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Editor's blog Saturday 14 May 2011: Steve Field's Guardian piece: game-changing or change-gaming?

The Guardian's Denis Campbell has a fascinating interview with Professor Steve Field, of the Future Forum listening exercise.


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Field, past chair of the Royal College of GPs and a strong advocate of the White Paper on its publication, tells Campbell that "If you had a free market, that would destroy essential services in very big hospitals but also might destroy the services that need to be provided in small hospitals.

"The risk in going forward [with the Bill] as it is, is [of] destabilising the NHS at a local level. It would lead to some hospitals not being able to continue as they are. If you were to say 'we're going to go out to competition for vascular surgery services', University Hospital Birmingham wouldn't be able to run their own trauma centre, for example, because you wouldn't have the staff and the skills on site to do things and the volume of procedures needed to ensure clinical standards remain high.

"We need some significant changes in how the role of Monitor is described and enacted in order to reassure patients and doctors and nurses".

Field backs competition and patient choice to drive up standards, and also also backs the abolition of the private patient income cap on FTs.

He also suggests the following changes to the legislation:
• All GP consortia should have a reserved place on the board for a nurse and a representative of local hospital doctors

• A series of new "clinical cabinets" should be set up containing local health, social care and council representatives. They would advise consortiums, NHS hospitals and public health departments.

• GPs do not have the skills to commission several key sorts of healthcare‚ "including maternity services and end-of-life care", so in those areas will need to do so in new "networks" – groups of consortiums, overseen by the NHS National Commissioning Board.

• Plans to overhaul medical education and training will be slowed down.

• A potential new levy on private hospitals (which do not train doctors) to fund the NHS's training

Changing the game, or gaming the change?
Field's eye-catching intervention fits with reports from Whitehall and policyland insiders that there will be a minimum of changed rhetoric around competition, possibly with Monitor being given a duty to ensure co-operation in patient care (which should outweigh the current proposal for its duty to enforce competition).

Other than that, most of this is basically Dorrell and delay.

Much of the Dorrell-chaired Health Select Committee report on commissioning would seem to be going in, whether Secretary Of State For The Time Being Andrew Lansley likes it or not. (And he does not.)

There is an interesting resonance between Field's chosen examples of change and those picked by Conservative MP for Totnes Dr Sarah Woolaston in Monday's Opposition Day  motion debate on the NHS: "I fear Monitor will become an impassable barrier to co-operation between professions" and "where the NHS performs among the very best, competition has not delivered the results, but rather a relentless focus on patients".

Labour might be sniffing a victory in their gambit to have Section Three of the Bill (on competition and the role of Monitor) removed: they would be partying before the final whistle if they break out the bunting. Field is quite clear that competition will endure (being as it is, already firmly present in the NHS), as will Monitor.

There will be tweaks, is Field's hint.

It would be risky for people who have serious concerns about the Bill to see this show of Field force as a protective force-field. While it would be churlish for those such as Team Health Policy Insight who have pointed out the many dangers presented by the Bill not to welcome changes that genuinely mitigate risk (and being a churl is a bad look), it is certainly too early to be clear whether any risks have been mitigated.

I'm reminded of the planning development application trick: property developers will often submit terrible and wilfully-inappropriate plans for a development, knowing full well that they will be rejected. A second (but in truth, the first real one) plan of reduced size or lesser hideousness is then submitted, which will be approved after relatively minor changes. As the local council can tell residents, "look what you nearly had; this is better than that would have been".

It's worth considering that this may be, in the naff neologism, a "game-changer". But what is changing may be the presentation game, rather than the substantial one.