I must admit I’ve been wondering a little at being so contrarian.
My mobile phone address book and filofax (yes, I’m a certain age) is full of people who say they are too busy to talk to me this week because they are working hard to kill the NHS Bill.
I am not. What’s the matter with me? I’m going the right way to being thrown out of the lunatic fringe.
So please, if you read this blog. Have a heart. Tell me where I’m going wrong.
Here’s my problem. I cannot see why we should be striving to maintain the NHS exactly as it was bequeathed to us by Blair and Brown in 2010.
After the New Labour years, the PCTs had become massive, overblown and thoroughly dysfunctional target machines – hugely wasteful, staggeringly ineffective, wholly undemocratic.
Welded on top of this structure remains another massively bureaucratic structure, a proto market – inappropriately competitive and designed at vast expense by McKinsey’s and other management consultancies.
It was massively more expensive than it needed to be, funnelling money from frontline services into wasteful IT regimes, the main purpose of which was to allow managers increasing control over the front line.
Nothing effective was being done to genuinely re-design a system that was not spending 80 per cent of its budget and time tackling, or rather not tackling, chronic ill-health. Nothing effective was being done to reshape a bottom up service that could deal with an ageing population.
Why should anyone want to struggle to maintain that sort of NHS, doomed to unravel under the weight of its own giant bureaucracies and fake markets.
I would be the first to agree that many of these issues remain completely untackled by the NHS Bill as it stands. But some of it is, especially bringing in a democratic element from local government.
But then fate flung the Lib Dems an extraordinary advantage – an absolute veto over the legislation.
That is why amendments are being tabled in the Lords to begin to unravel the pseudo-market that McKinsey has concreted in.
The Social Value Bill, thanks to Lord Newby, provides a major safeguard against the wrong kind of commissioning – but the opportunity remains to put in other safeguards, and to begin to row back the disaster-waiting-to-happen created by New Labour.
So why on earth should we pass up an opportunity that surely will not come again? Why defend the NHS as it stands?
Let’s make the most of it, and then accept that the NHS Bill fiasco has been at least partly of our own making.
For ten years, we failed to work out what a Liberal NHS might look like for the century ahead. When the new legislation was being drafted by the coalition, there was a vacuum where major Liberal thinking ought to have been.
All we could do was to look back fondly to the way we imagined things to be a generation ago, and we clung to it manfully. All we could say about the NHS was – apart from the usual principles – what we didn’t want.
So I hope we take both opportunities. Keep and amend the NHS Bill and be ready to build a genuinely Liberal NHS capable of meeting the problems that lie ahead.
Now tell me, am I insane?
* David Boyle is a former Lib Dem parliamentary candidate and the author of Tickbox (Little, Brown). You can buy the book from Hive or Amazon.
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28 Comments
you’re not insane David, just wrong. Wrong to equate opposing this bill as it currently stands with a desire to “defend the NHS as it stands” and a ” striving to maintain the NHS exactly as it was bequeathed to us by Blair and Brown in 2010.” Opposing these changes is not the same as opposing any changes – it just means recognising that despite all the amendments LDs have made to Lansley’s original mess, the bill remains a mess.
The NHS must evolve and reform to keep pace with the demographic, medical and financial challenges it faces, no-body denies that. However, we should ask whether this bill as it stands makes meeting those challenges more or less likely – it is my assessment, and that of virtually the entire medical profession, that it makes meeting them much harder. I won’t go into why, the arguments are familiar.
Please do not equate opposing this bill with wanting to somehow preserve the NHS as it is. Yes we need more clinical engagement in commissioning, yes we need to reverse Labour’s ridiculous fake market, yes we need a more integrated NHS – but no, this bill as it stands is not the only way of delivering those things. many of the necessary changes have already happened without the bill passing – so let’s ditch the bill & work with the profession to bring about the Liberal service we all want to see.
I could, but I agree with yoU whole heatedly
Your initial problem is slightly wrong, it should be “Why should we be striving to maintain the NHS exactly as it was bequeathed to us by Bevan?”
The trouble with the entire NHS debate (this one or any other one) is that it is 50% emotional, 49% political and 1% pragmatic – and the 1% gets left off more often than not.
If any issue should be be booted outside of politics, then this should. When Bevan first announced the plan, a health service that would be nationally funded and controlled and free at the point of delivery, the only way he got it past the health professionals was by bribing them: “I stuffed their mouths with Gold,” he said.
The most important part of the NHS should be the following, and these should be enshrined in law:
1. It should be free to the patient
2. It should put excellence above anything else
3. It should be accountable to the user
4. It should always put the stakeholder first (that is, the NHS patient)
5.It should be innovative and enduring and be able to evolve to meet needs
Exactly how that should all happen should be down to pragmatic and pretty obvious management practices and skills. If you restrict the way the it can be run by some idealistic philosophy (and that can apply to both sides of the current argument) then it will never meet any of the above criteria.
The current debate leaves most voters stuck in the mire. The only thing that they can really understand is that there are a lot of people shouting ten tons of rubbish on both sides of the debate – emotion and politics have gotten the better of the MPs, the Lords, The Unions and the Media, and the rest of us are simply left in the dark. If anything has shown that MPs are sometimes incapable of running a party in a brewery, then this is it. Personally, I cannot get a wafer between Milliband and Cameron on this issue – they are the very embodiment of Tweedle Dum and Tweedle Dee.
So, should this bill go through? Probably yes, as long as it meets the five points above. In many ways it is not needed, but although many of the vital reforms could happen without it, the chance of them actually being implemented in the current system are slim!
No, you are sane. I am very happy that informed good sense is at last beginning to prevail.
How do you answer the fact that even with the few agreements most recently made between our parliamentarians and the Tories, many aspects of the competition elements of this bill remain, and I am sure the PWCs etc will be able still to get in there!
@Tim13
“many aspects of the competition elements of this bill remain”
I haven’t commented on this subject to much as I haven’t had enough time to go through it in a proper manner. But from your comment you seem to be saying that all competition should be done away with, if that is the case then perhaps they are there because the LD manifesto also wanted competition?
Sounds sensible to me, this is mostly what I’ve been saying all along. Regrettably, I don’t think it’s going to happen; the NHS bill has become politically unrealistic, and further reform during this parliament is unlikely.
Well said – I couldn’t have put it better myself. http://livingonwords.blogspot.com/2012/03/david-boyle-sums-up-my-thoughts-on-nhs.html
I’ve tended to avoid thinking about this until recently because I don’t have much familiarity or feel for the NHS structure. However, I can’t discount the opposition that is coming to from the medical bodies. It seems to me that if this really were a sensible removing of bureaucratic structures, you’d be getting be hearing some cheers from the medics, but there seem to be none. The line “but the medics opposed the NHS when it was first set up” may be thrown – but they did so in the face of a great deal of popular support for it. There is no popular support for these NHS reforms is there? People are not rushing off to learn about them in the way they rushed off to buy the Beveridge Report.
It may be that there are good intentions in the reforms, but people are just not going to believe it, and they have good reason not to knowing the extent to which the Conservative Party is funded by big business and works in its interest. Our party may have worked hard in Parliament to amend those aspects of it, but in the end applying patch upon patch does not work. The brave step may be “OK, let’s start again”. If that isn’t done, the reforms will be forced on people who have said they don’t want them yet will be expected t implement them. I don’t think this is a good start.
I would hope we do stand for a different model of politics – one which works in co-operation with the people rather than one which says “We’ve won power, now we’ll do what we like”.
One thing I’ve become more certain about in recent years is that the idea “competition drives up quality”, is wrong, particularly when repeated as a mantra with little regard for how it works with real people. This was the driving force behind these reforms, and they are somewhat curious if it is taken out. Let’s do it again and this time actively involve all those who must work with it in deciding it, rather than start off with it being pushed from the top by those who hold onto the failed belief in cash markets as the solution to every problem.
Nobody has ever suggested that the NHS needs to be preserved in aspic, that it has no faults and cannot be improved. Or indeed retain the market based Blair/Brown tinkering. Far from correcting that, this Bill, even with it’s amendments, still remains a framework to drive a fully commercial market based health model into Health Provision in England (which will inevitably have knock on effects to the devolved health care systems in Northern Ireland, Scotland and Wales).
It was and remains Lansley’s objective. He has been talking about it for years. See his speech to the NHS Confederation in 2005 quoted at http://abetternhs.wordpress.com/2012/02/28/cc/ where several other aspects of the implications of the Bill actually says rather than what this contribution aspires to saying it is..
Yes we need Healthcare reform but the HSBC even after having as a coalition partner the Lib Dems have engaged with the Bill for the last year, it is still not fit for purpose, or even fulfills the aspirations of much of the coalition agreement. There is no need for this primary legislation to achieve the reorganisation of the NHS.
There are no doubt some in the Party who do consider that a commercial market based provision of health care is desirable. I just don’t happen to agree with them and I don’t think the evidence from other Nations where there are such systems, give much of a good example.
The whole point of any reform is it should complete the long overdue project of integrated health and social care that was originally envisaged all those years ago. This bill does not achieve that. It was never intended to. Support should be withdrawn.
Excellent article. Do you think the amendments go far enough to get rid of the pseudo-market? That is my main concern – I’ve been worried that the bill does too little to get rid of Labour’s pseudo-market and that our competition-limiting amendments would hinder rather than help in this regard. I’m happy to be reassured that they will in fact help.
Except commercial market-based provision is what we have now, based on value for money for the PCT. The new Bill introduces competition based on value to the patient, which is a huge improvement from Labour’s system and one which will encourage improving patient outcomes.
@Liberal Majority. May I suggest that the five principles proposed by the inaccurately named “Liberal Majority” are not beyond debate. These principles were
1. It [the NHS] should be free to the patient
What does “it” include? Not everyone supports cosmetic surgery on the NHS, for example, and recent newspaper reports show that even healthcare professionals are reluctant to spend scarce reources including their own time on operations to address hugely excessive obesity
2. It should put excellence above anything else
Excellence costs money, and money costs lives elsewhere – lives in inadequately equipped troops, in unremediated slums, in accidents from unrepaired or unsafe roads . Cost is a relevant factor.
3. It should be accountable to the user
Yes, the user must be satisfied with the service, but users are not always best placed to assess the service they receive. Not wanting to be inflammator4y, but Dr.Shipman’s patients of a few years ago might well have expressed themselves as satisfied with his work upo to the time he killed them. Less dramatically, inadequate or incompetent service is not always recognizable by a user. So, the user needs to be assisted by being able to call on independent, more informed assistance
4. It should always put the stakeholder first (that is, the NHS patient)
Is the patient really the only stakeholder? I am not a patient at the moment, and I don’t believe I have a communicable disease. But I insist that those who do have such diseases are treated. For instance I support treatment of typhoid and I am willing to support the costs of Aids drugs and research. I am a stakeholder in the effectve treatment of others. “Business” is a stakeholder in the senese that health problems cost businesses money through loss of output, with a knock-on effect on staff motivation, wages as well as profits.
5.It should be innovative and enduring and be able to evolve to meet needs
Yes indeed!
May I suggest a sixth requirement.
6. Work, organizational and compensation arrangements and status should motivate and inspire NHS staff.
This is vital, and far-reaching. At a general level, no organization is effective if its staff are demotivated. At quite personal levels, there are important issues about the health and support of nurses, for example – I know people who quit as SRNs partly through work-related back pan, and partly through the drudgery and unpleasantness of some of the things they have to do. Changes may be needed to the relative status of different actors in the service. Training may be needed so that people are able to properly balance the not-inconsistent requirements of competition and cooperation.
@Richard Dean. The contents of this Bill were never put before the British (or English) electorate by ANY political party for approval prior to the last General Election. You must know that both the LibDems and the Conservatives denied any intention of “top-down reorganisation” of the NHS. The Coalition has absolutely no democratic mandate for the Bill (nor would Labour have, if it was in power). Therefore those people opposed the Bill (of any political persuasion or none) have democracy on their side. As a consequence, I believe that Labour will be gifted a golden opportunity to be ‘holier than thou’. In future elections we can expect Labour to promise to repeal the BIll lock stock and barrel, along with threats of no compensation for any private company that invests money in NHS services. I fully expect Tony Blair to get involved – along the lines of “yes we introduced some reforms into the Health Service but they were for the benefit of patients, the Bill is for the benefit of Tory business friends”.
I think you have framed the argument incorrectly, as I think those with opposing views have.
There is no valid argument for keeping the NHS as it was in 2010. It is one of the largest single employers in the world and as such is unlikely to be perfect (or even adequate) in all areas. But that does not make this a good Bill.
It has been stated that PCT’s were dysfunctional, perhaps so. But many of the (dys)functions have not been removed but changed into partnerships or incorporated into local authorities. Cameron makes great play of the fact that 1000’s of managers will be removed from the NHS – most only to local authorities or enterprise partnerships.
The drafters of the Bill made great hay early on by claiming the support of the professionals within the Health Service, this has been eroded to the point that the balance is now that most do not support it. To be clear, it is not the RCN and BMA that I worry about, but the Royal Colleges who are responsible for so much that is good about the standards within our current system. A helpful list can be found at:
http://aomrc.org.uk/about-us/members/members.html
It has become easy for those championing the bill, including Ministers, to discount their viewpoints and start to merge the Unions with the Colleges in the public eye. To see how successful this disinformation has been you only need to see some of the threads on this site. In one of these I did attempt to explain the difference, and why I believe it is essential that the Colleges are not discounted. They have great expertise and have not withdrawn support lightly or early in the process. I wholly accept that the Government may need at some point to disengage with the Unions or they will achieve nothing.
The Bill is a mess, if it were not for the political ramification then a full re-write would be the best solution. The trouble is that while it is seen by both sides in terms of a contest rather than an exercise in identifying the best route forwards for the NHS real improvements will escape this and any future government.
It is worth considering that those people went out and voted for the same Conservative Party in large numbers at the last election, so perhaps their opinions are not so one-sided. If you’re going for a populist argument, you must always keep firmly in mind that the Tories are popular, for better or for worse.
Agreed. It is frustratingly hard for anybody to accomplish anything in this environment.
Just because things need to be improved does not mean that the NHS Bill as it stands (or even as it will stand when all the LD amendments are included) is the answer.
Let us be very clear – the underlying purpose of the Bill is to expand the private sector involvement in the provision of NHS services. Commissioning by CCGs will achieve this, steadily and remorselessly, and there will be nothing anyone can do about it.
All the arguments about competition (and the LD amendments are useful safeguards as far as they go) are a side-show to the fundemental issue which is about commercialisation and privatisation.
Tony Greaves
@Tony Greaves
“Let us be very clear – the underlying purpose of the Bill is to expand the private sector involvement in the provision of NHS services. Commissioning by CCGs will achieve this, steadily and remorselessly, and there will be nothing anyone can do about it.”
So you didn’t really mean it when you told the public:
Giving Local Health Boards the freedom to commission services
for local people from a range of different types of provider, including
for example staff co-operatives, on the basis of a level playing fi eld
in any competitive tendering – ending any current bias in favour of
private providers.
Because tbh, I can’t see how the end result of that would be any different to what you seem to be fighting against
As long as reform is on the agenda and stays on the agenda then I’m less agitated by the outcome of this bill.
It is because the debate on the HSC Bill has been presented as between ‘wreckers of the NHS’ and the ‘saviours of the NHS’ that I’m sceptical about the claims of either side, and I am therefore unwilling to accept the passage or blockage of this piece of legislation as the end of the matter.
Whether the bill passes or not we will need a new bill almost immediately, so I think the party should be getting in good exercise now for more of the same – so that we can be more united in arguing the case for a more liberal, more democratic NHS.
@Oranjepan. With respect, the way things are going for the Lib Dems, soon not much of “the party” will be left to argue over a second Bill.
If this bill is passed thanks to Lib Dem votes it would be the one thing worth quitting the party for. That is despite the sterling efforts of many of our parliamentarians to modify it.
I’ve listened to the arguments and I’ve been silent until now. I will continue to listen to the arguments when it is (no doubt) debated and voted on in Newcastle.
I have to say David that I think you’re completely right. I have yet to hear a convincing argument in favour of the NHS status quo that does not come from either: a) the clear self-interest of some doctors / health officials who want to retain the vast costly bureaucracy we have in the NHS or b) the “the Tories are evil and eat your children, so anything they come up with is clearly evil too” brigade that have sadly started to shout louder within our party in recent months.
The concessions we secured at our last conference and the further concessions we have secured recently are a huge testament to our power in government. They also show that coalition can work – compromises can be reached which are acceptable – and coalition does not mean endless paralysis as parties can’t ever agree on anything contraversial.
Those who want us to throw our toys out of the pram and vote the bill down should remember how this will make the Lib Dems look – petulant and unable to act responsibly. In the long run this will be very bad news for us as it will only revive those who claimed that coalition could never work – the reason people didn’t vote for us 2 years ago.
And don’t worry about Labour’s hyperbole about this being the end of the NHS – if we defend our position as I believe we can, in the long run people will respect us and realise they’re talking rubbish.
Andrew Suffield
It is worth considering that those people went out and voted for the same Conservative Party in large numbers at the last election, so perhaps their opinions are not so one-sided. If you’re going for a populist argument, you must always keep firmly in mind that the Tories are popular, for better or for worse.
No, I’m not going for a “populist argument”, I’m going for the argument that I place a great deal in what professional people have to say about proposed policies on the discipline in which they work. As I said, I don ‘t know much about how the NHS and the medical profession works. I do, however, know a lot about how my own profession works, and from that I know what utter tripe much of what politicians say about it is. I would most certainly trust professional who work in my area many times more than politicians spouting off about it. So when I hear politicians praising this Bill and those who must work with it professionally condemning it, whom am I to trust?
If the professional bodies are not properly voicing the opinion of their members, then it is up to those members who dissent to put the other side. I’d listen to them, if there were any, this would be helpful in me making up my mind. But it seems to me the voices within the medical profession speaking in favour of the Bill are few, and have diminished rather than increased as the Bill has progressed. If the professional bodies have got it wrong, then so be it – they must bear the consequences if as a result of their opposition the Bill falls. This is similar to the argument that you are using when you say we must take into account what people have expressed when given the opportunity. I have indeed used this line on many occasions to defend the coalition – so far as I am concerned the people voted for it in 2010 ,and more decisively in the referendum on 2011 when by two-to-one they voted to retain the electoral system which made it inevitable following a campaign which praised the virtue of the distortion which gives the Conservatives so much power and greatly reduces that of the Liberal Democrats. So far as I am concerned anyone who voted “No” to AV after that campaign should follow the logic of that campaign and their only criticism of the Liberal Democrats should be that they are trying to stop the first-past-the-post winner of the general election having all its own way.
The above is, of course, slightly tongue-in-cheek, because it’s deliberately ignoring the reality that people often vote in a particular way without thinking through the consequences, or because the options are limited so their vote cannot be seen as universal endorsement of everything the line they voted for stands for. So it is with voting Conservative. I hear what you say, but if there is this great body of Conservative voters eager for this Bill and angry with the professional bodies for opposing it, let them come out and make that position clear. I do not see them. Support for this Bill seems to be limited to a few professional politicians and a small claque in the national media who throughout my lifetime have cheered on the idea that privatisation and “competition drives up quality” is the solution to everything. The more I live and see the consequences of what that mentality has done to my country, the more I see how wrong it is. I have canvassed enough to know that while it may be the official view at the top of the Conservative Party, it is not nearly so much held by people who vote for that party as a great many of its voters vote that way more through socially conservative views than what has become known as “economically liberal” views. To my mind, “economic liberalism” is the Trotskyism de nos jours, an ideology which starts off with a reasonable basis, a viewpoint which needs to be taken into account, but which takes that viewpoint to absurd conclusions because it is being pushed by an out-of-touch elite who have no sense of real humanity and instead like simplistic theories which seem to offer easy solutions to complex problems.
Anyone interested in epistemology would know that the basic model of an organisation that informs the thinking of the Tories AND Labour is that the best (business) organisations that are run top down, that people only work better with financial incentives, and that competition is what drives organisation performance.
Speaking as an academic, this is bollocks.
The best organisations are run “outside in”,i.e. driven by demand, not by shareholders or regulators. The job of the leader is to design the best system for the employees who meet that demand to work in and then to encourage collaboration so the best practices are circulated throughout the industry and then everyone works together on improving delivery. The intrinsic satisfaction that ensues gives rise to innovation. Any extrinsic incentive comes from profit -sharing in a private company. NOBODY deserves or gets performance-related bonuses. So, it is a self-regulating entity that does not require the burden of governance that is experienced across the public sector service industry. This slashes costs immediately. An executive in the NHS said that if we followed this we would get 60% cost savings!!!
But the problem starts with the fact that politicians do not work in an culture of trust and cooperation; just the opposite in fact. So their mental map of how organisations work cannot encompass that; hence the dog’s breakfasts of public sector service companies they have created – from Railtrack to the NHS.
So, what to do. Reform the policies and behaviours at the top of the NHS, starting with what you reward and what you don’t. Then have a look at what the blocks are to good service and get people around to sort them. Do not use consultants, especially McKinsey.
Then and only then look at the structures. And, guess what, like the very best companies, you will have a fit for purpose NHS. That is why we need to stop the bill, because it does not start at the right place.
I understand “codswallop”, it is what the protesters speak, but what is the academic definition of “bollocks”? 🙂
I do like the idea of outside-in, but it’s not that simple. Doctors are applying their expertise to treat patients, and sometimes this means the patient needs to do something he or she doesn’t like. Let me generalise – the outside is being served by the inside, and the inside sometimes knows better than the outside what is best for the outside.
Excuse me, I have suddenly developed a huge hunger, and must go for lunch! 🙂 My inside is telling my outside what to do!
Richard
An Anglo Saxon word meaning testicles, used to illustrate contempt.
Outside in: yes, it is that simple. You have confused affectiveness with need. People often say what they want; but that is not always what they need. On a serious note, the doctors and nurses must be in the best possible shape to understand the needs of patients. A system that distracts them from doing that is not fit for purpose.
Graham Winyard, who knows more about the NHS than most of us, having worked in it all his life and been NHS Medical Director, has, I think, given the current debate the perspective that it needs: ‘Liberal Democrats will be judged on our overall stewardship of the NHS, not the details of the Bill…, The NHS faces the worst financial crisis in its entire history in the need to save £20bn over the next four years. The coalition Government is responding to this by imposing an unnecessary root and branch restructuring against near unanimous opposition by NHS staff. This is bound to end badly- you cannot achieve successful change in difficult circumstances, without taking people with you. We are already starting to see different local variants of lengthening waits, rationing and other arbitrary service restrictions and loss of financial control, and this can only get worse as the reforms are pushed through.
The NHS will be severely damaged and the Liberal Democrat party will be held responsible, and rightly so. We cannot say we have not been warned; virtually the entire NHS is telling us not to do this, as are most Liberal Democrat voters’. There are better ways forward – including working with the parts of the Bill that most LDs support. Won’t letting this legislation through result in more litigation (it’s a lawyers’ paradise), more transaction costs, more of a postcode lottery, more health inequalities, much more privatisation and more confusion and dissatisfaction among patients?
Robert
I could not agree more with everything you have said, except the last sentence. The bill must be dropped. The implementation will be horrendous. Any normal reorganisation in an organisation of, say 1000 people, takes about 18 months to bed in, during which time it operates at well below par. Think of that times 10, and times 10 again, as it is such a bad new structure. But politicians only think of grand gestures. Civil servants are most content just with policy.
Look how they tore the heart out of HM Tax system and stuffed up our immigration with their combined agency approach – not to mention the NHS IT debacle. It makes you shudder.