SECOND OPINION
Julia Manning, chief executive of think tank
2020health.org, takes a step back from the NHS reforms debate to examine the big picture.
T
he Health and Social Care Bill will bounce back into Parliament on
September 6th after a tortuous journey through its initial stages and (a record?) twelve re-sits of the Health Bill Committee. I do believe that how we deal with health now will be one of the key determinants of our entire fi scal and cultural future. The Americans certainly think it’s a fi scal game- changer, and with similar demographics here and care still ‘free at the point of use’ (usually) there is no reason to think we are any different. Yet despite this, it seems that many (for instance the BMA) have forgot- ten just what an unparalleled mess we are in with an eye-watering budget defi cit and unsustainable pension promises.
The coalition government recognised that demands on resources were unprecedented and that reform of the NHS to make it fi t for the 21st century was vital. Yet by the spring of 2011, professionals were confused and the public were bemused. The NHS had never had such a high public apprecia- tion rate (73% appreciation rate of users), despite appalling scandals such as Mid Staffs. On the whole their attachment was as strong as ever and the public case for re- form had not been made.
Professionals on the ground knew that de- spite the progress in improved outcomes
16 | national health executive Jul/Aug 11
and the extra cash they received for work- ing fewer hours, there were still many prob- lems. Despite all the investment, demand had not been contained. Reversals in pub- lic health achievements (the rise of malnu- trition and infectious diseases), risk dis- placement (where people take greater risks with their health due to a real or perceived safety net and no penalties), questionable treatments and screening, and unrealistic expectations of what medical interventions can or should be offered had all been go- ing virtually unchecked. Then there are the well-known pressures brought about by the fact there are more people in the population to treat, an inexorable rise in long-term conditions (e.g. type 2 diabetes, which is not because of ageing, but because too many people over-eat) and technologi- cal advances resulting in our ability to keep people alive and living for longer.
Add to this an institutional resistance to systems redesign, fraud and malpractice cover-up, poor leadership and the distrac- tions of a spurious ‘privatisation’ debate that polarises the long-established inde- pendent and public partnerships who pro- vide our NHS healthcare and they were all spelling out a different meaning for NHS: Not Healthy or Sustainable.
Policy sets the framework, the standards,
tries to ensure both the safety net and eq- uity of care. The 2011 Health and Social Care Bill was extensive but the direction of travel wasn’t new. For the past 25 years there have been three basic elements of policy development: the internal market split between the provider and purchaser of healthcare; some competition between providers (‘contestability’, ‘choice’ and ‘any willing provider’) and the decentralisation of decision making, most recently encom- passed in ‘no decision about me without me’. So if the direction of reform has been fairly constant with universal recognition that a monopolistic and paternalistic NHS is bad for health and bad for the economy, why has there been so much opposition?
Poor communication and the unnecessarily complicated Bill aside, competition has be- come the focal point for resistance. Certain vocal opponents now want to be reassured that not only will promotion of competi- tion be withdrawn as a function of health regulator Monitor, but that competition itself and the ‘Any Qualifi ed Provider’ pol- icy should be abandoned. Whereas I have sympathy with the challenge facing the potential commissioner in this fragmented world of the purchaser-provider split, I do fi nd myself marvelling at the chutzpah. For the very doctors who are complaining are either independent, self-employed provid-
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