Opinion: It wasn’t in anybody’s manifesto, was it?

I haven’t read the Health and Social Care Bill (soon to be Act). More pages than a Harry Potter novel, and qualified by a thousand amendments, I’m not sure reading it would throw much light on my darkness. However, there are aspects of the bill I am aware of.

I know, for instance, that the NHS Bill was in no one’s manifesto, and I know there wasn’t the slightest hint of its major elements in the coalition agreement. The government has absolutely no mandate for NHS reform at all. It all seemed so clear … and then I made a foolish mistake. I went back to the three party manifestos, and the coalition agreement, and looked at what they said.

If you’ll excuse a little over-simplification, it seems that the two most significant changes proposed by the bill are the dissolution of the current bodies that commission healthcare (Primary Care Trusts) and the handing over of these powers to GP consortia, and the opening up of healthcare provision to ‘any willing provider’.

Let’s have a quick peek at the Conservative manifesto.

‘…we will give every patient the power to choose any healthcare provider that meets NHS standards, within NHS prices. This includes independent, voluntary and community sector providers … We will strengthen the power of GPs as patients’ expert guides through the health system by … giving them the power to hold patients’ budgets and commission care on their behalf … putting them in charge of commissioning local health services’. To be honest, that looks rather like the two main elements covered.

The Labour manifesto: ‘All hospitals will … be given the freedom to expand their provision into primary and community care, and to increase their private services … We will support an active role for the independent sector … Patients requiring elective care will have the right, in law, to choose from any provider who meets NHS standards of quality at NHS costs.’ Hmm. Not much about commissioning powers, but a distinct whiff of encouraging private provision – more of the marketisation and competition that dominated NHS reform throughout Labour’s time in office.

So – what about the Lib Dem manifesto? Not much there, actually; there’s the promise that if patients do not get diagnosis and treatment on time, ‘the NHS will pay for the treatment to be provided privately.’ And there’s a pledge to ‘scrap Strategic Health Authorities …’ (top-down re-organisation?).

So – all three parties were in favour of privatisation, to a certain degree, and some re-organisation. And there’s no getting away from the fact that GP commissioning was writ large in the Tory manifesto.

The Coalition Agreement has both the ‘any provider’ element and GP commissioning straightforwardly cut-and-pasted from the Tory manifesto.

I don’t like the NHS Bill, and I don’t understand why the coalition partners have been so desperate to see it enacted; but we do ourselves no favours if we simply condemn it as undemocratic and claim the coalition has no mandate to bring it before Parliament.

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  • Was your “peek” really so quick that you missed everything in both the Lib Dem manifesto and the coalition agreement about strengthening “democratic participation” in the NHS through elected representatives on PCTs?

    Or did you set out to pick out the bits that were consistent with this bill and omit the rest, telling us there “wasn’t much there, really”?

  • Mr Cumberland, you are yet another person who ‘doesn’t like’ the NHS Bill. Shirley (Baroness) Williams doesn’t like it, Nick Clegg bemoans the fact that it’s not a Lib Dem Bill, and it seems difficult to find any Liberal Democrat who is enthusiastic – or anything close to it – about this Bill (Act). Add to that the fact that nobody in the Tory Party can understand a word Lansley says (or wants to), thus there are probably a good few Tories who are luke-warm. So I have to ask again; how did we get to a situation whereby we have a gigantic new law that nobody seems to like or want. This has to be a question for the LibDems in particular to answer, because they definitely had the power to stop it.

  • P.S. In my list of those who don’t like or want the NHS Bill (Act) I forgot to include the medical and allied professions in their entirety (almost). This is the very peculiar bit; Doctors’ opinions on the Bill (Act) have counted for nothing (not trusted?), but it is Doctors and GPs in particular who will make this whole this run (very trusted!). “It’s a funny old world” as JImmy Greaves almost used to say.

  • Andrew Suffield 28th Mar '12 - 1:22pm

    This “no mandate” argument seems to be the worst kind of misdirection.

    I don’t know, much of the opposition to the bill has been misdirection that could be called worse than this.

    I don’t like the NHS Bill, and I don’t understand why the coalition partners have been so desperate to see it enacted

    That one’s easy. The NHS is in trouble – it’s way past “stretched” and pretty close to “breaking point”, and neither member of the the coalition wants it to collapse on their watch. We’ve got to break the cycle of “burn more hours on doing what we’re currently doing” and start solving the problems, and the current structures have been clearly proved to block this.

    Most people don’t like this bill. The Tories certainly don’t; one of the most satisfying things I’ve seen in politics is Nadine Dorries screaming in outrage about how LD amendments have “ruined” it. Again the coalition’s attitude is easy to understand: they do not believe that it’s possible to write an NHS bill that, under the present circumstances, will avoid being disliked by most people. They’re willing to settle for “grudging dislike” as being better than “impending crisis”.

  • “That one’s easy. The NHS is in trouble – it’s way past “stretched” and pretty close to “breaking point”, and neither member of the the coalition wants it to collapse on their watch. We’ve got to break the cycle of “burn more hours on doing what we’re currently doing” and start solving the problems, and the current structures have been clearly proved to block this.”

    I.e. Something must be done, this is something therefore we must do it. The acme of policy analysis.

  • jenny barnes 28th Mar '12 - 2:45pm

    “The acme of policy analysis”

  • @jenny barnes

    Sarcasm :).

  • Acne, possibly?

  • @ Sid Cumberland

    I don’t know why you fail to mention the clause in the conservative manifesto claiming that there would be no top down reorganisation of the NHS both in this article and the last one you posted. Claiming that you couldn’t fit it in this time would seem a little bit disingenuous.

    @Dave Page

    I think that we must agree as liberals (no doubt of different sorts) that the legitimacy of government and its actions ultimately rests upon the public as a whole. Claiming simply that ‘nanny knows best’ with regards to the NHS bill, in face of the opposition and objection of most of the public, healthcare experts and, as it turns out, many civil servants seems quite illiberal to me. I’m not saying that there may be good arguments for this bill, although IMO I have yet to see an honest, good, argument advanced by the pro-bill crowd (and I have to say that many of the bill’s supporters are people who are simply ideologically opposed to the idea of the NHS as an entity). I, however, as a liberal, cannot stomach the twin arguments of ‘something must be done, so let’s try everything and if it makes it worse what the hell- didn’t like the NHS anyway’ and ‘trust the government and don’t complain, they know best’.

    One major problem I have with your argument is that it appears to suggest that MPs should never feel compelled to stick to the principles, pledges or policies upon which they are voted in. That, to me, frankly seems illiberal and absurd. I do understand that there must be some leeway given with regards to manifesto promises etc… but for the conservatives to claim, for example, that there will be no top down reorganisation of the NHS only for it to be revealed that these policies were devised well before the government actually came to power is, in my opinion, a gross violation of the democratic spirit of our country and can only help further disillusion the public and delegitamise Westminster. I am not partisan here, I would be equally appalled if Labour did a similar thing.

    The point is that it may not be reasonable for the public to expect no deviation from manifesto proposals but neither is it morally reasonable for a party of government to flagrantly lie or deceive in order to win votes without giving some sort of exculpatory explanation for doing so which stands up to scrutiny. The fact that the government can get away with it doesn’t make it morally right or right within the context of a democratic society, and the end result of these kind of authoritarian, unaccountable decisions will ultimately be a greater fragmentation of liberal, democratic public discourse (and that criticism applies equally to all political parties).

  • @Andrew Suffield

    ““That one’s easy. The NHS is in trouble – it’s way past “stretched” and pretty close to “breaking point””

    I would like to see some evidence for this. It seems like a well worn shibboleth spread by the likes of the Daily Mail, but without any actual grounding in fact. From the evidence I have seen, such as reports by the commonwealth fund, the NHS is the most cost efficient healthcare service in the world, if not the service with the best outcomes. Why, exactly, must a major restructuring be embarked upon (which, as the risk register suggests, might well end up costing us much more) to drive down the costs of the most cost effective service in the world? Realistically you are not going to create a more cost effective system than the one we already have, although efficiency of the system itself can always be improved upon to a certain extent.

    I would like to see the real evidence that the NHS was/is in an efficiency crisis other than the one currently being created by the government instead of merely being spoon-fed the received wisdom ‘everybody knows’.

    The other problem I have is that the tactics of the politicians and the supporters of this bill in promoting the bill have been brazenly disingenuous in character. It was not really ever made clear at the beginning that these changes were about reducing costs but more to do with improving outcomes and ‘increasing choice’. When this is criticised for being the load of hokum it is politicians then turn around and tell us ‘these reforms are necessary to ensure the survival of the NHS’ or some such malarkey. So are the reforms about costs, outcomes or choice or none of these? The message has always seemed deliberately vague and deceptive.

  • Andrew Suffield. “‘ The NHS is in trouble – it’s way past “stretched” and pretty close to “breaking point”, …”‘. If the NHS is in such a dire situation it must have been obvious to the political parties for a long time that drastic corrective action was necessary, even “top-down reorganisation”. We were promised No top-down reorganisation. But we got it anyway. To my mind this represents a big failing of our democracy. That is not to say that our (or any) democracy is an idyl or utopia, democracies usually go about their governance with well-meaning muddle and fudge, because that is what human behaviour results in. The “no top-down reorganisation” of the NHS however was a real howler, it ranks with Harold Wilson’s “the pound in your pocket………”, or even “the Fees”.

  • I seem to remember, I think it must have been a year ago now, that the first Newsnight report on resistance to the Lansley reforms mentioned that the two parties had agreed on those reforms (I was sure Newsnight said they had been in the coalition agreement), and Nick Clegg was particularly keen on them.

  • @Rob – you’re not going to believe this, but it was in the original 900 words, which I was asked to edit down to about 500. But the question of how you can reconcile the ‘no top-down re-organisation’ pledge in the Tory manifesto, and indeed on Cameron’s lips throughout the 2010 election campaign is not one that I can answer.

  • Andrew Suffield 28th Mar '12 - 5:43pm

    We were promised No top-down reorganisation. But we got it anyway

    Please read the article at the top of this page. The Tories may have made some promises along those lines, but they aren’t here. The Lib Dem manifesto most definitely promised reorganisation from the top down, albeit not precisely the reorganisation that’s on the table here. Nobody on the orange side promised you “no top-down reorganisation”.

  • @Godfrey – you’re complaining that I wrote about what I wrote about and not about something else. There’s is plenty of stuff about the goodness or badness of the bill. I am simply pointing out the futility of saying the government has no mandate because it wasn’t in anybody’s manifesto.

    @Chris – the coalition agreement is ambivalent about the PCTs – it says it will strengthen them, and then says “The local PCT will act as a champion for patients and commission those residual services that are best undertaken at a wider level, rather than directly by GPs.” I don’t regard giving PCTs the leftovers after you’ve handed most stuff over to the GPs as strengthening (though I know that’s what it says) – that’s why I left it out.

  • @Sid Cumberland

    Fair enough :). Sorry for the accusatory tone.

  • @Sid Cumberland
    Residual Services are not left overs. Health visitors are not left overs, nor are other services that need to be commissioned on a non individual basis.

    The coalition agreement was clear that PCT’s were to be retained, made more democratic and represent patients better. None of which has happened and looking at the draft risk register were never intended to happen by the SOS. There is an argument for GP’s commissioning for their own patients (although the Royal College of GP’s oppose the Bill) but the way other Clinical PCT employees have been treated is atrocious in some areas.

  • @Steve Way
    OED: ‘2. gen. Remaining; still left; left over; (also) of or relating to a residue.’ If they didn’t mean that, they shouldn’t have said that!

  • Rob

    Of course the NHS doesn’t work properly. I have had to nurse my wife through 15 months of surgery and recovery made far worse and extended by the sheer incompetence of the bureaucrats that run it. What could have been a relatively quick repair of a slightly damaged hip socket became major surgery to a badly damaged hip socket also requiring a hip replacement and extensive bone grafting because A+E misdiagnosed the injury when it could have been fixed quickly. This had nothing to do with the surgeons, who did their job superbly when they were allowed to. In the end my wife only got on the surgery list because I started complaining to the hospital chief executive after the second operation had been delayed for 12 months.

    As a result of this incompetence my wife has lost her job and had to have an artificial hip and months of enforced inactivity which is going to take months of slow painful work to recover from.

    The new Health and Social Care Act may not be perfect, but if it puts doctors in charge rather than non-medical bureaucrats then it must improve.

  • Jayne Mansfield 29th Mar '12 - 4:30pm

    Given that the Bureau of Investigative Journalism has found that at least 50% or more GP’s on some of the new Consortia have links to Private Healthcare companies, my fear that this bill is about privatisation of the NHS seem well-founded.

    As patient’s , we will now be concerned about conflict of interests when these CCG make decisions about the care that is commissioned on our behalf.

    The Liberal Democrat party were prepared to sign off the original Lansley bill. Any amendments that sought to protect the NHS from privatisation, seem to have been made by the peers in the House of Lords. How ironic, and I suspect how futile. It is becoming clear that the GP’s who have put themselves forward to make commissioning decisions on our behalf appear to be the more ‘business minded’ ones.

    What exactly do Liberal Democrats mean when you use the word ‘Localism’?

  • Jayne Mansfield 29th Mar '12 - 4:32pm

    @mickft- private companies will not run A and E departments. There is no profit in it.

    Maybe you should read the leaked risk register especially the section on the management of emergencies.

  • Richard Dean 29th Mar '12 - 4:44pm

    Jayne, Pribat companies certain can run A&E departments, who could make a good profit on a cost-plus contract without loss of quality of care. Evan on a lump sum basis for providing A&E covverage, good profits can be made without scarificing care standards. One way to do this is to convince the contractee to base judgments on over-estimates of what will be needed. Another way is to arrange contracts on a lump-sum basis for a certain amount of A&E work, with more work being paid at cost-plus.

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