11 min read

Editor's blog Monday 13 June 2011: The 'Oops' Factor, Lansleyism as Schrödinger's Cat, the Future Forum and the escape route


The new polling by ComRes for ITV obviously doesn't take into account the Future Forum's report launch today, but it does cover the period following PM David Cameron's NHS reform reform speech last Tuesday at UCLH.


Click here for details of 'Strongman Cameron's J-turn on NHS reform: neo-classical clinical senates (or what did the Romans ever do for us?)', the new issue of subscription-based Health Policy Intelligence.


The ComRes polling's finding, of 2005 people (interviewed over the past weekend), are stark.

56% of survey respondents do not trust Mr Cameron to keep his NHS promises, while only one in four (23%) report that they do trust him.

While 20% of respondents believe that the NHS is safe in the Prime Minister’s hands, 54% disagree and 27% do not know.

Asked whether, as per the Conservatives' promise, 'public sector spending cuts will not harm the NHS', two-thirds (66%) of the sample surveyed disagree with that statement, while 18% are not sure and 16% agree.

Half of the group surveyed (49%) agree that the Government should scrap the current proposals for NHS reform and start from scratch, with 32% unsure. Only one in five (19%) believed that it is not necessary to start again.

51% of the group surveyed agree with the suggestion that that Conservative Party's plans for the NHS are 'just a way to privatise parts of the health service'; contrastingly, one in four disagree with this notion (23%) and a similar-sized group are not sure (25%).

Finally, the numbers of respondents who believe that their local NHS services have got worse in the last three months have increased to more than one in three this week (38%), compared with one in four (24%) when asked the same question last October.

Now, it is very unwise to seek any particular confirmation of anything from a single poll. Moreover, media reports make it clear that Mr Cameron and Mr Clegg have both sold it to their parties as a victory.

Nonetheless, the mood music that this will create for Mr Cameron, Mr Osborne, Mr Clegg and Mr Alexander will not be wholly welcome.

They also reflect what Mr Cameron's personal polling person Andrew Cooper (formerly of Populus) is reported to have been analysing from private polling for some time now.

So what of the Future Forum reports?
Having drawn out some key points at the bottom with notes, I'm not going too long on the Future Forum reports because briefings to Health Service Journal and the BBC are already making it clear that the Government intends to do what the private sector will apparently not be allowed, and cherry-pick what it wants.

There is something truly interesting about the Monitor / CCP stuff, as I wrote this morning. Not so much the lack of essential clarity (i.e. how would the statutory competition regulator that the CCP would become relate with the NHS Commissioning Board and quality regulator), as the concept that these are simple changes.

Much else that appears in the Future Forum reports has been widely-trailed (Monitor losing its primary duty to promote competition being the prime example. Andrew Lansley has still been making bullish noises that his reforms are essentially unchanged (again tonight to The Guardian).

Quantum policy and Schrödinger's Cat
Mr Lansley's NHS reform plans are in truth currently best understood as Schrödinger's Cat: they are in a state of uncertainty, both alive and dead at the same time.

This is quantum policy, in other words - but it is not a quantum of solace.

When we see the detail of the revised clauses, the box will be opened. Here, kitty! Here, kitty, kitty!


The escape route
At some point, should the polls not shift, an escape route will be required. Which is interesting, because Mr Lansley used the old-school powers of the Secretary Of State For Health to trash the old system machinery so comprehensively that going back is genuinely not a realistic option.

The Future Forum realised and said clearly today, that manager-bashing must end. Perhaps it may, but much damage has already been done.

In some areas, GP-led clinical commissioning (or whatever the hell we're calling it this week) will fly. In others, it won't even pass check-in. And there is a ready-made centralised-as-you-like Plan B in the shape of Comrade Sir David Nicholson's tightly centrally-gripped system, with 1/3 of the previous PCTs and a still-undecided four or five regional Commissioning Board offices.

For now, competition remains on the table with the NHS Future Forum's defence. Its limits are undefined.

There was one other interesting thing: Field attacked Monitor CE Dr David Bennett's infamours Times interview language about the Monitor role as "utlility regulation", calling it "very unhelpful" - strong meat, in Whitehall terms.As I wrote in my piece this morning, his deputy Chris Mellor has finally received mainstream media attention for his time chairing Northern Ireland Water.

It's interesting timing for the top of the office at Monitor to get a kicking.

Selected quotes and brief notes on Future Forum reports
The Steve Field letter in the main document makes seven key overall points. (I'm ignoring the things we already know (i.e. consortia not getting cash independence till ready).

• It is right that GPs should take responsibility for the health of their local populations and the financial and quality consequences of their clinical decisions through a comprehensive system of commissioning consortia. But, they cannot and should not do this on their own and must be required to obtain all relevant multi‐professional advice to inform commissioning decisions and the redesign of patient pathways;

• Services must change in order to meet the needs of local populations. This will require difficult decisions, especially about the location of some services and hospitals. These decisions will need to be sensitively handled but must be clinically‐led;

• The place of competition should be as a tool for supporting choice, promoting integration and improving quality. It should never be pursued as an end in itself. Monitor’s role in relation to ‘promoting’ competition should be significantly diluted;

• The declaration of ‘no decision about me, without me’ must be hard‐wired into every part of the system – from the legislation through to each and every encounter between a patient and a healthcare professional;

• There has been too much focus on different parts of the system – GPs, hospitals, public health – and insufficient attention to how they all join up to provide the integrated care that patients need;

• Because the NHS ‘belongs to the people’ there must be transparency about how public money is spent and how and why decisions are made and the outcomes being achieved at every level of the system; and

• The education and training of the healthcare workforce is the foundation on which the NHS is built and the single most important thing in raising standards of care. More time is needed to get this right ‐ the effects of mistakes made now will be felt for a generation.


"I believe the current model of care cannot be sustained in the future. The NHS of today is mostly about the provision of episodic treatment of illnesses such as cancer and cardiovascular disease. Priority has been on acute hospitals and providing effective interventions and treatments for people affected by those life threatening conditions.
I believe that the NHS must change. It must reassess the old model of hospital based care. A high priority now needs to be given to meeting the needs of the increasing numbers of older people. As people get older, they will require more support from both the NHS and social care to enable them to live independently in the community for as long as possible.


"To give clinicians like myself the headroom to offer our patients the very best care that we can, we are going to have to decide where to disinvest, how to become more efficient, where to root‐out waste and target our limited budgets on where we can do the most good for the money spent.


"At best, the Health and Social Care Bill has received lacklustre support from many staff groups, open hostility from others and has been lambasted in much of the press. This opposition was not merely political – it stemmed from genuine fear and anxiety that the reforms would not deliver the improvements that we all want.


"Some of this fear was misplaced and the result of a failure by the Government to clearly explain how the structural and technical details of the Bill would help the NHS improve today and tomorrow … However, in other areas we found people’s concerns to be justified. Whilst there was never any intention to introduce a market in the style of the utilities sector into healthcare, the Bill contained insufficient safeguards against cherry-picking and was not sufficiently clear that competition would only exist when it served the interests of patients not profit. In other areas, whilst NHS staff supported the general thrust of the reforms, they were anxious that the deadlines would force them to take on responsibilities before they had the skills or capacity to undertake them in a way that would improve patient care. And, in a few areas, such as the proposals for education and workforce training, there were genuine concerns that there was simply not enough evidence or detail to justify such radical change where the consequences of failure are so significant and long lasting.


"All commissioners and significant providers of NHS‐funded services, including NHS Foundation Trusts, should be required, as a minimum, to publish board papers and minutes and hold their board meetings in public".

The private sector will love this

"Foundation Trust governors must be given appropriate training and support to oversee their Trust’s performance – until governors have the necessary skills and capability to take on this role effectively, Monitor’s compliance role should continue".

Clear conflict of interest with Monitor's role as sector regulator. How will this be managed?


"The Bill should require commissioning consortia to obtain all relevant multi‐professional advice to inform commissioning decisions and the authorisation and annual assessment process should be used to assure this. In support of this, there should be a strong role for clinical and professional networks in the new system and multi‐speciality clinical senates should be established to provide strategic advice to local commissioning consortia, health and wellbeing boards and the NHS Commissioning Board".



"A Citizens Panel, as part of Healthwatch England, should report to Parliament on how well the mandate has been implemented and further work should be done to give citizens a new ‘Right to Challenge’ poor quality services and lack of choice".



"Competition should be used as a tool for supporting choice, promoting integration and improving quality and must never be pursued as an end in itself. Monitor’s role in relation to competition should be significantly diluted in the Bill. Its primary duty to ‘promote’ competition should be removed and the Bill should be amended to require Monitor to support choice, collaboration and integration.
• Private providers should not be allowed to ‘cherry pick’ patients and the Government should not seek to increase the role of the private sector as an end in itself. Additional safeguards should be brought forward".

Detail rather urgently required here


"The ultimate aim should be to have a multi‐disciplinary and inter‐professional system driven by employers. The roles of the postgraduate medical deaneries must be preserved and an interim home within the NHS found urgently. The professional development of all staff providing NHS funded services is critical to the delivery of safe, high quality care but is not being taken seriously enough. The National Quality Board should urgently examine how the situation can be improved and the constitutional pledge to 'provide all staff with personal development, access to appropriate training for their jobs and line management support to succeed' be honoured.

"We need to move beyond arguing for integration to making it happen, whilst exploring the barriers. We would therefore expect to see the NHS Commissioning Board actively supporting the commissioning of integrated packages of care building on the ideas that many organisations, including the King’s Fund and the Nuffield Trust, have presented as part of the Listening Exercise".

Detail rather urgently required here


"We therefore recommend that there should be a clearer choice offer, set out in a ‘choice mandate’ as a core part of the overall mandate that the Health and Social Care Bill says the Secretary of State should give to the NHS Commissioning Board. All players in the system should then be held to account for delivering this offer. We also recommend a stronger push to offer personal health budgets where these are appropriate.

Detail rather urgently required here


"Competition already exists in the health service, and the Forum is convinced that it has a place in enabling choice and improving quality. But, it will not be appropriate everywhere. The current policy is not clear enough about this".


"The report also recommends that there should this institutional duty on Monitor to “promote” competition is replaced with a new right for patients – the right to challenge commissioners at local level where they feel that choice does not exist and where they feel that services are not good enough. Further policy work is needed to ensure this right to challenge will lead to real change, driven by patients and citizens".

Detail rather urgently required here

Sir Stephen Bubb's Choice And Competition section

"In delivering choice, the NHS will need help from across the public, private and third sectors to secure those real choices that citizens expect. It will need that help to utilise scarce resources to deliver cost effective and better quality services.

"Choice is much more than the ability to choose a different provider of elective surgery. It is also about the choice of care and treatment, the way care is provided and the ability to control budgets and self‐manage conditions".


"We know that self-management improves health outcomes and can be more cost effective".


"We also believe competition will play an important role driving change.

"There has been real concern that competition could undermine the integration of care or collaboration. But there are still too few examples where NHS organisations have worked with each other to provide that integrated care. If commissioners want to commission integrated care they will only succeed in doing this by creating a new market in integrated care services and stopping the current commissioning of episodic services from different NHS organisations. This will involve existing NHS organisations taking a leadership role in developing integration. But it needs also to involve other providers".

"Drawing from the NHS Constitution’s ‘right to choice’, we recommend that the Secretary of State gives the NHS Commissioning Board a ‘Choice Mandate’. This would set the parameters for choice and competition in all parts of the service, for example promoting more integration and a focus on outcomes. It would also ensure that people are not excluded because they have complex conditions and that health inequalities are tackled.
Based on these principles, the NHS Commissioning Board would publish its plans to deliver choice and outline how competition should be used. It would then report on progress against these plans in terms of health outcomes and effective use of resources".



"Competition in itself should never be the driving factor. The best safeguard against misuse of competition will be effective commissioning and strong regulation. Consortia must be effective, guard against conflicts of interest and properly engage communities.

"We suggest that other safeguards should include the removal of the provision in the Bill for Monitor to ‘promote competition’ and to clarify Monitor is a sector regulator for health not an ‘economic regulator’. Monitor’s primary duty should be to protect and promote the interests of patients and citizens. And Monitor will need to ensure that the NHS is able to develop integrated care. There needs to be an effective regulator that tackles abuses that are not in the interest of patients or the taxpayer. We therefore do not advocate that Part III of the Bill be removed, though we do propose significant amendments to the Bill".


"We recommend the Health Bill is amended to give citizens and community organisations additional rights to challenge poor delivery and lack of choice through a ‘Right to Challenge’ (currently in the Government’s Localism Bill). This new addition to the Health Bill, together with the Citizens Panel, will reinforce the new framework we propose and give more power to citizens to enforce their choice. This will undoubtedly require further detailed work on how this could operate in practice to make sure this approach is the right direction.

"Personal budgets are very powerful tools in driving choice and greater control and could be particularly effective where people are receiving both health and social care services. We recommend that within five years all those patients who would benefit from a personal health budget should be offered one.

"We believe there is also great potential to give NHS staff more control by expanding the use of the ‘Right to Provide’. Giving NHS staff the power to form social enterprises or mutuals will increase the diversity of suppliers but also drive more innovation. We have been told that changes are needed to remove barriers that prevent expansion and the chance for NHS staff to exercise this right. The NHS Commissioning Board should review this".

Sounds like NEW BUREAUCRACY. And how is a 'Right To Provide' not basically just a pseudonym for 'preferred provider'? It is covered by the Right To Request, which began back when DH had pump-priming money and wasn;t even popular then. That NHS pension is sticky as hell ...


"Finally, I have concluded that it is an error to suppose effective and properly regulated competition threatens the fundamental principle of an NHS that is universal and free at point of delivery. The reverse may well be true; that it helps protect the NHS into the future. We need to move the debate from whether or not competition works to how best to maximise the benefits whilst minimising the risks".

Phew. Thank goodness we now know that the argument about the role of competition in public services has been settled. Hail humble, self-effacing Sir Stephen!