its previous readings, the Pause and revision, but uncertainty remains. The Bill continues to focus too heavily on structural issues, leaving unanswered those more important questions dealing with roles, responsibilities and effective governance. Such ambiguities include:
- detail of how Clinical Commissioning Groups (CCG) will be held to account;
- how Monitor will promote the integration of services whilst deterring anti-competitive behaviours;
- how the NHS Commissioning Board (NCB) process will work to evaluate and strengthen CCG Boards.
Current indications are that the NCB will continue conflating its important role to determine what needs to be done, with interference in how things should be done. If CCGs are to drive innovation, improvement and best possible outcomes, then they must feel a real sense of ownership.
Much commentary focuses on these individual issues, but the real risk lies in the unknown cumulative effect of how these interact. Current debates tend towards passionate defence of both ingrained vested interests and the proliferation of silo working. These have proven time and again to prevent progress, always keeping internal issues in the spotlight, instead of giving real attention to transforming the way customers (patients, carers, relatives, service users) are meaningfully engaged. “No decision about me, without me” will never become more than a collection of words until these internal issues are relegated to the back seat. What we need is an open-minded focus on how to achieve successful transition to a new shape. The health system is too big and complex, to be susceptible to management by central diktat. We need more emphasis on applying the best management science to understand how such a complex beast can be steered to achieve the desired outcomes, by using the right incentives.
We welcome the increased attention on integration, but success in tackling quality and efficiency, requires incentives to be aligned with outcomes throughout the whole system. GPs manage 90% of patient encounters, and need to retain identity as primary care providers, properly integrated with all other aspects of community and hospital care. There is a real danger that concentrating on developing their role as commissioners will prevent opportunity for better integration of provision. That GPs will be subject to conflicts is clear in recent stories, and the solution to place commissioning responsibility for primary care in the NCB makes a mockery of localism – surely primary care is the area which most needs and deserves to be given a local commissioning flavour.
Achieving the right balance here demands that Health and Wellbeing Boards are strong enough to direct the NCB and robust enough to hold them to account. Health and Wellbeing Boards bring the different cultures of NHS and local authorities directly together. Success of these boards is pivotal to the future. It is essential that they are rapidly gain maturity to deal with difficult issues robustly, demanding significant organisational development to face up to and overcome these often ingrained cultural differences and tensions. We see no attempts being made to nurture the new relationships on which success can be assured.
The Lord’s second reading has much to discuss and shape, but its biggest challenge will be to avoid the polarisation and misunderstanding which has shaped debate to date. There are important matters to be understood, which will make a real and important difference.