Positions in this debate have become increasingly polarised, notwithstanding concessions made by the government in response to the report of the Future Forum and concerns expressed in the House of Lords. The irony is of course, that many of the changes included in the Bill could proceed without legislation in the unlikely event that the Bill is dropped.
The government may be guilty of a major tactical error in deciding to enact its reforms through a lengthy and complex piece of legislation rather than through the evolutionary change we and others advocated, but many of the Bill's critics have undermined their case by making exaggerated claims that it heralds the end of the NHS as we know it. Their credibility is also weakened by the fact that some of them have made similar claims since the introduction of the internal market in the 1990s and yet the fundamental principles of the NHS remain intact. Patient choice and provider competition will become more important, but this does not amount to the wholesale privatisation of provision that some fear.
At The King's Fund we continue to argue that the reforms need to be assessed on their merits. In our view, competition could bring benefits in areas such as planned and elective hospital care, where many patients would welcome the opportunity to choose which hospital to use. We are also clear that in many services there are strong arguments for health care providers to work together: the care of older people and of people with long-term conditions are good examples. This is why we have argued for integrated care to be given a higher priority.
We see no inherent contradiction between competition and integration. The complexity of health care and the wide variety of patient needs mean that one approach to organising care and ensuring resources are used efficiently is unlikely to be sufficient. As so often in health reform, the challenge is to put the right mix of incentives and levers in place, and to ensure that bold plans for reform are supported by plans for implementation.
We have therefore moved on from high-level analyses of the government's plans – in which we clearly set out the risks inherent in them – into more detailed studies of the proposed regulatory regime and into how payment systems need to be reformed to support integrated care. We have also drawn on research evidence and international experience to analyse the challenges involved in using both competition and integration to improve performance.
In undertaking this work, we are acutely aware of the need to plot a path to reform that avoids the destabilising effects of frequent restructuring. This is an issue on which the government is especially vulnerable and where senior NHS leaders have done much to limit the potential damage of the radical organisational changes that were set in motion after the publication of the White Paper. Despite their efforts, major questions remain about how the newly established organisations, including the NHS Commissioning Board and clinical commissioning groups, will deal with complex service changes when strategic health authorities and primary care trusts are abolished, as we discussed in our recent paper on health care in London. This is a serious concern in view of the need to accelerate the process of hospital reconfiguration that is underway in many areas.
Our view is that by the next election it will be the government's record in maintaining the improvements in performance seen in the last decade that will be under the most intense scrutiny. The Prime Minister's personal commitment to keep waiting times low throughout this parliament reflects this. The allocation of extra funding to support the 18-week referral-to-treatment target and the four-hour target in A&E is further evidence that government attention is shifting to issues that really matter to patients.
In 2012 we shall continue to analyse the impact of funding pressures on services and patients through our quarterly monitoring reports, which provide updates on NHS performance through the use of key indicators and by seeking the views of NHS finance directors. We will also be returning to our analysis of the impact of funding pressures on local authorities – in particular on social care – and the implications for the NHS. This work will be complemented by an audit of how performance has changed since the election, including shifts in public attitudes to the NHS.
Recent surveys, including one by the Commonwealth Fund, have shown the NHS in a positive light, but there is no room for complacency. The political and policy challenge is to adopt an approach to reform that leads to further improvements in performance while minimising the serious risks inherent in major organisational change and the loss of experienced managers. This approach must engage frontline staff, for it is their actions and decisions that ultimately will bring about real improvements in patient care.
From this perspective, the main worry for the government in the RCN's stance is not that it represents a fatal blow to its cherished legislation but that leaders of the biggest group of clinicians working in the NHS have come out publicly against the reforms. The question now is will the medical royal colleges follow suit, thereby adding to the pressure on the government? If so, how will health ministers respond to what could become an NHS version of the Arab Spring?