Observations Body Politic

Lansley had no choice but to make a full frontal assault

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d470 (Published 24 January 2011) Cite this as: BMJ 2011;342:d470
  1. Nigel Hawkes, freelance journalist, London
  1. nigel.hawkes1{at}btinternet.com

The health secretary had the advantage of surprise, but his opponents have rallied

In battle, confusion reigns. Amid the clash of arms, the smoke, the noise, and the cries of the wounded, the disposition of the opposing forces and even the terrain become obscured. Reason disappears; instinct takes over. Tempers rise, and a lot of blood is shed.

So it is, in a minor key, in the row over the government’s health reforms, which reached a climax with the publication last week of the Health and Social Care Bill (BMJ 2011;342:d418, doi:10.1136/bmj.d418). Seldom have so many old enemies used the cover of confusion to pay off so many old scores. Tattered banners have been raised bearing the legend “Save our NHS.” Tocsins have been rung, deaths foretold. Is this the end of civilised life as we know it?

Hardly. The NHS, as I have remarked before, is only a means of delivering healthcare, not a belief system that binds its adherents to an unchanging catechism. So, for my benefit as much as for that of BMJ readers, it is worth exploring what the bill is about and what it is not about. Is it a big change or a small one? (England’s health secretary, Andrew Lansley, has at different times claimed both, so confusion on that point is understandable.) Is it about saving money or spending it better? Is it about providing juicy profits for the Conservatives’ friends in private industry, in the process elbowing out the existing workforce?

This last question is the easiest to answer. The bill is not about privatising the NHS: that’s just a scare. Primary care is a hotbed of private enterprise already, so what’s new? General practitioners who turn up their noses at any private sector involvement in commissioning or in providing services are engaging in the purest humbug. Judging by the latest figures on GPs’ earnings they are hoovering up most of the juicy profits already. Public sector trade unions are the last people to trust over the merits of the private sector, but at least—unlike the GPs with whom they have been making common cause—they aren’t actually part of it.

More tricky is the question of whether the bill marks a big change or a little one. Almost every feature of it is familiar—GP commissioning, foundation trusts, any willing provider, patient choice, old Uncle Tom Cobley, and all—because they were the invention of New Labour in its braver phase. Primary care trusts (PCTs), remember, were supposed to bring commissioning into primary care (the clue’s in the name) before they were subverted by managers into mini-health authorities, to which Labour responded half heartedly with practice based commissioning. So this feature of the bill is less than revolutionary: it could even be described as reactionary, because it seeks to restore the PCTs’ original purpose.

Why not simply reform the PCTs by abolishing their boards and putting GPs in charge, if they are the people deemed best at commissioning care? That seems to have been the plan up until the July white paper, which threw people into a flurry not because it championed GP commissioning (in the Conservatives’ manifesto) or abolishing strategic health authorities (in the Liberal Democrats’ manifesto); neither party had mentioned abolishing PCTs.

Why the change? The reason, according to the health minister Paul Burstow, was that if public health were moved to local authorities and commissioning to GPs, that left PCTs with the modest role of assessing needs and passing action to the GP consortiums—a job so limited that it did not seem to justify all the apparatus of a statutory body. Unlike the PCTs, GP commissioning groups will be bodies corporate, not statutory bodies under government control. That should make possible much leaner organisations and lower overheads, though at some financial risk. It also diminishes the chance of managers regaining control, as they have done so often in the past.

But if in reality it is rather a modest change, why does everybody think it is huge? Enter the demon king, the über-manager David Nicholson, chief executive of the NHS, who has been telling everybody that the change is so huge it can be seen from space. Mr Lansley has tolerated Sir David’s disloyalty with astonishing forbearance because in the short term he cannot do without him. Mr Lansley’s reforms may or may not save money (probably not much) and certainly won’t in the short term. But the NHS faces a short term financial crisis that can be resolved only by some old fashioned bullying of the kind that made Sir David the man he is.

So, by a delicious irony pointed out by Paul Corrigan (a Number 10 health adviser in Labour’s aforementioned braver phase), Mr Lansley has to use the old technique of central direction to avert a meltdown, before his new decentralised system can even begin. It is possible, as Professor Corrigan asserts, that an alarmed Number 10 imposed this on him. Whatever the precise details, the old techniques of saving money, which Mr Lansley says don’t work, are back on the agenda and Sir David’s anticipated retirement postponed. If they succeed, and £20bn is somehow saved, Mr Lansley’s argument will be undermined as his authority already has been. If they fail, he’ll be gone anyway.

In the NHS, culture nearly always trumps reform. When gains are made they seldom prove sustainable. As Marc Baker, Ian Taylor, and Daniel Jones argue in a fascinating analysis for the Lean Enterprise Academy, The NHS Bermuda Triangle (and How to Escape it) (www.leanuk.org/downloads/LS_2010/paper_nhs.pdf), endless efforts are made to devise perfect policies, but it matters little whether they are perfect or imperfect because they won’t get implemented anyway.

Mr Lansley knows this full well. Only a full frontal assault early in the parliament stood any chance at all. It is his misfortune to have launched this assault when the NHS stands high in most people’s esteem and when money is tight. He had the advantage of surprise, but his opponents have rallied. He will need to be more the politician and less the policy wonk to emerge triumphant when the smoke clears.


Cite this as: BMJ 2011;342:d470


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