Opinion: A radical, Liberal and localist alternative to NHS commissioning

nhs sign lrgLast week at Liberal Democrat Conference in Glasgow the party amicably and democratically settled one of its longest-running disagreements, about the way in which NHS services should be commissioned.

This is a subject Liberal Democrats need no introduction to. It has been a thorn in our side ever since Andrew Lansley first published his White Paper, “Equity and Excellence: Liberating the NHS” (2010), and culminated in Conference’s refusal to endorse the policy in Gateshead in 2012, instead neutering the so-called “Shirley Williams amendment”.

Outwardly that argument may have subsided, but it never really went away, and, as the General Election approached, it was necessary to formally agree a policy. For this reason a Public Services working group was set up, with the Herculean remit of reviewing all of our public services policy, including the NHS.

A dissenting group, led by John Pugh MP and Dr Charles West, submitted detailed, substantive evidence to this body that took aim not merely at the Lansley reforms, but, more fundamentally, at the market-driven, commissioning-led consensus that has been the continuous direction of travel in the NHS for more than two decades.

Contrary to perceptions that NHS commissioning started with Andrew Lansley, this approach was introduced by the Conservatives in 1991 and subsequently deepened by Labour, who first let in the private sector, leading to Andy Burnham’s landmark £1bn franchising of Hinchingbrooke hospital. The Health and Social Care Act (2012) accelerated this trajectory.

It was not obvious how an accommodation between these two positions could be reached, and when the dissenters’ arguments were rejected in toto, on the grounds that another top-down reorganisation of the NHS was a bad idea, the scene was set for what one MP I spoke to anticipated would be a “massive row” at conference.

Instead, to the surprise of many, both sides managed to find common ground in the form of an amendment that I submitted on behalf of every local party in Cambridgeshire and Peterborough, an area whose health economy has been brutalised by Labour’s experiments. This added the following words:

Permitting NHS commissioners and providers in a local area to form a single integrated health organisation, responsible for managing the provision and integration of NHS services in that area, subject to public consultation, endorsement by local Health and Wellbeing Board(s), built-in arrangements for rigorous evaluation of effectiveness, and approval by Monitor and the Department of Health.

This isn’t the wrecking amendment that some people wanted. In moving it, we acknowledged that it is possible to commission good services in the current system, contrary to Andy Burnham’s wilful simplifications.

However, we also recognised that the current approach has significant downsides. Foremost among these is how it internally splits the NHS into commissioners and different providers of services – each with their own, often conflicting, priorities – which can make integrating care at the level of the patient extremely difficult.

To achieve integration in this environment commissioners must procure vastly complex inter-organisational contracts that can take years to design and award, during which time integration is often put on hold. This approach has amost certainly contributed to the sharp and continuing rise in NHS management costs that has occurred since its introduction in the Nineties.

Unfortunately it is not possible to make a definitive overall assessment of this approach, because successive governments’ reforms have been wholesale. That is why the political debate about health care in the UK invariably takes the form of a grindingly dogmatic ideological argument between Left and Right.

Our characteristically Liberal solution is therefore to be more flexible, localist, and bottom-up than either Labour or the Conservatives, who prefer to stick to one fixed model that is inflexibly imposed, top-down.

Instead, we propose to create an option – outside the Lansley framework – that would allow NHS commissioners and providers who desire to do so to merge to form a single organisation, whose prime purpose would not be to procure services, but to directly provide integrated services to meet the needs of local people on an ongoing basis.

As the amendment’s co-author and Cambridge’s former Director of Public Health Dr Spencer Hagard explained, this proposal is radically localist and bottom-up, because the impetus would come from local NHS organisations, not meddling ministers.

Labour, in keeping with their preference for simplistic binaries, will undoubtedly portray this as a lurch to the left. It isn’t. This proposal is about allowing the NHS to explore all of the options for achieving integration and to gather evidence about which work best, instead of being always confined to the personal preference of whoever happens to be in Government.

Returning to Glasgow, of the thirty-four speakers who were summoned to the platform, not one, including the various MPs and Ministers who spoke, opposed our amendment. Jeremy Hargreaves, summating on the main motion, acknowledged that this new option was consistent with its view that “no one fixed model” was appropriate in every case, and urged delegates to support it.

The amendment was carried overwhelmingly. The Party’s Director of Policy has subsequently confirmed that it is now policy, and that it should be ‘read across’ from the Public Services paper into the Pre-Manifesto.

Now that Conference has spoken we must work to ensure that this bold Liberal option appears in the manifesto proper, alongside Nick Clegg’s radical and inspirational commitment to make ‘parity of esteem’ for mental health conditions a reality.

Bold Liberal policies like these will help to create the fairer society to which Liberal Democrats are committed.

Let’s promote them!

* Kilian Bourke is a Liberal Democrat councillor on Cambridgeshire County Council and chair of the council's health scrutiny committee.

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14 Comments

  • Tony Greaves 13th Oct '14 - 5:59pm

    This is very useful stuff. All it really needs to make it truly Liberal is to find a way of making the local decision-making democratic rather than by the rather odd present commissioning structure.

    Tony

  • Kilian Bourke 13th Oct '14 - 6:07pm

    For some local context to this amendment, which was backed by all six local parties from Cambridgeshire and Peterborough, see this previous article in LDV: https://www.libdemvoice.org/opinion-what-andy-burnham-didnt-tell-you-about-nhs-privatisation-42072.html

  • Anyone who is seriously interested in this subject should take ten minutes to just skim through Nicholas Timmins appropriately named “Never Again”.  
    It is very accessible and well set out — you do not have to closely read all 150 pages to spot the gems.
    It is published by the Institue for Governent and The Kings Fund — two highly respectable and independent organisations — whose aim is to prevent the sort of car-crash of policy which top down NHS reorganisation has become a prime example.
    Warning —- Danny Alexander, Nick Clegg and David Laws do not come out of this very well.
    Anyone who thinks Danny Alexander is a credible candidate for party leader after Clegg should read this.

    http://www.instituteforgovernment.org.uk/sites/default/files/publications/Never%20again_0.pdf

  • Stephen Donnelly 13th Oct '14 - 7:33pm

    I was not in Glasgow, but it seems that the argument that won the day was the plea that the NHS should not be subject to another re-organisation. It is very difficult to disagree with that.

    The main driving force within the NHS is the need to contain costs. The Lansley bill has enabled savings to come from a reconfiguration of the service, particularly local hospitals, without too much outside scrutiny. Services will be lost, and hospitals will close. But after the election.

    The remit of the Public Service working group was far too wide to allow a proper consideration of the subject.

    Liberal Democrat policy joins Labour and Conservative policy in avoiding the main issue : how do we close the funding gap. The issue will return.

  • Richard Coe 13th Oct '14 - 8:52pm

    It was alarming to hear from Dr Charles West how this policy group had been gerrymandered. It is even morte alarming that so called Lib Dems like David Laws have actively supported the nationalisation and subsequent privatisation of our school system. We have always championed devolution, but the coalition government has removed schools from democratic local control and placed them into a Gauleiter system run by the Education Secretary. This totalitarian control of our schools must be anathema to all Liberals and will have Mill turning in his grave, but has not been anathema to our party leadership.

    Both the Conservatives and Lib Dems were elected on a devolution agenda, yet the coalitions first major move was this nationalisation of schools. One of the ways we address the NHS funding crisis is economy of scale, achieved by reintegration of the NHS and abolition of the internal market with all it wasted money on accountants and lawyers. Another way is to stop expensive privatisation of services, giving our taxes to the Conservatives private medical friends.

    Ultimately our NHS is one of the most cost effective health services, so we cannot escape that fact that an older population needs more health care and the balance between public and private spending will over time have to tilt towards a larger public sector, unless we are happy to watch old people die on the streets.

  • Kilian Bourke 13th Oct '14 - 9:01pm

    @ Tony Greaves

    Good point, Tony.

    One of the main challenges would be to significantly strengthen the democratic element that Health and Wellbeing Boards and the transfer of public health to local government have brought, where LAs have fully taken advantage.

    Of course, some localities have only put a councillor or two on their HWB, and have ‘disappeared’ public health into local government (some even failing to appoint a DPH) in which case these much-ignored democratising elements of the reforms will not have been experienced, and the situation may even be worse than it was before.

    My view is that although the current system leaves plenty to be desired, commissioning under Labour was significantly less accountable than at present. Andy Burnham’s Hinchingbrooke procurement is a good example. A £1bn 10-year contract to franchise the management of an NHS hospital that involved no formal public consultation whatever. None.

  • Spencer Hagard 14th Oct '14 - 8:26am

    @Tony Greaves, @Kilian Bourke

    An expected conventional challenge to the Cambridgeshire & Peterborough amendment at Conference never happened. Nobody stepped forward to claim that marketisation provides an essential discipline against public sector inertia in the efficient and effective deployment of resources. Counter-arguments about alternative ways of optimising the use of public resources were therefore not presented by the proposers of the amendment and not debated by Conference. They need to be rehearsed now because they’ll certainly be needed when the implications of the Party’s change of policy become more widely known, and deeply vested interests begin to defend their positions.

    The platform on which to challenge the market fundamentalists has four main planks:
    • Democratic control and accountability
    • Full transparency
    • Rigorous peer-to-peer review mechanisms
    • National and international bench-marking

    Only one part of our nationally directed but locally managed NHS has ever had democratic control and accountability – the local authority health service between 1948 and 1974, which was responsible mainly for local public health functions. It was swept away in the Heath Tories’ massive two-tier, management-speak, re-organisation of health and local government. Since the mid-1980s, the NHS has also steadily lost the quasi-representativeness of health authorities, and – with a stroke of Alan Milburn’s red ink – the public and patient voice carried by Community (Local) Health Councils. With their demise, and the arrival of the perverse concept of ‘market confidentiality’ in the provision of public services, all notions of transparency vanished.

    Health and Wellbeing Boards are a first step towards righting these wrongs, but are still well short of Liberal Democrat policy of democratically accountable direction and management of public health, health care and social care services together, a long-established arrangement that was too localist for Nye Bevan’s centralising tastes.

    ‘Serving the Public’, the alternative report from the Party’s Public Services Working Group reminded us that target-led, box-ticking both burdens and dispirits professionals and fails to improve quality and cost-effectiveness. Peer-to-peer standard setting and review is now an established approach that engages and enthuses professionals across the world and continuously raises standards (see for example http://www.hqip.org.uk), while national and international benchmarking, backed up by effective management approaches for service organisations (see for example http://www.systemsthinking.co.uk) achieves results that no markets in health have ever demonstrated.

    Monopolies have never been the first choice of Liberal Democrats. Wherever they exist in public provision we always strive, where fitting, to open them up and promote voluntary sector entry, and well-regulated, competitive private provision, but always within the ethos and quality standards of accountable, transparent, democratically controlled services. In health care services, the Party’s new policy would bring about a major subordination of the huge vested interests in markets that have developed for over 20 years in the UK. They will not be democratically restrained to subordinate roles without a major struggle. We therefore need to find and sharpen all the powerful weapons in the modern public services armoury in readiness for the battle ahead.

  • Sounds sensible. Just two thought snippets. Commissioning services from the private sector has been a large part of the NHS since its creation, as GPs are private service deliverers commissioned by public bodies. Their position has of course been massively confused by making them also commissioners (though not of their own services). And on the other side, I suppose: read publications about private sector management and you may well find the proposition that when a company considers outsourcing, it should define what its core functions are, that determine its organisational culture (for the NHs caring, say, or public service) and keep them in-house.

  • David Evershed 14th Oct '14 - 12:29pm

    The merger of local Commissioning Groups and Providers sounds like the creation of a local monopoly.

    Whatever the NHS structure should it not allow poor quality providers to be replaced with alternative providers?

  • My challenge is to the conceptual underpinning. The definition of ‘integration’ seems to be focused on healthcare (NHS) when the need is to better connect healthcare and social care together. Commissioning was supposed to be both about procuring sufficient provision to meet current need AND looking to the future to ascertain what future needs might arise; the definition of commissioning here seems to be solely on the former, but it is failing on the latter that ultimately causes the greatest challenge, and cost. Models such as ‘House of Care’ and ‘Lead Provider’ are looking at these challenges, and reflect what is happening across much of the developed world.

    Put simply (I know but bear with me) we need to move to a wellness service, which prioritises preventative and rehabilitative care, with an illness services attached to assist where it is unable to do so, and a regular life occurrence service to cope with the predictable elements of life, such as birth and end of life.

    The public is interested less in these mechanics that in how it is all paid for, who gets access to it, and how it decides what will and will not be provided. Most of the battles at the political level have been about these issues, and they are hard to decide on a purely utilitarian basis. It really boils down to hard choices: IVF cycles versus life saving liposurgery, premature baby care vs 6 months of life extension from an expensive cancer drug…

    In a finite world, with finite resources these issues are the ones that we need to debate, and secure agreement on: everything else is simply moving the proverbial deckchairs. Unless of course, we want to spend our entire GNP on healthcare, which is a projection that is easy to make on current trends.

  • Kilian Bourke 14th Oct '14 - 8:10pm

    @ Prateek
    Thank you. Where did Patrick Wintour say that?

    @ Mark Platt
    You’re right about integrating health and social care. The supporting text provided to the conference committee included the following wording: “This bottom-up approach would permit a significant degree of flexibility about the detail of local arrangements, including whether social care is incorporated into or works closely with the integrated health organisation.” We didn’t want to overspecify how to integrate health and social care in the amendment as there are different ways of doing so and being overly prescriptive would contradict our localist approach. Personally, I think pooled budgets will be necessary in the long-term if we want to see a real shift of resources into care in the community, although Simon Steven’s “two leaky buckets” analogy is a good one…

    The Lead Provider model that you mention is a good approach in the current system, indeed Cambs & Pboro CCG have just commissioned an £800m integrated older people’s care contract using it. What I would say is that, whilst this approach a lot of sense in the current fragmented commissioning environment, in that it requires different providers to form a single conglomerate with a specific purpose, this model makes sense precisely in that it tries to overcome the inherent limitations, conflicts and perverse incentives of our fragmented system. The Lead Provider model is arguably this fragmented system’s way of trying to mimic an integrated NHS. Why not see whether an integrated local health service could not deliver the benefits of the lead provider model, more widely and more efficiently?

    You’re right about needing to move to a whole-system approach to encouraging healthiness. The transfer of Public Health to local government that our party secured as part of the HSCA revisions has the potential to kick-start this shift where there is a political will to do so. This was a massive, liberating decentralisation and we should make more of it…

  • simon F
    Thanks for the link to the Patrick Dunleavy analysis. It reflects the Nicholas Timmins account entitled – “Never Again”.  
    published by the Institute for Governent and The Kings Fund.

    Both use the description “car crash” and with good reason.

    The evidnce should rule out Danny Alexander as a credible candidate for party leader after Clegg has gone.

    http://www.instituteforgovernment.org.uk/sites/default/files/publications/Never%20again_0.pdf

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