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Health bill sceptics can still be won over


The Health and Social Care Bill will reach the House of Lords in October. Indications early on were for a relatively smooth journey once there. The pause had, apparently, helped to soften opposition from key professional groups, and there was a growing sense that prolonged parliamentary wrangling would make the job of dealing with frozen budgets and rising demand more difficult.

However with hindsight predictions of a quiet autumn look premature. Opponents of ‘Part Three' (the section of the health bill dealing with competition and economic regulation) are still sceptical, if not outright opposed.

To this group we can now add the original enthusiasts of primary care led commissioning, increasingly alarmed at the new range of oversights and accountability mechanisms promised by the Government. Is the situation salvageable?

The Government's failure to articulate the need for change or engage fully with stakeholders may continue to prove problematic. Crucial parts of the reform package are being left to secondary regulations or are as yet unclear (notably how to deal with financial and/or clinical failure in hospitals), and the climate does not lend itself to trust.

The more important question is whether this matters.  Like past attempts, the current round of reform focuses more on anatomy (structures) than it does on physiology (incentives). Yet patients, clinicians and the organisations in which they receive care or work are rooted in contexts that powerfully shape behaviour, and are themselves explained by more than just structures. 

Why for instance did managers and clinicians at Mid Staffordshire NHS Foundation Trust not act to prevent the catastrophic lapses of care? Why did it take financial incentives for GPs to improve the care of people with chronic diseases? Why did it take 60 years for waiting times to reduce to more acceptable levels? And so on.

The substantial variations in clinical practice, the continuing gaps between health and social care and the failure to get to grips with prevention make it clear that while talent, motivation and hard work abound in the NHS, these assets may not be optimally focused.  

In England we have responded by experimenting with a range of incentives designed to influence the behaviour of care providers, ranging from ‘command and control' Whitehall directives, ‘regulations' that assess and enforce improvement where appropriate, and financial incentives, such as those given through QOF.

The issue is no longer binary – whether one approach should be used rather than another - but rather, what is the right blend?

To that question there is no immediate answer. What is needed is slow and careful learning that reduces the risk of policy taking a blind alley. The existing NHS already reflects this, with new models of integrated care apparent alongside tough commissioning requirements (including the use of any willing provider).  From that viewpoint the health bill tries to build on those previous domestic and international reforms.

Andrew Lansley's mistake was to have gathered these up into a terrifyingly long piece of legislation into a reform programme that does not look implementable given the financial squeeze.

But it is an expensive luxury to oppose reform. Unless significant efficiencies are made over the next few years, we may not have an NHS which commands popular public support. Calls for top up financing from private sources will grow louder. A change to the financing of health care would surely erode the whole basis of NHS.

So the search should be on for effective solutions. Many groups skeptical or opposing reform could be won over if there was a stronger analysis, backed up by evidence for why his preferred solutions are needed, and if longer term, the Secretary of State showed himself willing to take decisions based on the data.

Dr Jennifer Dixon is the director of the Nuffield Trust