Why the plans to reform the NHS may never be implemented

Irrespective of the outcome of Unison’s request for a judicial review of the coalition government’s plans to reform the NHS in England (BMJ 2010;341:c4716, doi:10.1136/bmj.c4716), ministers will have to fight on several fronts to implement the white paper Equity and Excellence: Liberating the NHS. Major challenges include completing the design of the reforms, winning the support of those they are seeking to liberate, and holding the coalition together to secure implementation.

The white paper and the accompanying consultation documents set out the government’s plans in broad outline and lack the detail needed to give confidence that they will deliver the improvements in care that have been promised. Much more thought must be given to managing the transition from the current system to the one proposed and to how commissioners, providers, and regulators will relate to each other in future.

Critically important will be ensuring that general practitioners are ready to take on their new responsibilities as arrangements are made to abolish primary care trusts and strategic health authorities. Liberating frontline staff is a laudable aim; but, as experienced generals know, winning the war is different from securing the peace. Unless the new general practice commissioning consortiums have the leadership and resources to take on the functions they have been given, there is a real danger that the government’s plans will be undermined before they have been given a chance to work.

It will also be necessary to secure stakeholder commitment to the white paper. In an organisation as large and complex as the NHS an ever present risk is that policies set out at the national level will be diluted and modified. This risk is particularly acute because cuts in management costs will remove many of the managers who in the past have been at the forefront of carrying policies into practice.

As in a war, much hinges on the ability of the invading army to win the hearts and minds of those they are seeking to liberate. In the NHS the support of general practitioners is especially important in view of the expectation that they will play a major part in ensuring that services are responsive and of high quality. Early indications are that, while some general practitioners are enthusiastic about the government’s plans and are eager to be in the vanguard of reform, others are suspending judgment until the outcome of negotiations with the British Medical Association on their contract is clear.

These negotiations hold the key to implementation of the white paper, because ministers need to secure agreement on their proposal that practices be placed under a duty to be a member of a commissioning consortium. Other issues to be resolved include linking a proportion of each practice’s income to the outcomes that practices achieve collaboratively through their commissioning consortium and paying a quality premium to the consortium on the basis of its performance. The government’s longer term aim is to work towards a single contractual and funding model to promote quality improvement, deliver fairness for all practices, support free choice for patients, and remove unnecessary barriers to new providers.

Add to this list the expectation that the Quality and Outcomes Framework (QOF) will be reformed and that practices will take back responsibility for providing out of hours care and the ambition of ministers becomes clear. All these issues have to be resolved with no new money on the table, suggesting that lengthy and tetchy contract negotiations lie ahead.

A further challenge relates to the ability of the Conservative and Liberal Democrat coalition partners to sustain their commitment to govern together for long enough to enact the white paper proposals. With one or two exceptions the government’s plans are based on thinking developed by Andrew Lansley while in opposition and set out in Conservative Party policy documents. The Liberal Democrats have been willing to lend their support to Lansley’s thinking, but there is no guarantee that this support will continue indefinitely.

Much hinges on the outcome of next May’s referendum on electoral reform. If the referendum goes against the Liberal Democrats’ wishes, then their willingness to work with the Tories for the duration of the parliament will come into question. The pressure on the Liberal Democrat leaders to review their role in the coalition will grow if public spending cuts have adverse consequences for services such as social care and education and if the economy descends into a double dip recession. To revert again to a military metaphor, coalition forces will need to hold together if their campaign is to succeed.

The history of NHS reform is littered with examples of radical plans that have delivered much less than they have promised. Equity and Excellence will suffer a similar fate without meticulous attention to transitional arrangements. The effort put into writing the white paper has to be matched by the unglamorous task of planning of implementation to enable frontline staff to inherit a secure future rather than an unstable war zone.

Even if this is done medical politics and party politics could yet frustrate the enactment of proposals that in prospect amount to the most radical transformation of the NHS since its inception.