Editorial Tuesday 20 March 2012: Health Policy Intelligence 43 and 44 - From Bill-Killing to blamestorming
The following extract is the first part of the new issue of our regular subscription-based product Health Policy Intelliegence. Subscription costs £69 for a year. To subscribe, email editorial AT healthpolicyinsight.com
From Bill-Killing to blamestorming: how The Health And Social Care Act 2012 will define all three main Westminster parties for a decade
Welcome to the latest edition of Health Policy Intelligence, the analysis and summary of the key events in policy by Health Policy Insight editor Andy Cowper.
The 2012 Health And Social Care Act will become law later today.
At one level, this can be called the end of an era of a nationalised NHS. The raising of funding will remain broadly nationalised, via general income taxation. The Government is extracting itself from the provision business, ending the existence of NHS Trust status. Providers will make it to FT status or die trying; in many cases, probably the latter.
Planning is also firmly consigned to the dustbin of history, with the abolition of strategic health authorities (which in fairness, were deeply variable in their strategic intent or capacity). This farewell to planning is probably the single biggest danger in the Act.
Why? Because the provider landscape of the NHS in England urgently needs re-shaping to a) reduce costs. and b) deliver improved care and support self-care in primary and community settings.
The Act bets the farm that between them, national tariff cuts, Monitor oversight of providers (which conflicts beautifully with its role as the NHS’s independent economic regulator) and utterly unproven CCGs and Health and Wellbeing Boards will achieve this.
Topically, a newly-published story by HSJ suggests that Monitor plans to send in ‘hit squads’ to troubled FTs, outlined in a recent Board paper. It proposes that such Monitor-appointed “chief restructuring officers” would go into FTs in breach of their terms of authorisation, advising the FT on recovery but also reporting back to Monitor “whether board members needed to be replaced”. The document foresees “the perception of Monitor running an NHS FT, thereby taking responsibility away from the board”, saying that the chief executive would have to remain “still the accountable officer, but (one who) acts on advice given by the CRO. In particular, the CE should regard the CRO as a supportive adviser rather than a threat”.
So no confusion in store there either. That came on the back of Monitor chair Dr David Bennett’s recent warning in the FT that “you want your prices to be as cost reflective as reasonably possible because otherwise, you do create cherries, which people then go and pick” … and yet “if you’re providing an essential service to users of the NHS, then ... you jolly well should be doing your best to make sure that that service is available on a continuing basis. I’m afraid that’s the nature of providing these sorts of services”.
Oh, and there is another player in the reshaping of provision: Monitor’s new statutory duty to prevent anti-competitive behaviour – which is in no way a homonym for Monitor’s originally-proposed duty to promote competition. ‘To market, to market, to buy a fat pig’?
It is a heroic investiture of faith. But it does - nominally - get the Secretary Of State For Health off the hook of having to listen to providers in the poo making ‘the poor mouth’.
So much for nominally. Politically, what about the impact of shutting services, departments or even entire hospitals?
Ah. Yes. Ahem.
That is the bit Andrew Lansley (saviour, liberator) has not discussed with his backbench colleagues in the Coalition. We will see increasing dissatisfaction among shire Tories and coastal Lib Dems who have essentially been sold the line that it will be up to the good old GPs in their local CCG to decide that everything must stay open everywhere for ever, to avoid any political pain come the election.
That won’t happen. The reductions in the national tariff will, as Simon Stevens pointed out, do the heavy lifting of giving the black spot to acute providers. Health Policy Insight was the first to spot the bungs formula in the DH failure regime, and latterly the fuck-up fund in Monitor’s ‘distressed gentlefolk NHS provider’ regime.
At another level, it can be seen as the birth of a centralisation the like of which the NHS has never experienced with the arrival of the Nicholson Commissioning Board. As I wrote in July 2010, and mentioned again above, not only is it a fact that “Monitor is going to be hugely, immensely powerful in the new system”, but “the independent NHS commissioning board will also be very powerful”.
The Nicholson Commissioning Board will authorise and de-authorise CCGs (with no clarity about what will trigger the latter); it will also hold the primary care contracts of every GP practice that makes up the CCGs’ membership. Too little attention has been paid to that double-whammy of power over the new world of primary care. (Oh and attention will start turning to primary care provision, which also faces significant challenge and change. There has been almost no discussion of this.)
The NCB will be as light and lean a body as any with four regions and fifty local branches. And it will allocate the budget to CCGs on the basis of need, while holding top-slices for the achievement of financial balance.
The Nicholson Commissioning Board seems to have incredibly little in the way of checks and balances on its considerable power. Making an annual report to Parliament on its delivery against the mandate from the Secretary Of State sounds ever-so-slightly like the Quality Accounts of NHS trusts (each with its lovely stock photos of happy grinning children receiving error-free treatment from cheerful-but-professional-looking NHS staff in ironed uniforms).
There are other, deeply real issues. The FT reports on the DH’s unsurprising warning that austerity will not end in 2015, which is something John Appleby of the Kings Fund has long been saying. Ominously, the familiar number of another £20 billion efficiency and productivity challenge forms part of the story.
Then there is upstream. The Health and Wellbeing Boards of local authorities will initially have ring-fenced budgets, but the pressure on local authority funding will be immense. There will also be fresh temptations for elected local politicians to play to party agendas. The logic of greater involvement for local government is clear, yet huge questions remain around this new system’s practical capacity to deliver better public health, upstream of healthcare to anticipate and minimise costs and maximise health.
Areas where health and social care integration has long been more advanced may of course be disadvantaged by their getting earlier than many to efficiency in health and social care provision, as this HSJ story about infamously integrated Torbay rather suggests.
Oh, and local and national HealthWatch is not going to be statutory, suggesting that the proud tradition of valuing public and patient involvement and engagement is alive and well.
Despite all of this, there are some impressive emerging leaders in clinical commissioning groups, and it may indeed be harder for acute providers to bullshit fellow-doctors (in the clearly hypothetical case that such a thing ever previously happened to PCT commissioners).
Where clinical commissioning gets traction and works intelligently and reciprocally across a local health and social care economy, it will do impressive things. We should never underestimate the desire of NHS staff to do their best for their patients.
But for all this, the 2012 Health Act will define all three main Westminster parities for a decade in domestic policy terms.
The extract ends here. If you wish to see the full issue, email editorial AT healthpolicyinsight.com