Lord Alderdice writes: The NHS Bill is substantially improved

As Liberal Democrats we are reformist by instinct and as in every other area of our community life we want to see reform of the NHS, not only to enable it to deal with the major resource and demographic challenges of the next twenty years, but also to ensure that it is more clinician-led, patient-centred and outcome-focussed than it has ever been before. That is why our MPs supported the principles of the Secretary of State’s original NHS Bill when it came to 2nd Reading in the House of Commons.

Our very public concerns have centred round whether the precise organizational changes proposed would bring the outcomes we all want to see and as we examined the detail we began to press for modifications in the reform proposals. It is important to be aware that many of these concerns were shared by some of our Conservative colleagues in Parliament.

Our first task was to set down the key improvements that needed to take place in the Bill and at our Sheffield Conference we did this publicly and with some clarity. Nick Clegg then undertook to persuade the Prime Minister that these were genuine, reasonable and widespread concerns which merited a ‘pause and listen’ exercise before taking the legislation on to its next parliamentary stage.

In parallel with the listening exercise conducted by Professor Stephen Field, Nick engaged directly with party colleagues, NHS and professional stakeholders and the Conservative leadership in detailed discussions which not only confirmed that there was widespread public and professional support for our ‘Sheffield stance’ but which resulted in very substantial change and improvement in the Bill.

What has been the broad thrust of these changes?

The responsibility of the Secretary of State for the provision of a universal health service free at the point of need will be entrenched rather than reduced, returning to the principles of the original NHS commitment. The NHS Constitution will be maintained.

The commissioning of health care will be by clinicians – not only GPs but also informed by nurses, secondary care specialists and others; and those who need more time to develop the skills and processes they require to undertake these new responsibilities will be given more time.

The Commissioning Groups will be public bodies with transparent governance structures and accountable through the Health and Well-Being Boards to locally elected representatives. This will prevent conflicts of interest, but facilitate increasing integration of primary and secondary health care as well as of health and social care – an approach we have long championed.

The new proposals also put in place the greater democratic accountability which was an essential element in our manifesto commitment – as was our determination to cut out bureaucracy, something else that is being achieved in the new proposals though now at a more realistic pace than was originally envisaged when the Bill was introduced.

One of our biggest worries in Sheffield was that the ‘utility regulator model’ which was being used to inform the equivalent new NHS body ‘Monitor’ was too simplistic and too focussed on competition for its own sake rather than as a facilitator of improving standards and enabling cooperation and integration of services. These concerns were reflected in the Future Forum Report and the Prime Minister has accepted this hugely important change to Monitor. This will protect the future development of the NHS and prevent unacceptable ‘cherry-picking’ by private providers. But it goes further and repairs some of the damage done to the service by outlawing the practice of the previous Labour Government which often discriminated in favour of private providers over against NHS providers.

There was concern that with removal of the Strategic Health Authorities (something we campaigned for in the last election) and the disbandment of PCT’s some necessary managerial skill and experience would be lost but with the longer period of transition now envisaged, and the National Commissioning Board adopting the PCT clusters as a regional presence, we can achieve our joint aims of reduced management cost and maintenance of regional specialist and commissioning functions.

The rubric “No decision about me without me” was a hugely welcome commitment by Mr Lansley when he presented his proposed reforms however it was puzzling that the original Bill actually said very little about patient, carer and family involvement. This has now been put right and patient and carer involvement is being ‘hard-wired’ into the reforms.

Though we have already seen major improvements to the Bill, more will emerge as it returns to the Committee Stage in the Commons for re-examination by MP’s and then passes to the Lords in the autumn for detailed scrutiny and revision there. In addition there will be much work to be done in the process of implementation especially during a period of profound economic austerity and unprecedented demographic change and increasing treatment costs.

Despite these challenges my Lords colleague Shirley Williams, who has played such a significant role in this process, was surely right to say yesterday in The Independent, “Liberal Democrats can comfort themselves with the realization that one of England’s most trusted and best loved public services will now survive as the framework for our healthcare; the Prime Minister will be able to say with confidence that the NHS is safe in the Coalition’s hands.”

Lord Alderdice is Co-chair of the Liberal Democrat Parliamentary Policy Group on Health and Social Care.

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  • mike cobley 14th Jun '11 - 4:47pm

    Sadly, I do not share the noble lord’s assessment, neither of the party’s reform penchant, nor of the ongoing proposals for the NHS.

    The Liberal Democrats are reformist … by instinct? I was under the impression – formed from decades of observation of party policy formulation, and mindful of the comments of Lord Jenkins – that we were a party of rational problem solvers. Reforms are a serious business, and cannot be trusted to whim or instinct, at least I would have thought. The process of reform should address serious and pressing matters, which the Lansley reforms scarcely do at all.

    As for the nature of the counter-reforms, I have little confidence in them. Cameron and his backers will be quite satisfied now that the principle of NHS fragmentation and private sector involvement in all areas of frontline provision has been established. Give it another few years, they`ll be thinking, and we can have it all. Because for-profit companies do not have an off button – they don’t say okay, we’ve earned enough profit, lets stop there. Nor do they say, right, we’ve got control of, say, 45% of urology operations so we can stop now. No, they will go on pushing and lobbying relentlessly and ruthlessly until there is nothing left of the NHS but some kind of logo on the GP Consortia headed notepaper.

  • formervoter 14th Jun '11 - 6:31pm

    I’m sorry, but ‘free at the point of need’ is not the NHS. The NHS is free at the point of USE – it’s a point that might slip past people. ‘Free at the point of need’ mean mean-testing; if you have money or assets (a house, a business) you will be expected to sell them to pay for treatment; if you have no assets, then a different kind of treatment, which leads to a two-tier health service.

    Also I have seen no comment on whether these revised reforms leave the NHS open to EU competition law. If so, they will be disastrous.

    Kill the bill, it’s the only way to stop healthcare going the way of education.

  • “That is why our MPs supported the principles of the Secretary of State’s original NHS Bill when it came to 2nd Reading in the House of Commons.”

    I must have been living in a different dimension…..

    In my world there were plenty of Lib Dem MP’s and Ministers supporting the content of the Bill. Remind me again Lord Alderdice, when you sign a Bill is that only supporting it’s principles…

    On a day when Clegg at least admitted he had got it wrong we get yet more spin. If it wasn’t for Lib Dems outside of Westminster this Bill would not have had it’s “pause”, or the much welcomed major changes. Pretending otherwise is frankly a little pathetic.

  • The whole bill is an utter mess and needs scrapping. The thing is that the Conservatives don’t really matter in what configuration the NHS is as long as it fails and their friends and donors in the private health providers can pick up the pieces.

    There is still a massive unpiloted and thrown together change going ahead whilst the NHS managers (those that are still left) try to cut 4% in efficiency savings. Is it really wise to make big cuts whilst trying to adjust and change a system ?

    NHS safe in conservative (or coalition hands) I think not. I am not convinced and it does matter to me who delivers the care.

    This is the only thing that made me laugh today – a consultant puts a spanner in the Conservative PR machine.


    Someone obviously didn’t clear the interview with the Consultant.

    Perhaps he is also not amused as Ward Managers on his ward cannot get cover for nurses off sick and have to beg one of the off duty to come in or have to work with an understrength ward. Not great for patient care or health for nurses. This is happening at Guys and St Thomas Hospital.

  • The thing is that the Conservatives don’t really care in what configuration the NHS is as long as it fails and their friends and donors in the private health providers can pick up the pieces. So a few changes here and there on the road to privatisation. I still don’t think that thrown together policy on the NHS or any policy makes good policy. There is far too much of this going on with the Conservatives in this government. It is thrown together because as the Archbishop of Canterbury quite rightly pointed out is that the electorate did not vote for much of the polices out there. T

    The Conservatives did not discuss things such as privatising the NHS because their vote would have reduced to 35% and lower. Nice try on this bill from the Liberal Democrats but it is still a badly ill thought through bill. Like I say the Conservatives do not care about that as the end in mind is privatisation and defragmentation and an Insurance type US system.

  • This is one of the biggest pieces of nonsense I’ve read. The White Paper “Equity and excellence: Liberating the NHS,” has a considerable amount of detail including (for example) numerous mentions of Monitor as having a role to promote competition and to prevent anti-competitive behaviour.

    It was signed up to by Nick. To claim now that we didn’t support the detail but only the broad principles is a complete calumny.

  • Bill le Breton 15th Jun '11 - 9:16am

    OK, so we are agreed: Conference had a better grasp of this issue than the Leadership and the Minister. The Parliamentary Party on the backbenches, for what ever reasons, were not able to keep the front bench in check.
    How do we now ensure that:
    a) Backbenchers strengthen their ability to scrutinize the front bench, before the front bench signs up to policy?
    b) Our members of the Coalition Government make more use of the Party institutions such as Policy Committee, Conference and the membership before signing up to policy?

    My analysis is this: the Leader believes that differences between himself and the Party are ‘generational’. Those from earlier (older) generations don’t ‘get it’. He therefore surrounds himself with those he defines as of his ‘generation’, he promotes and gives office to these. Older generations are sidelined and ignored, which is why the likes of Williams, Ashdown and Campbell are ‘outsiders’.
    As these older generations form the majority of conference, the majority of Party Committees and the majority of the Parliamentary Party, these institutions and their membership are seen as ‘part of the problem’ and are ignored or conspired against. The ‘bunker’ becomes populated by those who ‘get it’. Anyone or anything that smacks of the older generation is viewed as wrong and unreliable.
    Wise leaders surround themselves with people of different experience and different views – different generations. They value different views and have a respect for collective wisdom.
    It doesn’t matter for Liberal Democrats whether Cameron has learnt from this experience, it does matter whether Clegg has come to appreciate and value the Party as it is.

  • @Bill Le Breton
    “The Parliamentary Party on the backbenches, for what ever reasons, were not able to keep the front bench in check.”

    The trouble is there is no evidence of this. During the progress to date they have been absent from the critical voices. I’m afraid that in this case, unlike on tuition fess where there was a vocal minority opposing the Government, Lib Dem MP’s were complicit…

  • @Simon McGrath
    From our discussion the other day, you said: “But as a simple matter of fact nowhere have I said that “private sector = good, public sector = bad’.”

    You might not have explicitly stated this prejudice, but it informs every comment you ever make (see above).

  • @Bill – not often I disagree with your analysis but none of our MPs – (front or back bench) voted against this at second reading.

    In fact AFAICS the only ones who contributed to the debate with Andrew George and Gordon Birtiwistle (who supported it – say what you will about Gordon not speaking his mind isn’t one of his faults!)

  • Bill le Breton 15th Jun '11 - 1:40pm

    @Steve and @ Hywel. I must have expressed myself badly when writing, “The Parliamentary Party on the backbenches, ***for what ever reasons***, were not able to keep the front bench in check.” As I didn’t know the detail I tried something polite.
    Perhaps I should have said ‘did not prevent/challenge the front bench …’
    Surely, the point is still that on all these issues Conference and its elected bodies have shown a surer touch, wiser counsel and a more Liberal approach. Yet will these the views of these bodies be sought and valued?
    On the issue of the Parly Party: it is of course now divided into: those in Government, those hoping to get into Government, those whose loyalty to the ‘team’ is such that they hold their counsel and those in such despair that they don’t know where to turn to.

  • @Simon McGrath
    “becuase of course our state education system is such a success…..”

    What evidence do you have to support your opinion of the quality of state sector education? Is it informed in any meaningful way or is it, as I suspect, nothing more than what you reckon?

  • Stephen W,

    Where does this system you speak of exist? As far as I am aware the systems that deliver better outcomes than the NHS do so at a much higher cost. Apparently Netherlands spends 60% more per person than us. The same research that is usually quoted as putting the NHS as falling behind the best in Europe in terms of outcomes also apparently states that on the trends measured at the time we would out-perform the best in Europe on those same indicators within five years.

    We are told that our system will become unaffordable if we do not follow a market model yet everywhere a market model exists cost more for a similar or worse coverage. If our system will cost 130% of our GDP by 2050 as Cameron is fond of telling us then how will adopting a more expensive system alleviate the problem?

    The pause in the health bill has been used to debate side issues that are of little importance to the impending privatisation of health care on the american model. For instance much has been made of the importance of getting secondary health care providers and nurses on commissioning bodies. This makes little difference to the outcome of the bill but will in any case probably never happen once it is pointed out that it is a ridiculously obvious conflict of interest. The privatisation of our health system will be facilitated, not by side issues such as who sits on commissioning panels, but by the fact that foundation trusts will be dependant on private work, that the cap on private work undertaken by trusts will be uncapped, and that trust will be allowed to fail and taken over by other trusts or any other willing provider.

  • Simon McGrath 15th Jun '11 - 10:06pm

    “@Simon McGrath
    “becuase of course our state education system is such a success…..”
    What evidence do you have to support your opinion of the quality of state sector education? Is it informed in any meaningful way or is it, as I suspect, nothing more than what you reckon?”

    I was going by our position in the International Pisa ratings

  • @Simon,

    Nice to hear you parrotting Michael Gove, but fortunately for the evidence-based community, some of us were paying attention to PISA back in 2010 and not just looking at it through the lens of partisan sniping.

    In brief, we couldn’t have ‘plummetted’ down any PISA table in 2010. The tables were completely different to the previous years due to the inclusion of new countries over the previous version.

    When PISA started in 2000, it covered 43 countries, and now it looks at 65, so comparisons between relative positions are meaningless. Also, because there is a great deal of bunching in the middle, there is not a statistically significant difference between a lot of the countries amongst which the UK is ranked.

    However, there did appear to be a fall in attainment in Wales (but not the rest of the country), which did bear examination.

    here’s the England report, which refers to the other nations; it is always best to refer to source material wherever possible. http://www.nfer.ac.uk/nfer/publications/NPDZ01/NPDZ01.pdf, and if anyone who *isn’t* Simon wants to use the data, it’s here: http://pisa2009.acer.edu.au/

  • If a person can’t even film a public council meeting on a mobile phone without getting taken away by the police – how “democratic” does anyone really believe the new commissioning bodies will be? I’d settle for effective. They won’t even be that. GPs are not procurement specialists. I don’t want them to make a fatter profit if they fail to send me for a scan I need. Fragmenting procurement will simply water down the purchasing power that the existing NHS has, GPs passing over commissioning to new private entities simply adds another middleman and extra layer of cost. We shouldn’t spend years and years training a person up with medical skills and then expect them to spend their time haggling on the phone for treatments. There will be a layer of transaction costs that doesn’t currently exist which will dwarf the savings made by slimlining management, and we’ll end up like the US. There are challenges with rising costs of drugs and treatments but those challenges are not going to disappear just because the NHS is privatised.

  • Radicalibral 18th Jun '11 - 12:09am

    Perhaps in achieving improved efficiency of scarce resources we should try to deal with the problems we can deal with in the NHS at a micro level as well as a macro level. A couple of observations first. Why is Alan Milburn, A Labour Politician possibly cut from the same stone as Frank Field? so unhappy about the proposed changes to the NHS Bill?
    JRC whilst you are right to draw our attention to the amount per person that is spent on Health given the size of the country, and the type of Health Service provided is the Netherlands a good comparator?
    In terms of the micro picture can I make one suggestion. Aftercare for patients not needing to stay in specialist hospitals for their recuperation does appear to be an area that we are struggling with. My concern is the size of these hospitals gets in the way of their aftercare. I believe that a more “effective” but not necessarily “cost efficient” way of providing such treatment (especially for the elderly) might be to see the return of Cottage/ Mini Localised Hospitals to help those patients who cannot be returned to their homes quickly and easily. What are people’s thoughts?

  • Radicalibral,

    The Netherlands comparison is simply economic and is a proportional comparison, therefore the size of the population shouldn’t matter. Likewise, unless we are comparing our system of universal coverage delivered to those in need regardless of the ability to pay, to a type of system that offers something more than universal coverage, then the type of healthcare being offered can only be relevant as offering a favourable comparison to the cheaper system. If a system that has a different structure to ours costs 60% more per person than ours then how is the justification for change, i.e. that increasing costs render our system ultimately unmanageable, legitimate, when the more expensive system, which is under the similar demographic and inflationary pressures, is not rendered unmanageable? Surely logic would suggest that such a system should be moving towards the cheaper system in structure?

    In focussing on the micro-picture you are on the right track towards sorting out the problems that the NHS suffers but the micro-picture does not require legislation. For that matter, nor does the macro as stated by the government in its declared aims for the NHS. Nor does the micro picture offer any opportunity for ideological change. The declared aims of government could be achieved without any legislation at all so we have to look at the macro-picture and see where the white paper leads to try and discern the undeclared aims of the governments legislation. That is, we need to look at the ultimate end that the white paper will achieve to find the ideological reason for the structural changes.

    The white paper as initially composed, and still, after the changes brought about under the ‘pause’, leads ultimately to an insurance based system with taxation paying only for safety-net health coverage for the less well off, as we presently have within the provision of dental health services. In fact that is the implicit meaning of the argument that states demographic changes, improvements in health treatments and health care inflation require us to change the system to a less expensive one. To solve the funding crisis that has been promoted thus as imperative by the anti-NHS ideologues we have to solve only one of these problems, a) change the demographics, many despots have tried such solutions b) stop making advances in health treatment and let people simply die to get them off the books, or c) stop the inflation in health provision. If these are the questions that need answering then the only solution can be to end universal coverage on the basis of need and distribute health care on some other basis, i.e. find an alternative to need being seen as the basis of desert. Alternatively we could question the legitimacy of their arguments. The widespread presence of systems that offer less for more by way of health provision and are not considered to be in crisis render their arguments wholly illegitimate.

    We may retain a slightly better safety-net than the American system but ultimately that will probably fade as the emphasis has moved from health care being seen as an issue of need to being considered a lifestyle choice, as we are also seeing in education. The white paper lays the ground not only for a plurality of providers but also the requirement for a plurality of funding, (In fact the white paper states clearly that partnership funding between individuals, private insurance and other funding bodies is the preferred method of funding social care. This is exactly the kind of privatisation that we are told by the defenders of the white paper is not happening and is simply the delusion of the tribal lefty mind.). Tax funded patients will be in direct competition for treatment with fee paying patients. Foundation trusts will be dependant on the income from private patients for their survival.

    If you want to make the NHS better at providing universal healthcare free at the point of use distributed on the basis of need and funded through taxation then we are at a good place now to do that with creative changes at the micro-level.

    If you want to change the ethos of health care delivery from being needs based to one in which freedom from illness is considered a lifestyle choice in competition with whether to feed the kids, then introduce this white paper accompanied by arguments that focus on patient choice of provider. In other words return the system to a pre-1948 structure. Under these circumstances your proposal for cottage hospitals, whilst probably a good one, is not on the agenda, “cost efficient” being the key indicator, whereas I know of at least one such small community hospital that was built under the previous system using PFI.

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