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Alan Johnson questioned over his commitment to locally led change - Health Policy Debate, 30th June 2008

Alan Johnson questioned over his commitment to locally led change

Tom Smith on today’s heath policy debate

Alan Johnson has had a busy day: one  he has spent all year building up to, in many ways.  He was on the Today programme at 8am and spent the afternoon in the House of Commons, taking part in a debate on the Next Steps Review and the new Constitution announced today.  All day long he’s had to answer questions on the balance between local and central power.

Alan Johnson interview with Evan Davis on Radio 4’s Today Programme

Evan Davies opened up the interview by raising an eyebrow: “is this really the biggest change to the NHS in 60 years?”

Alan Johnson said was keen to emphasise that the plans amounted to a “bottom-up revolution”. “This has been a huge project working with 72 clinical leaders”.  He described the report as “national action to enable local change”.  He hoped it would take NHS reform to a new stage, moving beyond discussions about restructuring and reorganising.  He wanted to see “a pure focus by clinicians locally on how to improve quality” and said that there would be national standards to enable.

Evan Davies spotted a potential contradiction: “you will have both localism and uniform services?”

Johnson said people want consistency and NICE will help do this.  “Once we’ve been through the NICE process, any particular drug should be available all over the country”.  Johnson admitted this had been the case, but said implementation has been inconsistent.

Evan Harris asked the same question in a slightly different way (by my reckoning, one that Johnson was asked four times today).  “You say you want to encourage localism, but with polyclinics or super-surgeries, aren’t  you pushing through national policy that is locally unpopular?

Interestingly, Johnson said that polyclinics are a London idea.  “There are a lot of single-handed GPs in the capital, which is why this model is being adopted”.  Not for the first time today, Johnson said he was keen to ‘dispel some of the myths’ around the Government’s approach to polyclinics.  While he was aware that people talked about the private sector taking over polyclinics, he expects ‘consortia of GPs to win most of the contracts to run the new centres’.

Evan Davies continued his theme.  “So if this is what the public want, why not impose it?”  Davies declared himself confused that “sometimes you’re saying, ‘we know best’ and at others that locals should lead.”  

Alan Johnson said there are some areas where the centre should take the lead – delivering more capacity into primary care, negotiating pay for clinicians.  “There are three misnomers about polyclinics – they will not be based on groups of 25 GPs; patients will not be required to register; and they will not all be run by private sector providers”.
Evan Davies asked a question about co-payments and another about inequalities, but clearly the theme he wanted to explore was whether the government was serious about devolving powers.

Mr Johnson goes to Westminster

In his speech to House of Commons at 3.30 pm, Alan Johnson said he would “bring clarity to the concept of quality” – a very interesting ambition, given a range of interpretations and definitions.  His aim, he said, is to ensure “it is at the forefront of all healthcare organisations activity”.

A lot of what Johnson said seemed to drive at what he hopes will be greater accountability between patients and the public and their PCTs – he talked about the latter having “a duty of transparency”.

Furthermore, he said the report would give “power to the public”.  For the first time, in addition to financial accounts, all providers will have to publish quality accounts.  “Improvements to quality will be assessed and rewarded”.  Johnson said that feedback on quality and experience from patients will have an effect on income.

After talking about quality (in slightly vague terms – the detail is in the report, about which more tomorrow), he then returned to the theme of the day: greater local control.
Johnson said that to maintain the momentum of strategic reviews and to “sustain the clinical voice”, “new medical directors will be appointed to join nursing directors in every region”.  Presumably they will work at SHA level and oversee change plans.

And then, an unexpected announcement: “there will be a quality board that will report to ministers”.  The groans in Parliament were audible – what were they thinking, ‘another quango’?.   (This will join the innovation board).

The murmurs continued as Johnson boomed, “there will be no hiding place” for those who get it wrong.” For those of us looking for greater localism, both the tone and content of this sentence jarred.

Perhaps, however, he intends to free doctors to pursue quality in organisations. The recent staff survey suggested that clinicians don’t believe quality is important to management.  “We will ensure that NHS staff have the freedom to concentrate on quality”.   Then he went further, saying “our new expectations of professionalism redefines clinicians’ role as leaders of the NHS”; they will have “greater responsibility for the stewardship of resources”.

And then he began to talk about the ways in which staff might gain greater control.  He would be creating a right for staff to request to set up a social enterprise – “PCTs will have to consider any such request”.

Andrew Lansley responds

Andrew Lansley sounded very disappointed, but did not criticise Darzi and was particularly careful not to criticise local reports.  He started by expressing his disappointment at what he regarded as a missed change.  “This was an opportunity to show vision for the NHS and leadership”.

“Regrettably the work of the clinical partnerships around the country has been stifled by centralism.”  

“We must set the NHS free from top-down distorting targets”.  “Alan Johnson says there will be no new targets and yet the same targets remain”.  “If he doesn’t propose now to scrap the targets then how can we believe what we say”.

“What about practice-based commissioning?  Why no mention of foundation trusts?”  He raised these ideas because they are levers through which the Conservatives believe greater local freedom can be achieved.  But Johnson had mentioned foundation trusts, and that he wanted to extend freedoms at community levels.  It’s true that he didn’t mention commissioning, but a supplementary paper on this subject is expected on Thursday.

Lansley was getting fired up, saying that Labour has stolen its idea of a constitution.  But “if it is a real constitution where is the detail, where is the freedom for organisations?  ... A constitution needs to be more than a patient’s charter”, said Lansley.

“If the NHS is to be whatever the Secretary of State says it is, then it can never be free.”  

Lansley’s key point is a fair one.  He is worried that when the Secretary of State talks about localism and devolving decisions, that what he actually means is passing his powers down (just slightly) to Strategic Health Authorities – “bodies the Secretary of State regards as the regional Department of Health”.

And Alan Johnson responds again

Not to be outdone, Alan Johnson said he was disappointed with Andrew Lansley’s disappointed response.  “So many doctors have been involved”.  “These are not the plans of Strategic Health Authorities, it is built on visions that have been developed locally.  Johnson described the review as “an enabling report”.

Himself getting rather riled, he produced the 1995 Patient’s Charter and began to read from it.  “For hip and knee replacements we offer a waiting time guarantee of – wait for it – 18 months.  “It even says that from April 1995, we are prepared to extend this across all hospital treatments”. Johnson was asking Lansley who he was to question Labour’s management of the health service.

He hadn’t finished.  He denied the Conservatives had thought of a constitution first and asked Andy Burnham to back him up.  He then laid into the idea of an “independent NHS”, favoured by the Conservatives and believed by Johnson to be “a giant unelected quango”.

The conclusion to the day?

It is difficult to draw conclusions about who won the debate.  Indeed, it is not really the point.  The short-term challenge for the government is whether it can communicate over coming weeks that it is serious about enabling local change.  It won’t be easy with opposition (and some Labour) MPs keen to deny it.

Starting tomorrow, it will be interesting to see how some of the key figures respond to the content of the report, which, to be fair, few people have had the chance to read.