Sunday, February 5, 2012

Should the Health and Social Care Bill be Scrapped?

The papers are full of speculation about the future of Lansley's bill. Many Tory MPs are now privately concerned, Lib Dem peers and now working with Labour Lords to amend the bill to destruction and Lansley himself is looking increasingly isolated as the professions rally against him.

In more normal political times this would all be insignificant. But we're not. No single party has a majority and Parliament, since 2010, has enjoyed something of a revival as the 'cockpit of the nation'. You just can't ram things through anymore. Listen - or face rebellion is is the message from a Commons packed with the assertive new 2010 intake..

In some ways, the Bill is alreadyhalfway to oblivion. So far 136 amendments have been accepted from hundreds table. The net effect of this has been to reshape the Bill substantially from Lansley's original intentions. Many more amendments and the whole thing will be sunk by its own complexity and contradictions.

Although there is a lot of angles to this debate, it seems to boil down, in our current discourse, to one big issue - do private operators have a major role to play in the future NHS - or does this remain a principally state-funded, state-directed service? Where you stand on this question is a pretty good predictor of whether you basically support or oppose this Bill.

And that is where Lansley finds himself at the wrong end of the political argument. Most Britons instinctively oppose the idea of profit-making companies running the NHS. They fear its implications for access to free healthcare. For most people, it just seems instinctively 'wrong' that private companies take over the NHS.

Where Lansley has failed, I think, is to side-step the professions by successfully casting his reforms in terms of the real challenges facing healthcare in this country. In short, we need more primary and community healthcare - and fewer, better major hospitals. Anything worth of the name NHS needs to see this movement over time.

We also need to have an honest conversation about what the NHS is for, today and tomorrow, and what we should ask people to fund themselves. There is mounting evidence that the NHS will have to narrow its offer to a deliverable 'core' with more being paid for by ourselves with a logical consequence that more non-core treatments will have to be provided by other means, including the private market.

There is an urgent need for a long-term cross-party consensus about the future of both health and social care in this country if we are to avoid a major crisis within 20 years. The debate at the moment is infantile. 'Three months to save the NHS' is another facile piece of nonsense from Miliband, E.. The NHS today is a cruise-liner headed for the rocks within 5 years. The question really is how to change it over the next decade, reduce its costs and improve its offer. The left (including many Lib Dems) think this is all about planning and co-ordination. The right think it is all about ultra-devolution and introducing markets and private providers with the state well out of the way.

The sensible centre (and most of the non-political community) recognise that you need bits of both. High level planning is needed over the long term around the broad allocation of the health pound in our taxes. As a country, we need to agree what our response to our well-understood demographic and health challenges should be. This is the 'national conversation' we should be having, led by our political class. Then it is Government's job to set the framework. This is not the same thing as the 'co-ordination' offered during the Labour years - which led to the NHS being micro-managed like a nationalised industry.

Likewise we need to sensibly open up the non-core sectors of our healthcare needs to other sector. This has, of course, already happened in social care, where a diversity of providers has moved quality up and price down over the years - with notable exceptions of course. But this has to be done with care. The 'cherry picking' argument is a real one and cannot be ignored. We need to use the private sector where it can drive up standards - but keep an overview and retain powers at local level to hold the private sector in check where this isn't working for the common good..

Where do social enterprise providers fit into all of this? My fear is that they get lumped into the 'private sector' bucket and, if the Lansley Bill dies - which I see a 25% chance of happening - they get frozen out of the new NHS. There is, of course, a chance that they will be viewed as an alternative to privatisation, but the health social enterprises do not yet have the political clout to get this point heard in the current decibels.

If the Lansley Bill goes through, in a heavily amended form, it's also hard to see how things will work from here. The emerging picture is of a more complex commissioning environment than now and a very messy period of overall transition. A lot of the new structure has kicked off already. Clinical Commissioning Groups are already operating and the PCTs and SHA's all but gone - or altered to account for the bill. Very tough now to turn back the clock.

My feeling is that if politicians were up to a decent quality of debate on healthcare, I would want to see the Lansley Bill scrapped and we go back to the drawing board. But so poor and ill-informed is most of it that I fear this would throw us backwards into Frank Dobson/Andy Burnham era nationalisation with consequences I dare not contemplate. So overall, I would rather us make do with an amended bill.

However, Cameron should sack Lansley in the reshuffle and bring in a pragmatist with the operational head to see this through. So no, keep the bill - but sack this dreadful Minister.

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