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Happy returns for the health reforms?

A year on from the Lansley reforms.

It is now one year to the day, that the terrible beauty of Andrew Lansley’s mega reform of the NHS – the one that was not a “top down re-organisation” – lurched into life.

GPs to commission all local care. A separate commissioning board – now called NHS England – to do the specialist stuff and hold the GPs’ contracts. A more formal recognition of the role of choice and competition. New Health and Wellbeing Boards to bring health and social care more closely together, etc, etc So how is it all going? It is early days. The best of the clinical commissioning groups are doing some interesting things. Health and Well-Being Boards – an after-thought to Lansley’s own reforms – are emerging as some people’s favourite to be the dark horse of the changes. If genuinely joined up commissioning of health and social care is to occur – and increasingly it seems to be the received wisdom that that is needed – it just might be that they will be the bodies that evolve to do it. Although it is worth noting that that, in itself, would need another reorganisation. Competition is not working quite as intended. The intention, the politicians said and still say, was that commissioners should be able to choose when to use competition. But the lawyers have got their hands on this. Some clinical commissioning groups are succumbing to advice to put services out to tender when they don’t really want to, while some organisations that want to resist change are citing the potential loss of competition as a reason to block changes that others believe are to patients’ advantage. A long and difficult conversation continues between health ministers, Monitor, and the competition authorities to try to get the last on that list to recognise that health is different, and that loss of competition is not necessarily always against patient’s interests. And then there was Lansley’s big idea that under his new “autonomy and accountability” regime, health ministers would step back from day-to-day involvement in the management of the NHS. They would create a three-year mandate for NHS England – the big strategic goals that ministers want to see achieved – and then let it get on with the job. The legislation would "limit the ability of the secretary of state to micromanage and intervene," and indeed the Act does formally charge the health secretary with a duty to promote the autonomy of NHS organisations. It has not worked out that way. In one of those neat ironies of government, Lansley has been succeeded by Jeremy Hunt, who in some people’s eyes is one of the most interventionist of health secretaries on record. One of his first decisions was to re-write the three year mandate when it had barely taken effect. As A&E waiting times slipped, Hunt and Number 10, not NHS England, decided to inject extra cash into A&E to cope with winter pressures. There have been turf battles between the minister and NHS England about who should announce what. And there have been endless meetings. Hunt has all the main players (which include NHS England, Monitor, the Trust Development Authority but at times others) in twice a week to monitor delivery and act on problems. The chief executives of hospitals whose A&E waiting times have slipped have even had the health secretary personally on the phone asking what they are doing about it. Asked at a recent summit held by the Nuffield Trust health think tank if Lansley’s view of an NHS “free from day-to-day political interference” could ever be made to work, Hunt argued that any health secretary will have some priorities that they want to pursue – in his case, he cited issues such as the “compassionate care” agenda post the Francis inquiry into Mid-Staffs, and out-of-hospital care. “I do not think you could do a job like mine without deciding on a few priorities and focusing on how to change those,” he said. He maintained, despite many perceptions to the contrary, that “micro-management is something that happens less”. But he underlined that “I do not think it was ever going to be the case that the secretary of state that could step right back. We have to recognise that we are a democracy. And people want to hold people like me, rightly, accountable, for over £100bn of public money – and so there are always going to be times when the health secretary has to involve themselves in operational issues”. In other words it seems that culture, the personality of the secretary of state of the day, and parliamentary accountability are always likely to trump aspirational law. In the past, there have been health secretaries who did behave like chairmen of the board – Stephen Dorrell being a notable example. But the first year’s experience of Lansley’s brave new world is that there seems little to prevent a health secretary who wants to be the executive chairman from being precisely that, or indeed, something somewhat stronger. That relationship is just one of the many things that Simon Stevens, who takes over today as chief executive of NHS England is going to have to manage. Stevens, a former NHS manager, key adviser to Blair, and most recently president for global health at the United Health in the US, is arriving to messiah-like expectations that everything will change for the better now that he has taken over from Sir David Nicholson. The fact that he has taken the job should be a cause for celebration. But he is going to need every bit of support that he can get.
Publisher
Institute for Government

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