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Editor's blog Monday 31 January 2011: Defending NHS reform: is PM Cameron using the Royal "we", or taking the piss?

Prime Minister David Cameron spends more of his political capital on SOS Lansley's reforms and continues his unctuous self-anointing as the 'heir to Blair' by seeking to advance his political agenda with an appearance on BBC Breakfast to outline his desire to "cut bureaucracy and waste" and this article for Rupert Murdoch's Times on NHS reform myths.

Elsewhere, there's a sensible-sounding blog for The Independent on the privatisation debate from Confed CE Nigel Edwards: time permitting, I'll write about the meaning and timing of that.

For now, that nice Mr Cameron is worth a look.

The BBC Breakfast appearance is a classic - the Prime Minister implies that the reforms mean that "people will be able to choose between hospitals and services and sometimes trades unions don't want that kind of choice".

Um, yes. Dating back to April 2008. Under New Labour.


The Prime Minister completely dodged the question on whether hospitals will go to the wall. But they will, they will ... or else the plan will not have worked.

So we leave that neither wiser nor better-informed, and head over to his Times article, which is also beyond the paywall and on the 10 Downing Street website.

Its text is quoted below, with some responses in bold.

"The first myth is that we don’t need change. This simply isn’t the case. Just look at what’s coming down the line. The number of people with three or more long-term health conditions is set to rise by 30% in just 8 years. The cost of drugs has been growing by £600 million a year and medical technologies are continuously advancing. Now ask yourself: do you think the NHS will be able to cope with all this if we just put in a little money and carry on business as usual? The answer’s no. Fail to modernise, and the NHS is heading for crisis. Already our health outcomes lag behind the best in Europe. Without modernisation, the principle we all hold dear – that the NHS is free to all who need it, when they need it – will become unaffordable. That’s just not acceptable. We simply can not stand by and let that happen. But we will only prevent it if we change the way we do things so we really promote excellence and get value for money too."

First, weave your straw man. An ageing population and a pharmaceutical industry that wants to make significant profits are nothing new. Rationing - rational rationing - is part of the answer. (Greater attention to variations in cost, activity and outcomes is another. Appropriate specialisation is another part.)

It's not necessarily about putting in extra money, although we do have a system built for growth. The case remains to be made that the interim of tight Stalinist controls" is built for shrinking.

The UK 'health outcomes lag' canard was tackled with iridescent aplomb by Kings Fund chief economist Professor John Appleby last week.

Of course NHS outcomes have room for improvement: this much is not new. In fact, it dates back in policy terms to Barbara Castle's 1976 Priorities For Health And Social Care (which also said that more NHS work should be done as day cases, whenever appropriate. Sound familiar?).

But to be effective, outcome measures need to enjoy clinicians' confidence - as has been the case with the publication of data for heart surgery. It worked for cardiac surgery; but it took years - a politically-unfriendly timescale.

Clinicians are often competitive and driven people: they have to be to pass all those exams. Get the data good and reliable; publish it; and throw it into a room with a group of clinicians. Change will follow.

"The second myth is that we plan a revolution at the heart of the NHS. This is not revolution. It’s evolution. GP-led commissioning, patient choice, payment-by-results and Foundation Trusts have all existed in one form or another over the past fifteen years. And the NHS has always worked with a range of social enterprises, charities and private companies. The difference is that we plan to make these changes effective right across our NHS. Under the last Government, it was all far too piecemeal – and far too half-hearted. We understand that all parts of the NHS are connected, and they all need to be developed together in a clear and consistent way."

The changes planned in accountability and planning certainly do amount to revolutionary change. Every organisation which knows about healthcare has noted this - thinktanks; representative bodies and all.

A top-down structural redisorganisation of the NHS (as specifically vetoed in the Coalition Agreement) is certainly a revolution for the people who are in the process of losing their jobs, in PCTs and elsewhere.

There is continuity with the New Labour new public management 'choice and contestability' reforms. The PM's concept of patient choice, PbR and FTs has having been 'half hearted' will come as news to pretty much all managers in the NHS. PbR didn't apply to everything because working out tariffs for complex and ongoing care is genuinely difficult.

The connectedness point is a good one, but the incentives for connection being proposed are not even quarter-baked. More to the point, the reforms contain various potential incentives for fragmentation; which in fairness to the Prime Minister, happens already and always has. Boundary points between services are where patients get 'lost'.

"The third myth is that doctors are being forced to do something they don’t want to do. These are not like the changes of recent years, with politicians and bureaucrats bossing, controlling and re-organising from on-high. Our plans take ministers and management out of decision-making, and give doctors much more freedom. We propose commissioning by consortia, not individual practices, and it will be up to the GPs involved to decide how active a part they want to play. What we’re finding though, is that when you put that decision in their hands – they want to do this. Already 141 GP-led consortia have come forward, covering half the country. That, in anyone’s book, is an extraordinary response."

The PM's argument that doctors are all wildly enthusiastic because they are forming pathfinder consortia - the organisations to which they soon must join - is an interesting one.

Of course those keen on early adoption of changes they have long sought, such as NHS Alliance  (COI dec. for whom I do some paid work), have got stuck in early and are delighted that they have a chance to see primary care get its day in the sun.

Others are rationally figuring that they might as well try to shape the tent from within.

If that's an extraordinary response, one wonders what an ordinary one would look like.

"The fourth myth is that this is privatisation by the back door. That, somehow, GP consortia will be ‘forced’ to use the private sector to help them commission services. Again, not true. We have set no quotas and made no demands. This is about the freedom for GPs to choose whatever is best for their patients. That’s not privatisation – it’s progress. We simply can’t allow prejudices about the public, private or voluntary sectors to get in the way of what is best for patients."

With significant uncertainty about the transfer of NHS estates, especially those of provider trusts (which are all to become foundation trusts with unlimited freedoms to borrow), utter insouciance about a back-door route to more private companies owning publicly, taxpayer-bought-and-paid-for assets is a crass position to hold.

It is indeed pointless to demonise the public sector for doctrinaire reasons.

Equally, it is worth pointing out that what was sold as modern, sophisticated use of the private sector to provide PFI and LIFT buildings, ISTCs, NHS Connecting For Health and Darzi centres represents the value-for-money equivalent for us as taxpayers as being handed our arses on a plate.

Ladies and gentlemen, we have been well and truly had.

Even members of the PM's own cabinet have begun to notice that from a rational government's perspective, PFI stands for 'pure financial illiteracy'.

"The fifth and final myth is the most important: the suggestion that patient care will suffer. The opposite is true. Our changes draw on some simple logic – that professionals, not managers or politicians, are best placed to understand the needs of patients. And when you couple that professional freedom for doctors and nurses with choice and transparency for the patient, you get a mix that will expose poor performance and drive standards up.

"GPs have been telling me about the new possibilities open to them. One said that instead of his patients waiting two weeks for an ultrasound scan, he wanted to commission one for the same day he saw them. Another described how in Bexley, one of the first areas where GPs have taken on commissioning responsibilities, dozens of patients with suspected heart conditions have already been able to get specialist CT scans at a private clinic in Harley Street, free on the NHS."

It's an interesting implication in the PM's words of 'simple logic' that NHS managers are or were not professionals.

It's also balls (or if you want it in civil-service-speak, 'round objects').

Intelligent debate agrees that most managers were and are professionals. They are also, in their own little way and usually reluctantly, politicians - but that's another point altogether.

The PM's assumption that professional freedom for clinicians plus choice and transparency for patients 'will expose poor performance and drive standards up' are heroic, if not actually courageous.

Back in the era when medical professions enjoyed far greater freedoms, did they organise themselves to systematically collect, analyse and publish their performance data? No, they did not. Bristol, Ledward, Neale, Shipman and the small matter of health economics have combined to create pressure on the medical professions -  too slowly.

Free patient choice has, as I pointed out above, been a reality since April 2008. The Kings Fund research points out that choice is no panacea, but there is of course a danger of confusing our dear Prime Minister with evidence here. It's also worth mentioning that the asymmetry of information between providers and patients remains gaping.

"Nurses too will continue to play a vital role. GP consortia will have a statutory duty to work with nurses and other healthcare professionals, ensuring they have a real voice in shaping better care for patients. Many nurses are already taking advantage of greater freedoms to improve care for their patients by striking out and forming their own staff-run social enterprises.

"These sorts of changes are only possible with the modernisation we plan. Only by modernising can we achieve the world class care that we all want to see. That is why this matters so much and it’s why I’m so determined this coalition government will see it through."

Clearly the RCN successfully nobbled someone in Number 10 to mention nurses: quite rightly too, since nurses are the professional group who helped the NHS's new masters-in-waiting (GPs) to earn all the lovely Quality and Outcomes Framework bonus bunce.

It's also an interesting use of the word 'many' - as this DH list of the three 'right to request' waves to date reveals just 60 organisations have come forward to become social enterprises), of which the vast majority do not appear (from the available information) to be nurse-led.

Most seem to be former provider arms of PCTs and mental health or care trusts, which had to be spun out of the commissioning organisations. That was New Labour policy.

More to the point, right to request to be a social enterprise was a New Labour policy.

It is thus absurd for the PM to claim that "these sorts of changes are only possible with the modernisation we plan". Unless he is using the Royal "we" - and including in that "we" Tony Blair, Gordon Brown, Alan Milburn, Simon Stevens, Julian Le Grand and Paul Corrigan.

Maybe Big Society really means 'big tent'?

It might be the Royal "we". Or it might be taking the piss.