Words cannot do justice to the sheer surrealism of the recommitted Health Bill committee evidence session yesterday.
Fortunately, the wonderful people who do Hansard have the transcript of the morning session available here, and of the afternoon session here.
Thank you, Hansard people. You are lovely.
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Special highlights included the current Secretary Of State For Health Andrew Lansley making a joke about the committee raising hands for questions coming across as a Mexican Wave, and giving chunks of his evidence in Latin; and his obvious successor in the job Simon Burns alternating between appearing to be asleep, having his head in his hands and engaging in what appeared to be a bizarre mating ritual towards female members of the Labour side.
It is a tribute to MPs on both sides of the Committee room that they were able to keep a straight face.
Oh, and bureaucracy. Witness after witness confirmed that the plans to cut bureaucracy will increase bureaucracy considerably.
NHS policy history repeats itself: the first time as tragedy; the second time as highlights of the Yes, Minister script.
The Health And Social Care Bill, and the health-policy-and-politics interaction overall, can no longer usefully be conceptualised in terms of public policymaking, or politics, or power.
It is now to be judged in the same was you would judge a circus act like a performing seal. It's got some entertainment value, if you're in the right frame of mind. But it's no way to be managing reform of a health service, nor of spending 10% of GDP a year.
Below follow a smattering of key quotes from the two sessions:
Simon Burns: "This is not a completely different Bill". (Understatement of the year)
Steve Field: "We do not want to close down competition, but we do not believe that Monitor’s prime aim should be to promote competition. It should be about encouraging the best quality, most efficient, effective health care possible. In some cases that will encourage integrated care between health and social care. In other areas it will be about suggesting that more competition should be there. I think the wording changes completely the emphasis on that and needs protecting." (Monitor will promote competition, in other words)
Steve Field: "Our feeling was that in a way having Monitor as a specific sector regulator protects you from the OFT, because the alternative would be to let the OFT take on responsibility for everything, and perhaps it would never get round to health because it was so busy. We felt that being explicit and tying Monitor down to doing what we wanted it to do was the best course of action". (Don't be scared, but we're relying on feelings here)
Steve Field (on the FT private patient income cap): "If you wanted a gut feeling for what was happening in the listening, the feeling was that the private cap should actually stay, because people felt that that would provide a protection. However, it should be reviewed and set at a reasonable level, whereas it is unreasonable in some areas at the moment. We felt that that probably was not worth putting in the document, because it was divided". (Interesting)
Jennifer Dixon: "In some areas, the full policy is not apparent ... to what extent should the legislation be very specific about surpluses that consortia might keep? Is that more properly something that should go into the regulations? That is a key financial driver for the consortia".
Emily Thornberry: "Doctors paying themselves bonuses".
Jenifer Dixon: "Yes, or, quite apart from the quality premium, if they make savings, as in fund holding, can they keep them?" (Well, quite)
Chris Ham: "Our concern would be the risk of too much bureaucracy being built into the process, rather than too little". (Well, quite)
Mike Farrar: "This is the fourth reorganisation of the national health service in the past 12 years, but it is the biggest. ... This rather took people by surprise at first". (vying with Simon Burns for understatement of the year)
Chris Ham: "We do not see why you should set an artificial limit on how much of the commissioning budget commissioning groups should spend on management costs. If they choose to spend more because they see that as a good way of getting the support that they need, why not let them?" (How odd for an anti-bureaucratic, Conservative-led government to be proposing more central planning)
Mike Farrar: "One of the silver linings to the cloud of the big political debate has been that at a political level there is more engagement with some of the difficulties around the health service and making changes. I have talked to some MPs who understand in private the case for change, but feel compelled later on to take a rather different public stance. That does not help any of us. It would be enormously helpful if, on the back of this debate about health services, we could have a significantly more mature conversation, with political leadership and the NHS working together to put the case for change". (Hope springs eternal)
David Bennett: "The biggest gap at the moment is the replacement for the original proposals on the failure regime. That definitely needs to be set out." (We can wait till report stage for this, then?)
Sue Slipman: "We welcome the removal of the private patient cap, although we recognise, as we have all along, that there will need to be a great deal of transparency to indicate where NHS patients have benefited from bringing more money into the system." (In breaking news, the Pope confirms that he is in fact Catholic)
Sue Slipman: "Depending on a range of patient choices, there will not necessarily be fewer NHS patients if you expand the facilities as a result of the money that you bring in. It depends where you invest that money." (...)
David Bennett: "In the application of that regime now, we will be subject to tougher requirements in terms of burden of proof, for example, when we think that it might be appropriate to introduce further competition" (Cat exits bag)
David Bennett: "An effective failure regime also needs to stop those hidden bail-outs and ensure that everything that is done is done transparently. If a service needs to be subsidised in some way because it is an essential service—and, perhaps because it is in a rural location, it cannot be provided at the normal NHS tariff—that should be looked at in an objective and transparent way and a subsidy should be agreed, by the commissioners, of course, because they are the ones who have to pay it. " (Well, quite)
Hamish Meldrum: "Clarity is getting increasingly difficult. This was already quite a complex piece of legislation and it is now being very significantly amended" (Very significantly? Mmm)
Michael Sobanja: "The Bill is one thing; the culture and behaviours of the organisations that are envisaged as operating and applying the Bill are another. With the greatest of respect to the Committee and the parliamentary process, one might be concerned about the level of centralisation that could come about if, for example, the national commissioning board behaved in a particular way, irrespective of the way in which the Bill is written." (Well, quite)
Mike Dixon: "We need to ensure that the clinical commissioning groups are themselves sovereign. Our concerns with NHS Alliance are now mainly around the autonomy of those groups to determine the services that their local patients need. Now they are responsible to quite a lot of organisations, from senates to the health and well-being boards and the NHS commissioning board, and we must ensure that these are lean organisations, owned by the local practices, fuelled by the local population and able to make the innovative changes needed. Tying them up in knots will not allow for that". (Well, quite)
Clare Gerada: "The bureaucracy with the new Bill, post-pause, means that we have gone—we have calculated this—from 163 statutory organisations to a proposed 521, not counting the commissioning support organisations. Clearly, we have massively increased the bureaucracy, if one calls it that, within the new, post-pause NHS. With respect to the national commissioning board and whatever, the current, post-pause Bill seems to be very incoherent. No matter what one felt about the pre-pause Bill, it was coherent. This is not. It is neither liberating nor controlling. It neither allows for GPs to be innovative, nor does it give them tight restraints" (Well, quite)
Michael Sobanja: "The Bill puts too much potential power in the hands of the national commissioning board, to address your issue head on. Clinical commissioning groups should have the right to appeal to the Secretary of State, potentially, or some other body, which I think is suggested in the revised Bill, to avoid the national commissioning board from becoming too directive and to ensure that it focuses on its true role of holding the commissioning groups to account. There is a substantial difference between the two." (Well, quite)
Michael Sobanja: "It is a hard fact of life that doing something for the patient in front of you every time may disadvantage the patient who is not in front of you. So there has to be a balance in this. I would suggest that it is appropriate to incentivise the groups, not GPs and practices, with the caveat that that money can only be spent on improved patient care." (well, quite)
Andrew Lansley: "The last thing that I want to do is engage in some kind of theological exposition" (Eh?)
Andrew Lansley: "Strictly speaking, the Secretary of State for a long time provided, and in many respects now provides, the service. The intention is to create a structure of legislation around the proposition that the NHS commissioning board is actually responsible, through commissioning, for provision, but that the Secretary of State has a duty—not just a power, but a duty—to secure that provision. If, in any way, the NHS commissioning board or the other commissioning bodies were to fail in their duty, the Secretary of State would have a duty, and the power, to intervene to make the provision happen." (The language does indeed matter)
Simon Burns: "That the amendments dealing with the failure regime are very complex; they are being drafted. We are not going to rush it because we have to get it right, and it would be irresponsible to rush." (Pause away)
Liz Kendall: "There are two days for Report stage, and you are saying that that will be the only time that MPs can scrutinise how we are supposed to deal with failed hospitals".
Mr Burns: "No, I am sorry, but you are falling into the trap that we had to put up with during the Committee: a Minister says something, and you then reinterpret it to suit your argument and throw it back at us. I did not say simply that the failure regime amendments would be dealt with on Report. I said—you can read it tomorrow when the report of the proceedings is published—that it is a very complex situation. We will not get it wrong. So that we get this right, we will not draft it in haste. I said that there would be—this is the crucial thing—other opportunities in the legislative process in which the measures could be fully considered. There is no point you nodding in a negative way".
Liz Kendall: "For the record, it was a shake, not a nod".
Mr Burns: "Or moving your head in a negative way". (WTF?)
Tom Blenkinsop: "What is the Ministers’ response?"
Andrew Lansley: "They agree".
Simon Burns: "Don’t be too clever by half".
Words cannot do justice to the sheer surrealism of the recommitted Health Bill committee evidence session yesterday.