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ConservativeHome attack on NHS reform may prove game-changing

A consensus is emerging over which parts of the bill should survive if Andrew Lansley’s ‘big bang’ reforms are dropped

Among Conservative Home editor Tim Montgomerie’s telling points in his potentially game-changing piece about the government’s NHS plans is his description of the health and social care bill as “not only mangled and bureaucratic but also unnecessary”. The health secretary, Andrew Lansley, a minister for whom the word “embattled” could have been invented, has previously admitted that many of the radical changes he wants to see in the NHS in England do not actually require the gargantuan, hugely unpopular legislation that is now dividing the cabinet and may yet end his career rather than prove the defining highpoint he hopes. Many of the best-informed health policy experts, such as those at the King’s Fund thinktank, have said the same thing.

Over the past week the growing doubts about the bill – in the medical establishment and privately within the cabinet – have prompted speculation, none of it backed by strong evidence, about a possible “Plan B” that could replace Lansley’s bill. Influential NHS blogger Roy Lilley reported that sources at the Department of Health had told him they had had consultants in working on just such a fallback.

But Alastair McLellan, the editor of Health Service Journal – who keeps well-informed about goings-on in the Department of Health and upper echelons of the NHS – wrote on Thursday that the government does have a plan B. But he added: “Before anyone gets too excited about the idea of an alternative master plan waiting in the wings, it is important to put that ‘plan’ in context. What has not happened – as reported elsewhere – is that NHS chief executive Sir David Nicholson has employed consultants to develop this plan. Sadly the enticing powerpoint presentation that is doing the rounds detailing this work appears to have little credibility. But that does not mean people like [NHS chief executive] Sir David Nicholson, his deputy David Flory and other senior figures have not discussed – over past months — what would happen if the health bill was pulled or significantly reduced in scope.”

Despite this uncertainty, a consensus is emerging about exactly which elements of Lansley’s radical reorganisation would or would not survive the dropping, or huge scaling-back, of the bill. It is not black and white – there are many unknowns – but it does give a decent picture of how the NHS in England might look if evolution replaces revolution.

Despite the bill not yet having passed parliament, many of the changes it envisages have been happening anyway. The 150 NHS primary care trusts around England have merged into 50 PCT “clusters”, and the nine strategic health authorities (SHAs) have similarly been downsized into four mega-SHAs.

Under the bill they are all due to be abolished in April 2013, with their functions taken over by, respectively, GP-led local groups of doctors called clinical commissioning groups (CCGs) and the NHS’s new National Commissioning Board (NCB). There are already fledglings CCG in 95% of England, and the NCB – which is intended to fulfil the government’s promise of making the NHS more independent of ministers – already exists, albeit only in shadow form, with many of its key positions already filled.If the bill is dropped this massive structural upheaval would be left in a state of flux. But the key element of Lansley’s plan – handing CCGs £60bn of NHS funds to spend as they see fit on patients’ treatments – does not strictly need the bill to be passed for it to happen. The 50 PCT clusters could perform that role – as they do now – instead of the CCGs, which would wither on the vine.

Clinical commissioning is the bill’s motherhood and apple pie. Everyone supports that principle, even the medical royal colleges who want the legislation dropped altogether. So it would have to go ahead. But that could fairly easily be done by the clusters, although their boards would have to be stuffed with local GPs and other doctors in order to give them a measure of the control which scrapping CCGs would deprive them of. No one would argue with that, and the ferociously anti-bill Royal College of GPs would back that. Indeed, this is one of the many things that Lansley’s critics say he could or should have done from the outset to modernise the NHS through a gradualist, not big bang, approach.

The one caveat with that is that, if letting PCT clusters get on with the job of commissioning services became the new way forward, legislation of some sort would be needed to ensure that everything was above-board, legally-speaking, especially as such large sums of money are involved through the devolution of budgets. But Labour would not prove difficult over that. Their shadow health secretary, Andy Burnham, who preceded Lansley for 11 months and understands the NHS just as much as him, has already offered to help the government find a cross-party consensus on this and a Plan B generally.

Doing this would provide continuity. It would involve the existing NHS infrastructure being adapted. But the NHS, via countless other reorganisations, is a past master at adaptation and David Nicholson the ideal leader to smooth over the bumps of such a transition.

The future of the NCB is more problematic. It is politically more important as it in theory embodies the Conservative refrain – made since their days in opposition – of freeing the health service of direct political control. It does need the bill to assume its powerful and vital new central role in the NHS from April next year. But could it be constituted as a special health authority to get round that problem? Or is it even needed at all, if the 50 PCT clusters and (especially) four mega-SHAs end up surviving? Where, or is, the board would fit into the NHS system is unclear. But if the department and NHS top brass by and large kept on doing what they do now, few would argue that radical change was needed.

If the bill goes then the planned expansion of competition, transformation of Monitor into an economic regulator for the NHS and all the other “free market” moves that have caused the most concern of all the bill’s proposals would go too. Few would lament their passing.

Indeed, doing so might prove the most politically expeditious for the Tories. Plus the planning for all that is much less advanced than the structural reorganisation – another advantage.

All the way through this bill’s tortuous, increasingly divisive passage significant voices have argued consistently that the NHS should be concentrating on meeting Nicholson’s £20bn savings challenge by 2014-15, not being blown up and put back together in the sort of top-down reorganisation that David Cameron pledged not to implement. Stephen Dorrell, the last health secretary in the last Tory administration and now chair of the Commons health select committee, has cogently argued that position for months, his committee’s reports increasingly sceptical about the bill’s many likely negative impacts, but without ever explicitly criticising Lansley’s plan. At least three of his colleagues in Cameron’s cabinet are clearly less reserved. © 2012 Guardian News and Media Limited or its affiliated companies. All rights reserved. | Use of this content is subject to our Terms & Conditions | More Feeds