Evolution or revolution: the story behind the Health and Social Care Act 2012

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It was often difficult to know who to believe during debate about the Health and Social Care Act. The public were faced with baffling technocratic details from government with no accompanying compelling narrative to explain the need for such significant reforms, alongside sensationalised claims from some who opposed it that the Bill spelt the end of the NHS as we know it.

In his account of the story behind the Bill, Never Again?, published today by The King’s Fund and the Institute for Government (IfG), Nick Timmins sets the record straight. Through interviews with key players involved in the action, analysis of public speeches and documents and his own personal observations as a journalist reporting on the Bill, Nick has produced an illuminating account of the policy-making process and suggested some lessons for government. The IfG have elaborated on some of the wider lessons for policy making. But how revolutionary were the reforms? Were they just a continuation of the market reforms begun in the early 1990s? And could any of these ‘mistakes’ have been avoided if lessons had been heeded from previous major reforms to the NHS?

Ken Clarke introduced the purchaser-provider split to the NHS with the 1989 White Paper Working for Patients. These ideas had much continuity with Labour’s attempt at the market. The names were different – foundation trusts, practice based commissioning, payment by results and patient choice – but the elements were very much the same and all have been reflected again in the current reforms. Indeed the coalition government’s reforms were seen by some as completing the unfinished business of the new Labour project. So why, as Nick describes, were these reforms presented as a ’challenging and far reaching set of reforms’ in the government’s own White Paper? A puzzle indeed from a political point of view.

It was David Nicholson who vividly characterised the enormity of the reforms – ‘so big you could see them from space’. The reason they were seen as so revolutionary was the extent of structural change they brought. The programme for government had not signalled the abolition of Primary Care Trusts (or Strategic Health Authorities, which got no mention) but the proposals it contained – a mongrel created from the Conservative ideas of markets and the Liberal Democrat commitment to local democracy – were unworkable. The solution – hand over public health to local authorities, devolve commissioning to groups of GPs and abolish PCTs.

In our account of Labour’s health reforms, published after the publication of the White Paper but before the Bill, we set out some of our own lessons for government. One of these was ’Have a clear narrative about the reforms and make sure their purpose is clear to those responsive for implementing them’. Yet clinicians, and particularly GPs who were always going to be critical to the success of these reforms, were some of those who most actively mobilised against the Bill. Managers who traditionally saw NHS policies get implemented were under fire and many were working for organisations that were marked for abolition.

Our other lessons were around the implementation phase. This story is yet to unfold and, unlike Nick’s lessons of the policy making process, there is still a chance for the government to learn. Three are worth repeating here.

Firstly ’Be open to adapt and refine policies in response to the changing context’. When faced with a radically different financial context, Andrew Lansley made little change to his original ideas formulated in a time of plenty. It is vital that policies are adapted as the needs and demands on the system change.

Secondly ‘Do not assume that passing new legislation will change the behaviour of those within the system’. The focus of Andrew Lansley and senior civil servants has been on getting the Bill through. The issues of implementation have been left to David Nicholson to take care of. Delivery needs as much attention as design.

And a final note of caution: ’Expect there to be unintended consequences, amplify the positive and mitigate the negative.' As we, and others have highlighted, there are both opportunities and risks inherent in the current reforms. They could play out very differently in different areas and for different services. Careful attention will need to be paid to the impacts of these reforms in order to identify where things are working well and where they are not. If we are to learn lessons, there is an urgent need for the government to commission evaluations of the key components.

The art of good policy making is now well documented. And yet despite knowing how to do it, we seem to keep on forgetting. Let’s hope we don’t repeat the same mistakes over implementation.

Comments

#1277 Mike Stone

What strikes me, is that whether or not (and many people seem to think 'not') the reforms will improve the NHS, they were misrepresented to the public. The primary motivation was presented as being 'moving the purchasing-decisions closer to individual patients and their GPs', which appeared to imply groups of GPs, at a basically local-level, joining together to purchase secondary services. That does not square with the new GP Commissioning Bodies (probably not called that - I can't keep up with the names !) actually being the same size as the PCTs they are replacing - one can't help thinking, that more decision-making could have been devolved to GPs/patients, without abolishing PCTs and SHAs (which have been replaced, anyway, by new tiers of structure, within a framework where I for one am not 100% clear about who is responsible for what).

But it isn't my area of interest - but I am clear, that what we seem to have ended up with, is not what Cameron et al were stressing in their public speeches !

#1278 Vickie Ferns

Mike ,I would suggest that the new regime is there only to save money, I do not believe it is about better patient care at all. It will be the G.P's job to keep people out of hospital, particularly those with chronic , incurable diseases. Acute cases will still be treated in hospital but mistakes will be made because of the pressure G.P's will be under. Obviously, the higher the population the more potential to make serious mistakes. Your country has a much wider range of illness than a small country like New Zealand (where we have had community care for eleven years),with more potential for neglect and harm of chronic patients.
G.P's are not specialists but they will end up making decisions in care that will not be in the patient's interest ,I guarantee it.
What angers me more than anything is that Governments push through changes , testing out theories on populations who are powerless to stop it. Of. course Cameron hasn't told the people what the changes are really about, and the manipulation will trickle down until the doctors and nurses too will be manipulating the chronicly ill that the country can't afford them so this is all they are entitled to ,basic home care. Don't be surprised if the range of medications that can be used are cut back too in an effort to save millions of dollars. Our PHarmac organisation who decide what medications New Zealand can buy and who can use them, are ruthless. They stopped patients using a certian high blood pressure tablet which my Mother was on because her blood pressure is hard to control. The change caused heart failure with in two weeks, my Mother was than eligible to use it because of the heart failure--they could have killed her. It would be interesting to know just how many patients were adversely effected. My Mother rung a talk show about her experience on a morning when they had a representative on the show. The talk show host didn't have a hope in hell of arguing the case, pitted up against a doctor from Pharmac with his medical knowledge and ability to manipulate the talk show host backed down.

#1279 Mike Stone

Vickie, I'm sorry about what happened to your mother.

Most of us who have been following the story over here - such as me - actually do suspect that the two primary motivations were to spend less money on the NHS, and for the goverment to then say 'but you patients and your GPs made the choices yourselves'.

Well, perhaps I should say 'most of us over here, who are cynical like me'.

There still seems to be a very muddled piece of legislation, and only after a lot of amendments (not pushed by the goverment) are certain very obvious safeguards even slightly present - very few of the politically neutral, actually like this Act. Even if we agree the NHS might need to spend less money, it still looks like an untested (and untestable in advance) dog's breakfast ! And from a left-wing political perspective, I don't like profits flowing out from the NHS: the last major 'private business' involvement in the NHS was the PFI, and that is now coming home to roost with many PFI-funded hospitals in dire straits.

#1280 John Chater

I was at the King's Fund commissioning event on the 17th July and asked a question in response to a comment made by Stephen Dorrell that clinical-led commissioning had begun over 20 years ago. It occurred to me that the 'sense of continuity' that Mr Dorrell referred to might equally be described as the failure of a good number of very clever people to get frontline-led commissioning off the ground.

Behind the Health Act and all of the reforms of a similar ilk is the ideological idea (rarely questioned now) that GPs are best placed to lead the buying of health services. I cannot remember why this presumption was given so much weight, but now it is simply assumed that the question is not whether or not GPs should lead, but rather how they should lead.

Why? What is it that qualifies a generalist, who might most accurately be described as a triage expert, to spend billions of pounds on specialised services? As I recall the idea came from a belief that as 80 per cent of patients stop at the GP surgery, without being referred any further, then GPs should 'know' their patient population better and therefore be better placed to design and deliver services for them.

But this is a presumption, not a fact, and it could equally well be argued that as 80 per cent of the NHS budget is spent in secondary care then it is specialists who ought to determine how best the money be spent.

Which brings us to the second reason in favour of GP-led commissioning, namely that as out of hospital services are cheaper, encouraging doctors to provide services in a primary care setting should produce savings. But again this is a presumption and it may well be cheaper overall to provide services in a single hospital setting than in a number of more local primary settings (as well as encouraging the kind of specialisation that we know improves outcomes).

In fact, the closer one looks at the rationale behind GP-led commissioning the more one might be reminded of Andersen's The Emperor's New Clothes – we are convinced of the truth of it not because we know it to be true, but because the powers that be tell us it is true. Until that is someone steps out of the crowd to ask why, exactly, the Emperor is butt naked! (And yes, I know that the government rebranded GP consortia as clinical commissioning groups, but in reality this hardly translated into a modest fig leaf.)

My question to Mr Dorrell was 'Is the Health Act the last ditch for clinician-led commissioning, and if so whatever shall we do next?' I suspect I may find out soon enough.

#41789 jamaica joseph
nursery teacher

i did health and social at gcse and a-level its easy.

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