Bristling with incidents and opinion, this controversial paperback introduces a history of the Health and Social Care Act 2012, a bill which became law in March 2012 and involves a huge restructuring within the NHS. The richness of the text derives from the author’s background knowledge, access to numerous publications, and 30 interviews conducted for the sake of a wide assessment on the legislation’s evolution.
Early chapters reveal clashes between politicians (like Clarke and Thatcher), PCTs and clinicians well before health secretary Andrew Lansley’s proposal Liberating the NHS put into print what Professor Timmins ranks as the ‘biggest ever shift in accountability’.
Readers are left in no doubt that these plans are radical, introduced during a problematic economic period which forecasts cutting £20 billion from the NHS budget. In October 2012, the Daily Telegraph predicted the bill heralded the largest revolution in the NHS since its foundation 60 years ago.
A bullet-point list summarises the health secretary’s hastily produced 50-page strategy; requirements that appear in the white paper begin with three commitments:
all family doctors to be involved in commissioning consortia, with strategic health authorities to be abolished in 2012 and primary care trusts to go in 2013;
the establishment of an ‘autonomous’ commissioning board; and
a new economic regulator to be charged with ‘promoting competition’ and given current powers with the Office of Fair Trading ‘like other sector regulators, for instance Ofcom and Ofgem’.
Timmins’ readers may also sense that the coalition government’s ambition was not matched at a senior level by the necessary experience to engineer successful implementation. Implementation remains a bridge to be crossed, and therefore a chapter yet to be written. Perhaps there’s too much ongoing experience for busy MPs to study, in fact, to be fair, too many reports in specialist fields for any but a few to claim complete knowledge of medical matters. Precisely which group of MPs knows that most patients are happy to travel an extra 10 miles to support competition among health providers?
Now and then, the detail of the mammoth 550-page bill that emerged proved a difficult read; Shirley Williams told the NHS Confederation that elements were confusing and obscure, even after amendments; less politely, an unprecedented joint editorial by the BMJ, Health Service Journal, and Nursing Times described it as an unholy mess.
Numerous other issues are noted in the text, not least, a reluctance at a high level to set out exactly how the commissioning will work (described as an unwillingness to ‘talk about the wiring’), price versus quality, the impact of EU law on competition, and whatever reasoning led to this fresh approach, that is, why do it at all?
Timmins’ slightly whimsical layout for this book is to depict a drama in five acts, opening with Out of the Ark then Run Fast ... Run Very, Very Fast, and a closing chapter Never Again setting out lessons. I think an equally good approach would have been to illustrate the general political process of preparing ideas about the NHS for action; the author could have relied on his own experience or interviews to do this. This explicit notional logic (proposed as a diagram) may then be deployed to question interviewees, allowing their comments to be set alongside activities displayed in the diagram. For instance, if one activity in such a diagram is to gather opinion on major issues for the NHS 2011 to 2016 the contributors could have commented on how well this was done: did the government listen to the appropriate groups? Has some implicit government mission (which translates ideas into proposals for action) received insufficient attention?
However, despite introducing the idea of an autonomous, self-correcting system that allocates resources (and could be sketched as an abstract device as I’ve suggested here), the book’s 150 pages hold no diagrams to stir debate.
- © British Journal of General Practice 2013