Comment: Listening pause was too little, too late
Politics has trumped policy, and it is a squalid mess.
By John Kell
The prime minister's 'pause' to the progress of the health and social care bill is drawing to a close. The 'NHS Future Forum' is due to make its report this week, following a 'listening exercise'. So improvised is the whole thing that everything to do with it has to be described in inverted commas – proper names for these processes do not exist.
I was recently at one of the larger 'listening events'. Tables of patients and charity personnel chatted over a few questions and notes were taken. The prime minister and secretary of state strode in, surrounded by cameras and twitchy apparatchiks, and duly did the rounds of the tables. There was ample footage shot of Cameron listening intently. Lansley talked eloquently in defence of his plans. Then after 45 minutes Cameron made a brief but pleasant speech and they all buzzed off. The assembled charities had to have their report of the event synthesised into a single document to be handed into the Future Forum first thing the following morning. Cameron mentioned that he had returned that morning from Ireland, where he accompanied the Queen to see Guinness being manufactured. Conjuring the image of a brewery seemed brave in the circumstances – it invited an obvious comment that nonetheless went unsaid.
Of course, we all turned up to make our points – it would be inexcusable not to. Similarly we all sent in copious responses to the many consultations on the reforms when they were launched last summer (the now notorious white paper, and four more related consultations, with more following later in the year) – coming at the same time as proposed reforms to benefits, social care and pretty much everything else, this deluge of consultation forced many a poor charity policy wonk to run themselves into the ground just to keep them all covered. To little avail – pretty much all of our comments were ignored. To give just one example (jargon alert), the NHS' new 'Outcomes Framework' contains five 'domains' – all five of them unchanged from the draft proposals presented at 'consultation' despite many suggestions for modification.
That said, perhaps we all did hang back slightly. Some charities are now reflecting that we were too reluctant to spell out starkly the problems we perceived with the proposals, still more to suggest that they should simply not be taken forward, for fear of losing influence with a new secretary of state. Too late did we realise we barely had any influence to lose. Criticisms were made politely, framed with, "we welcome aspects of the proposals, but…" Inevitably (and, to be fair, not uniquely), the government purported to hear only, "we welcome… the proposals".
As the 'listening exercise' has shown, however, there is and always has been a lot of consensus around what needs to happen. Substantial NHS service redesign is needed, to address long term conditions in the community, via a co-ordinated approach with social care. Long-term conditions account for most of what the NHS spends its money on, and traditionally the NHS has tried to address them through the acute hospital model, which provides often less effective care for such conditions, at greater cost, than a community-based approach. This redesign should therefore find the efficiency savings necessary to meet the challenges of an ageing population and tight financial settlement while keeping quality high. Did we fail to put this across clearly enough, or did the government simply fail to listen? Either way, the reforms did not go out to consultation in a state designed to address these issues, and did not emerge from consultation much changed.
But that's in the past. Where are we now? The changes have already started and cannot be reversed. PCTs have shed staff and are being 'clustered' prior to their abolition (one presumes). GPs are trying to grapple with the task foisted on them by the government, many of the keener ones thoroughly demoralised by the 'pause'. Simultaneously, the effectively flat NHS budget settlement is biting: cuts are being made to front-line services, through leaving posts unfilled in a haphazard way, moving specialist nurses to general duties and other means. Social services, starved of cash even before the assault on local government funding, are shunting more and more demand to the NHS (most of what cannot be shunted simply goes unmet), and a tightening benefits system is having a similar effect.
Whatever changes are made to the government's plans therefore seem likely to be driven by expediency: amending a bill at break-neck speed while it is going through Parliament allows little opportunity for impact assessment. The process, moreover, is nakedly political, with the key dynamic seeming to be the Coalition fault-line between Lib Dem and Tory. Cameron needs to meet Nick Clegg's demands for changes in the wake of his electoral and referendum-driven misfortunes, while recovering his government from the bad PR generated when the professional bodies stood up to the government early in the year.
Politics has trumped policy, and it is a squalid mess. How the prime minister squares these considerations, if at all, with the fate of Andrew Lansley and the temper of the Conservative backbenches remains to be seen – it is the sort of political consideration that those of us who work in policy tend not to address directly in our documents and formal commentaries, as if it's somehow impolite, but always gossip about when we meet. Nonetheless, the future of the NHS hangs on these questions – and they could hardly be further away from the real questions of how to redesign the NHS to meet its real needs.
<b>John Kell is a policy manager at a medium-sized health charity. </b>
<i>The opinions in politics.co.uk's Speakers Corner are those of the author and are no reflection of the views of the website or its owners.</i>
