Since devolution in the UK after 1998, the English NHS — unlike the rest of the UK — has trodden the market route, building on the original Thatcher government reforms,1 with the short exception of 1997 to 1999. This has coincided with a trend in policy making which has prioritised hyperbole over well-rounded policies that can be implemented effectively. This ‘implementation deficit’ has been acknowledged by some of the key policy advisers of the time,2 and the negative consequences of policy making on the hoof are widely recognised.3,4
SOFA GOVERNMENT ON HEALTH
Health policy has been affected by ‘sofa government’ (a term coined by the Butler Report5 to describe the Blairite style prior to the Iraq War of 2003) since the 1980s, if one uses this concept generally to mean informality of process and domination of policy by hand-picked insiders. The NHS Future Forum, reporting to the coalition government since the infamous pause in passage of the Health Bill in 2010, is the latest example of health reform which is soft in both process and substance.
The NHS Future Forum was set up by the government as a fig leaf for its embarrassment when the Health Bill had to be temporarily delayed, as the result both of a revolt by the Liberal Democrats and of consternation on the part of many health professionals and citizens. The Forum's first report was born from the need of the Conservatives to reassure their coalition partners and the public that Mr Lansley's sudden shake up would not lead to privatisation, excessive market forces, or dissolution of the NHS. So the Forum adopted the comforting concept of ‘integration’, and the government accepted its report.6
SHIFTING THE BALANCE
The Forum's second report in January 2012 comprises a number of papers, including one on integration.7 The government, by retaining the Forum, hopes that a non-political team (seasoned with clinicians and insider executives, plus a sprinkling of the great and the good) will convey a Panglossian impression of optimism. We cannot doubt the good intentions of those involved, but we can recall where the road paved with good intentions led. One does not need to be a cynic who takes unanimity as an indicator of folly to note that an ‘NHS sofa government’ was responsible for possibly the most disruptive, expensive, and temporary re-disorganisation of the NHS in recent years, with the introduction of Shifting the Balance in 2001.8
The Forum's policy-making style takes us ‘back to the future’. It is a hybrid of recent reforms, both in approach and content: from the working papers which accompanied the Thatcher review in 1989,1 through the aftermath of The NHS Plan of 2000, to the quality ‘initiative’ provided by the Darzi9 report for Labour, as the then-government realised that its own market reforms were lowering morale in the NHS. There is little sense of even contemporary history. Sofa governments tend to marginalise institutional memory, while in the meantime cosy hand-picked teams tend to come up with warm words directed at political problems rather than analysis geared to solving policy problems. Regrettably, the Forum is no exception.
COMPETITION AND INTEGRATION
Since the Forum's first report, the amended Health Bill has changed surprisingly little: it is mostly about creating an NHS which resembles a privatised utility, and which fails to respond adequately to deep-seated worries (for example, in the House of Lords) that the Secretary of State is no longer fully responsible for the NHS (and adds to concerns that workers in foundation and private hospitals, and other providers, are no longer working for the NHS, which has been a source of great pride since 1948).
Yet the Forum's second report fails to ask, let alone answer, the following questions: can competition and integration (or collaboration) co-exist? Are integrated organisations (for example, covering hospital and primary/community services) to be natural local providers or are they to compete with each other? Are whole NHS hospitals allowed to be preferred providers; and, if not, how will mutual dependencies between hospital services be protected?7 What is the difference between promoting competition (Health Bill Mark 1) and preventing anti-competitive behaviour (Health Bill Mark 2)?
There is a worrying trend in English health policy towards both ideological closure and policy-as-mutual-appreciation-society. The King's Fund and Nuffield Trust are warm about the Forum's report, which is not surprising as it draws on their work on integration.10,11 But all we have in England when the warm words are stripped away is a series of ad hoc examples of where local health agencies have sought to collaborate against the trend of prevailing policy forged in what one might call the ‘London consensus’ which emphasises the market and in particular the inevitability of the purchaser–provider split.
This work does not provide the basis for dealing with the contradictions in the Health Bill; in the Forum's hands it instead becomes policy-as-platitude. For example, one of the main sections of the report, on integration, centres on ‘Mrs Crabtree from Number 3’, a lady with multiple chronic needs. This is as grating, in its way, as the term ‘world-class commissioning’, during the last government. But more importantly: the Forum does not realise that it may have to challenge the policy consensus to promote Mrs Crabtree's interests against the fragmenting effect of market forces, even though other papers in this second report (for example, on education) unwittingly show the severe knock-on effects of dismantling existing structures: collective functions, such as workforce planning, have to be re-assembled at great cost.12
‘ALL THINGS TO ALL MEN’
The irony is that many of the academics who have supported the purchaser–provider split13 are now promoting integration14 and seeking to square the circle through competition between integrated organisations. In these difficult financial times, this concept is almost ludicrously impractical, requiring huge capital investment to create the capacity for such competition. There is no evidence that the Forum understands the complexity of the integration issue in the present policy environment, which remains the neo-liberal London consensus.
Meanwhile, as with most recent health reforms, professionals — and especially GPs — have been sold the dream of power only to find it has become responsibility. This is part-conspiracy, part cock-up. The conspiracy lies in the desire of government to devolve harder-than-ever choices about which patients get what. The error lies in the lack of attention to a proper mix of decentralisation and accountability in the Health Bill.
As a result, ironically, central control is necessitated on the hoof: the control of clinical commissioning will be exercised from the centre, and the rationale for these expensive reforms will be undone. This also happened after 1991 and after 2001, after brave new world rhetoric about devolution had accompanied major re-organisations:
‘Those who cannot remember the past are condemned to repeat it.’15
Notes
Provenance
Commissioned; not externally peer reviewed.
- © British Journal of General Practice 2012