The government has undoubtedly made a major strategic error in deciding to enact its reforms through a lengthy and complex piece of legislation, but some of its critics have undermined their case by claiming that the Health and Social Care Bill heralds the end of the NHS as we know it.
Discussion about the reforms has become unhelpfully polarised around a debate about whether or not the Bill should be dropped. Our view at the Fund is that the complexity and importance of the issues at stake cannot be reduced to the simple question, are you for or against the Bill? This is because the Bill and associated reforms offer opportunities as well as risks, and our role as a think tank is to analyse, inform and seek to influence policy, rather than to adopt a campaigning stance that takes sides in an increasingly acrimonious debate.
We take encouragement from the amendments made to the Bill following the work of the NHS Future Forum as well as those that seem likely to be introduced following pressure from members of the House of Lords. As a result of these amendments, there is now explicit acknowledgement that the emphasis on competition needs to be joined with support for integrated care where it will bring benefits, and – assuming agreement can be reached, as now seems likely in the House of Lords – greater clarity about the role of the Secretary of State. At the same time, we remain concerned by the further reductions in management costs and posts that will be made following the release of papers on the role of the NHS Commissioning Board last week, and the loss of organisational memory and experienced managers that will inevitably occur.
One of our most important concerns is the impact of major organisational changes on the ability of NHS leaders to focus on the core business of improving patient care and maintaining recent improvements in performance. At a time when the NHS faces the biggest financial squeeze in its history, the priority has to be rising to the Nicholson Challenge and releasing resources to invest in service priorities such as the care and dignity of older people and improving care for people with dementia. Much work also needs to be done to tackle variations in quality and patient safety, often involving difficult but necessary decisions on concentrating specialist services in fewer hospitals able to deliver better results.
We made clear in our October 2010 response to the white paper which launched the reforms that the government would have been better advised to pursue its aims by building on existing arrangements rather than embarking on further major change. Almost 18 months on, the changes already made in anticipation of the Bill becoming law make turning back very difficult. This week's joint editorial by the editors of the BMJ, HSJ and Nursing Times argued that the result of the government's action is 'an unholy mess' but it is not at all clear that the mess would be avoided in the unlikely event that the Bill were to be dropped.
One of the roles of think tanks is to go beyond commentary and critique to set out alternative options. The Fund has sought to do that, not only by arguing the case for evolution instead of revolution, but also by proposing that integrated care should be given much greater attention. The policy tide is now running clearly in this direction and we shall continue to propose ways in which clinical commissioning groups and health and wellbeing boards can use their powers to make a reality of integrated care in practice. We have elaborated on our ''Plan B' – Where next for the NHS reforms? – through a series of contributions to the debate and continue to believe that there is no inherent contradiction between integration and competition.
In 2010 I wrote an article for The Times in which I argued that the choice was not between stability and change but between reforms that are well designed and deliver benefits for patients and those that are poorly planned and undermine NHS performance. While passions will surely continue to run high on an issue that matters deeply to the British people and to staff working in the NHS, now is the time for cool heads and rational discussion of how to make sure that the reforms really do work for patients and that the risks they represent are managed and minimised. A service already performing well can do even better if the energies and intelligence of all who have the best interests of the NHS at heart can work together to secure its long term future.