The process of government, the prime minister said as he announced his now famous “pause” on Andrew Lansley’s health legislation, “is about trying to improve the state of this country and institutions and take people with you at the same time”.
This is not easy. Any hope that the government’s decision to “pause, listen, reflect and improve on” the NHS plans would produce some sort of broad consensus about what needs to be done to the NHS has long gone.
Instead, as countless responses flood into the NHS Future Forum – the group of 40 experts set up to advise on the reforms – the government is receiving a cacophony of quite often diametrically opposed advice.
The British Medical Association on Wednesday urged the government to make the primary role of Monitor, the new economic regulator, one of promoting collaboration, not competition. Reform, the pro-market think-tank, says the government “must keep competition at the heart of the bill”.
The BMA wants “all relevant clinical staff” involved in commissioning. Therapists, as well as midwives, nurses and hospital doctors, are bidding for seats on the commissioning boards.
A survey of 20 of the embryonic GP consortia shows that every one of their leaders rejects the idea of having hospital doctors on their boards on the grounds of conflicts of interest. The government has been brow beaten into declaring that it will drop price competition on NHS services– despite Mr Lansley advocating that for a good four years before his NHS bill appeared.
David Bennett, the chairman of the planned new regulator – who has set out an admirably clear explanation of how it all might work– has said that ruling out price competition in all circumstances would be a mistake. Unison, the biggest health union, has argued that the bill should be dropped in order to eliminate any idea of competition. By contrast, Julian Le Grand, a former health adviser to Tony Blair, argues in today’s Financial Times that the bill should be scrapped for the opposite reason – in order to protect current elements of choice and competition in the NHS.
Liberal Democrat activists are still pushing hard for much greater involvement – by one route or another – of local councillors in the commissioning of care. But many GPs who are interested in commissioning would walk away if that happened.
Precious few of these submissions address the critical question that Stephen Dorrell and his Commons health select committee have repeatedly highlighted – the need for a clear explanation of how these changes, not just any old changes but these changes, will help the NHS get through the next four years of flat real-terms funding without services being decimated.
For the NHS there is a real risk that the outcome of the eventual bartering over the bill will be a dog’s dinner. It could involve a new regulator so bound by conflicting legislative requirements that it will be inoperable. It could also encompass commissioning boards so stuffed with assorted interests, and so bound to consult everyone in sight – at the same time as councils are given stronger powers to reject or appeal against their decisions – that nothing will ever happen.
David Cameron and Nick Clegg have a duty to guard against such a result, however much they may want “to take people with us”. In the final meeting to settle all this, the prime minister and his deputy will have to remember that “to govern is to choose”. And they need to choose correctly.
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