Editor's blog Thursday 5 May 2011: Reflecting on the HSJ reviews of Lansley's Year Of Living Dangerously
Andrew Lansley and I have something in common: we must both enjoy living dangerously.
A very interesting piece in Health Service Journal offers the thoughts of Stephen Dorrell, Alan Milburn, David Kerr and Bill Moyes on The Secretary Of State For The Time Being's own Year of Living Dangerously.
Click here for details of 'Cameron the Winner; Lansley the Magnificent', via subscription-based Health Policy Intelligence.
Stephen Dorrell expands on his view of the changes as both revolutionary and evolutionary, as set out in many media interventions including this HPI interview.
He reiterates his point that the real revolution is what he dubbed 'The Nicholson Challenge' of the NHS being forced to save 4% for 4 successive financial years, and the resulting need for the NHS to become a far more effective patient-centred chronic disease management system.
Dorrell sees trouble ahead, warning that "Of course it is possible that the sum of individual small decisions will precipitate a smooth revolution in the pattern of care provision, without the need for commissioners to manage the process. It is also possible that pigs might fly.
"But I wouldn’t count on it".
Alan Milburn cheerily excoriates Our Saviour And Liberator's political and policy incompetence, eschewing Dorrell's theory that evolution and revolution can co-exist and dubbing the Lansley reforms "the biggest car crash in recent NHS history. From the outset they were devoid both of advocacy and advocates". He appears genuinely baffled by the failures in politics and policies, warning that setting them right is no more PR exercise.
Milburn too sees trouble ahead, concluding that "despite Andrew Lansley’s protestations they will require substantive amendments in Parliament to the Health Bill. Of course that risks a health policy that is neither one thing nor another at a time when the NHS needs reforms to meet the challenge posed by an explosion in chronic diseases.".
David Kerr (who, tellingly, recycles Lord Crisp's old term "commentariat") writes dismissively of "a degree of daft shroud waving from the unions, The Guardian and the generally uninformed that the NHS will be “privatised” – this canard should be dismissed as there is absolutely no ideological case being made for this. Competition from any willing provider is a mechanism to enhance quality".
Professor Kerr's reasoning here is splendidly silly and specious.
He suggests that privatisation is not an issue because no ideological case is being made for it; thus missing the point quite spectacularly.
The Lansley reform policy's many mainstream critics tend not to see it as a straight move to privatisation.
Rather, they warn that the wholescale, system-wide, top-down structural reform at a time of needing to make unprecedented savings means that there is a very high chance of failure.
This observation has been made by the DH's own impact assessment; the Kings Fund; the Nuffield Trust; a plethora of other think-tanks and many academics; the Commons Health Select Committee; and by NHS Comrade-In-Chief and Commissioning Board-CE-designate Sir David Nicholson, who called it "a reorganisation so big you can see it from space", adding "most major change programmes fail").
An unintended consequence of spectacular failure of NHS reform could easily be a move towards privatisation.
Professor Kerr is happy to side with critics who "note an evidence gap linking the planned reorganisation to value added care, so there must be a strong element of evaluation built into the plan".
So it's nice to have him on board with some points. Unfortunately, his point here is deeply undermined by the Bill's clear refusal to undertake meaningful evaluation. Does this perhaps cast Professor Kerr as a daft shroud-waver and purveyor of canards to gentlemen and their sons?
(Kerr also adopts the Royal 'we' in his piece, which is just as good as green ink as a proxy to signal Articles One Should Not Unduly Bother Reading.)
His argument remains deeply confused, as he writes, "Clarity of communication describing the essential shape of the reforms, especially to patients and to clinicians working in the front line, has been noticeable only by its absence. There is a real and ever widening hierarchical disconnection between the authors of reform and its recipients. The truer narrative has been subtly corrupted by the Greek chorus of those with axes to grind and it felt as if the opportunity to debate, modify and refine the key elements of the plan was slipping away from those with the greatest experience to offer; clinical staff, patients and their carers".
This really doesn't make sense.
Kerr says there has been no clear communication - and yet the real message has been corrupted by axe-grinders. Meanwhile, he also admits a real and growing disconnect between reform authors and those whom they want to run the new system. As for opportunities to debate, modify and refine key elements, there was a small matter of all those consultations ...
These arguments are as senseless as they are colourless. A less respectful publication than uber-deferential Health Policy Insight might describe them as the work of a wan Kerr.
By far the best piece comes from Monitor's former executive chair Bill Moyes, who with laconic wit observes that the "scale of opposition is remarkable, probably unprecedented. Even the Iraq war had some supporters at the time. These reforms appear to have none".
Moyes elegantly bitch-slaps the Kerr hypothesis, warning "More dangerously Cameron and Andrew Lansley are unwittingly creating the conditions for a future government to conclude that free hospital care is no longer affordable ... that’s the real danger of the current crisis". Quite so.
Few know more about FTs than Moyes, and so when he warns that "the announced timetable [for all providers to become FTs] is unrealistic. And forced mergers/acquisitions for those hospitals not capable of becoming foundation trusts is high risk. The bill as it stands seriously reduces the freedom of foundation trusts.", it should be taken very seriously indeed.
FTs are not without failure, as Mid-Staffs reminds us daily - but overall, they appear to be a relative success story.
Moyes also rightly counsels "don’t rush into creating a competitive provider market. Get the fundamentals right first. A competitive market requires well governed and financial strong providers, with the freedom to respond to the market without political interference. The bill as it stands won’t deliver this".
It is interesting and unsurprising that the direction of travel in health reform - towards better management of long-term conditions and greater focus on health outcomes - is uncontested. It is also interesting that the Conservatives' policy adviser Kerr (formerly Labour's) gives the Lansley reforms far more unqualified support than ex-health secretary and health select committee chair Dorrell.
Moyes and Milburn see the general direction of the reform agenda as correct, but the former warns that "previously unannounced policies, a complete failure to build the necessary political and professional consensus and an apparent disdain for the detailed planning of implementation means that the vision has been lost", and the latter that "market mechanisms can work in healthcare but only when properly managed and regulated not when there is a free-for-all".
It's not a ringing endorsement of Lansley The Magnificent.