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Guest editorial Sunday 23 January 2011: Liberation Ltd.

Irwin Brown of the Socialist Health Association recaps key points on liberation, as seen through the prism of the new Bill

The long-delayed Bill has finally been published - although the Explanatory Notes are still absent.

Two things appear obvious.

First is that it is mostly about creating a regulated market; a very different type of NHS to the one we have now.

Second is just how extensive and pervasive are the powers of the Secretary of State to directly or indirectly interfere in just about every aspect of the system – using secondary legislation; exactly the opposite of the rhetoric which implied a “liberation”.

The ability of the SoS to intervene is hardly a model for liberation, but the powers  are there to stop anyone doing anything to prevent the smooth introduction and operation of the market.  It gives a route for the Treasury to step in if it gets too nervous. It will (paradoxically) also allow the SoS intervention to prevent unpopular decisions close to election!

The Bill is based on ideology, not evidence; based on the conviction that free markets are the best way to drive innovation, efficiency and deliver quality services.  The reasons why markets have limited applicability in healthcare and the dangers to patients of allowing competition through price have been ignored.

To make the market free, the key levers are:
- choice by patients, to be exercised at every stage of their treatment (and eventually having the money or vouchers);
- plural providers for every service all available to be chosen;
- and a variable price to be paid to the provider of the service.

In time, all NHS services will be like eyes and teeth are today. You take your prescription to any licensed provider, get treated, pay what you have to (or sign some demeaning form because you are exempt) and the provider sends an invoice to some central payments mechanism.  No planning, no commissioning, no public or patient involvement, no NHS-badged providers are necessary.

That is the future.

Two-term thing
Although these reforms are contrary to previous policy positions taken by the Lib Dems, their votes will ensure the Bill gets through the Commons.  A real fight will ensue in the Lords but in the end the Coalition will get its Bill.  And this has to be a plan for at least two terms in government, the second without the padding of the LibDems.

We must assume they will appoint people into all the key positions to ensure we have a very aggressive set of regulators and that the powers available will be used early and hard to force through establishing the ‘any willing provider’ model.  

Nonetheless, there are some very powerful forces they choose to ignore that will make achieving their vision for a free market quite hard.  

As everyone keeps telling LaLa, the need to deliver Nicholson’s Challenge which is The most imprtant challenge facing the NHS - and these reforms make it harder.

Generation terrorists
Establishing an effective market, even if that is possible, will take a generation.  Signs of financial problems during this year may slow down the transfer of power to the new institutions.

It is also paradoxical that aside from the usual few evangelists, most GPs are very wary about opening up provision of all services to competition – more so than PCTs are / were.  They see it as a vey real threat to their position of quasi-monopoly over aspects of primary care.

Proper investigation shows that in fact, large parts of the NHS are very difficult to open up to any kind of competition of the kind the Bill requires; emergency care, care of the elderly or of any patient with multiple conditions come to mind.

There are some natural monopolies, some services with very few providers and some where establishing a long-term relationship with a single provider has great value.  Some have suggested that at best 20% of NHS expenditure is really open to genuine competition - and that in fact, much of that has already taken place, like cold surgery.

There are good reasons to believe that reform is most needed in primary care.  Making the changes to move care out of expensive secondary care is the requirement.  But that is not brought about by competition between providers at all, it requires developing new types of services, and the AWP model adds nothing useful.

Integration and  collaboration between providers along the patient pathway offer the best opportunities - but these don’t fit into the market model.

There aren’t legions of alternative providers out there waiting to step in, with all the risks that implies; they might instead just be sub-contractors to NHS providers like the FTs.  There are those ready to take the easy pickings, but that does not go very far into the vast range and complexity of what the NHS delivers.

Foundations of success or failure?
What happens with the Foundation Trusts, once they become the default provider model for all services, will be very influential.  So far, the independent and autonomous FTs have not really taken off as innovators and mostly they have consolidated rather than set out to compete and expand.

Monitor’s own study showed FTs, once approved, did not progress any faster than established trusts.  As the ability to vary prices comes into play, will FTs start to fight each other or will there simply be an unwritten truce, respecting established boundaries?

All this may mean that the reforms will be introduced slowly and the NHS will gradually adapt, having first sorted out its financial issues as best it can.

The danger that everyone keeps pointing out is that forcing the pace of reform will divert focus and managerial attention away from patient care. That could be the route to the disaster of which  so many are warning.