Does anyone understand the government’s plan for the NHS?

Not only does there appear to be no reason behind this latest reorganisation of the NHS, but the practical details needed to implement it are strangely lacking.
As a GP, I still do not know whether my CCG will remain in the old PCT area (Bedfordshire) to make it co-terminous with the two local authorities (Bedford Unitary Authority and Central Bedfordshire) or be instructed to merge - probably with Luton and all the CCGs in Hertfordshire - to provide a population and budget large enough to cover risk.
Equally, the future funding and control of GP IT systems has not been decided.
All GPs in England hold their records electronically, and all governments since 1990 (and the previous Conservative reorganisation of the NHS) have decided what new functions are required across the whole country from all system suppliers to support their requirements.
GPSoC (GP Systems of Choice) ends on 31.3.13, while the CSC contract (which includes supplying a single GP system in the previous Accenture areas - North East, East Midlands and East of England) does not end until 2015: future strategy for post-GPSoC and post-LSP has not been announced - and Katie Davis' assurance at EHI Live last November that I needn't worry - the problem was recognised and number 10 was taking a personal interest somehow failed to reassure me!
Two small examples - but with 14 months to go until go-live on 1.4.13, I share all the concerns - and lack of understanding of the business case and implementation plan - assuming either exist - for this last, massive, top-down NHS reorganisation by a government lacking an electoral mandate!

I welcome this extremely valuable professional insight and food for thought from Professor McKee.1

The NHS will undoubtedly continue to undergo new changes mainly because times are changing and our population is ageing. The new element of change is the significantly visible and blurred boundary between the two sub-systems, health and social care, and mainly for older people. The interaction has been insufficiently dealt with until the new Health and Social Bill arrived and this has made it extremely difficult to understand where we are going with this Bill and in its current format.

A couple of recent news illustrating similar European situations come to mind. This from a comparative perspective as Professor McKee uses the comparative element in reasoning the NHS possible changes. North America’s systems and other European systems are the main types with which the NHS continuously and rightly compares:-

In the early 1990s, post-communist countries went through a rapid change. They dismantled old systems in a matter of a few years and most countries went through the change of becoming European social health care insurance systems, in short, by adopting the Bismarck model (1898). However, a decade of “change” later, a new dawn is knocking at their doors, too, as a history of over 100 years has caught up again with these countries. The new predominant feature is privatisation, a lot of it, and begs an answer to the following question: are these countries suitable for adopting health care private models? Moreover, are they ready? In other words can they afford to bring change in this way? If they move on with these changes and if professionals are not paying sufficient attention to what goes on behind political doors, then the utilitarian health and social care model will soon become history.

An example is Romania. A new Health Bill was published at the end of December 2011. This has now been withdrawn. It collaterally triggered social unrest throughout the country. However, this unrest appears to have a broader theme and a very unclear association with the Health Bill. There is a major and disjointed pull-push between professionals and political decision making stakeholders and a crucial issue remains as: to what extent does the professional opinion count any more in the organisation of a health and social care system in a country?2

To stay in the European region, a second example is Hungary which faces major issues in their health care system too, that is in spite of having tried to tackle informal, illicit and difficult to control payments for more than a decade whilst improving the health of its population. The current economic crisis is not abating any time sooner in this European country too making things even more complex.3

The English NHS as well as all other social health care insurance systems have ageing populations in common. This reduces a large part of the tax payers’ contribution towards the combined health and social care systems. The current economic crisis does not help either; unemployment is higher than usual. Concomitantly, the NHS pension issues are debated at the same time as this Health and Social Care Bill is debated. The coincidence and overlap of pension issues with this crucial Bill could have not come at a worse time. A non-motivated professional group is unlikely to bring optimal solutions to the core essence of the Bill. In turn, the Bill remains opaque, lengthy and does not help with what 21st century health and social care England must deal with on the ground.

There is undoubtedly a difficult road ahead for the comparative health and social care agenda and in particular for the newly proposed Health and Social Care English Bill. As Professor McKee suggests some answers may lie with the BMJ Group readership, but perhaps some may lie with the outsider (non-health) readership, some with politicians and some may not be found at all.

1.BMJ 2012;344:e399 doi: 10.1136/bmj.e399
2.www.adevarul.ro%2Factualitate%2FSpitalele_si_medicii_intra_in_competitie...
3.BMJ 2011;343:d7657 doi: 10.1136/bmj.d7657

Professor McKee’s essay is a clear exposition of the essentially vacuous nature of the UK Government’s arguments for the Health and Social care bill and the so called reforms that are being implemented even before Parliament has passed the Bill.

But that is not to say that the Bill is purposeless or that its proponents are determined to wreak wanton damage to the NHS.

I believe it is part of the Government’s response to the wider economic mess we find ourselves in after the banking crisis of 2008 and the mounting debt burden that threatens to cripple the economy.

If we were a third world country in a similar economic situation with the world’s money-men uncertain of our ability to repay our external debts, we would have had to turn to global financial institutions for aid. The IMF and World Bank would have offered financial help but on condition that we introduce one of their notorious Structural Adjustment Programmes.

The essential feature of an SAP is the scaling back of public services, reducing the state's expenditure on education, social welfare, help for the disabled, and health care; and handing them over, wherever possible, to the market to be provided on a pay-as-you-go basis.

This happened in numerous emerging economies since the late 70s and 80s wherever periodic banking crises led to the threat of sovereign default. People like Dorothy Logie were at the forefront of the campaign against such destructive programmes that led to great damage to public health in countries that were too small or too powerless to resist, or were ruled by an unaccountable elite who made common cause with global financiers.

But the UK is not a third world country; it has a leading place in the IMF. And so the Government is itself dishing out the same medicine that it prescribed to other highly indebted countries in the past. And because we are a democracy the reforms have to be dressed up as a necessary response to a health system that is falsely accused of failing patients, is overly bureaucratic, expensive and wasteful, and not responsive to people’s demands for choice. Where coercion is prevented by the rules of a democratic system, rulers have to resort to subterfuge to justify changes that are unnecessary and damaging.

The real tragedy is that the Government does not have the courage to come out with the truth – and say, "we can’t afford public services on the scale we have become accustomed to, we need to cut back, can we all agree on the least damaging way to do that." That would have required political courage and leadership. Instead we have a set of reforms that may or may not achieve its stated goals but will almost certainly dismantle the NHS as we know it, widen inequalities, enrich a few people and businesses, and leave the majority with worse health outcomes than before.