Friday 9 December 2011

How Lansley duped the professions into “supporting” his reforms.

The Health and Social Care Bill has been hugely controversial and has faced significant criticism from across the health sector. There was even an unprecedented “pause” of the reforms. Despite this, the bill continues on its course through the Parliamentary process largely unchanged (in terms of it’s key purpose to increasingly privatise and marketise the NHS), and its architect, Andrew Lansley remains in post. A key reason that the bill has got this far is that although there has been a lot of criticism, there has not been a united front from the health professions calling for the bill to be withdrawn. The British Medical Association is the only major organisation that has called for withdrawal of the bill, and now opposes the bill in its entirety. So how has Lansley managed to avoid total opposition from other NHS stakeholders?

A key reason is that Mr Lansley was very careful to make sure that the White Paper, Equity and Excellence: Liberating the NHS, (which preceded publication of the Health and Social Care Bill) contained key Motherhood and Apple Pie principles to gain and claim support, and deflect criticism from the main NHS stakeholders.

These crucial Motherhood and Apple Pie principles of the reforms can be found in the Foreword of the White Paper, which was co-signed Lansley, David Cameron and Nick Clegg.
There are 3 main principles of the reforms:

First, patients will be at the heart of everything we do. So they will have more choice and control, helped by easy access to the information they need about the best GPs and hospitals. Patients will be in charge of making decisions about their care.”

Second, there will be a relentless focus on clinical outcomes. Success will be measured, not through bureaucratic process targets, but against results that really matter to patients – such as improving cancer and stroke survival rates.”

Third, we will empower health professionals. Doctors and nurses must to be able to use their professional judgement about what is right for patients. We will support this by giving front-line staff more control. Healthcare will be run from the bottom up, with ownership and decision-making in the hands of professionals and patients.”

Who could possibly disagree with “putting patients first”, a “focus on clinical outcomes” and “empowering health professionals”. And that is the key point. These principles are designed to be very powerful rhetorical devices that state one thing (which is hard to argue against) but can actually mean something completely different. In the case of “putting patients first” and having “more choice”, this is a mechanism designed to increase competition in the new healthcare market. A market cannot work without choice and competition. In the case of measuring “clinical outcomes”, this is also key to the functioning of the market, because in order to choose services between different providers of services, patients need the information to do so. It’s a way of countering the problem of information asymmetry in healthcare markets. Finally, the idea of “empowering health professionals” is just as much about devolving power and responsibilities away from the Secretary of State. The reforms will lead to healthcare rationing and eventually a mixed funding system, so it will be clinicians (GPs) that will be held accountable, not the Secretary of State. This is why Clause 1 of the bill (and its associated clauses) on the duties and powers of the Secretary of State for health are so crucial.

The powerful political rhetoric of these 3 principles certainly registered with the Medical Royal Colleges and the Royal College of Nursing, who made the following press statements following publication of the White Paper to support these key principles:

The Academy of Medical Royal Colleges stated:
The Academy shares the Government’s vision for the NHS, as set out in the White Paper. In particular we welcome:  

The clear commitment to putting the needs of patients and the public first
The use of improved health outcomes as the driver and measure of success
The empowerment and engagement of clinical healthcare professionals.”

The RCN stated :
“The principles on which the proposed reforms are based – placing patients at the heart of the NHS, focusing on clinical outcomes and empowering health professionals – are both welcome and supported by the RCN.”

Furthermore, as late as 6th of September 2011, despite being critical of the reforms, even the BMA stated public support for these 3 principles in a joint letter to the Times with Peter Carter (RCN), Clare Gerada (RCGP), Professor Cathy Warwick (Royal College of Midwives), Professor Sue Baliey (Royal College of Psychiatrists), Phil Gray (Chartered Society of Physiotherapy) and Peggy Frost (British Association of Occupational Therapists):  
"We support a vision of healthcare that is patient focused, clinically-led and based on outcomes."

The following day, in Prime Minister’s Questions, David Cameron took full advantage when he told the Commons:
"now you've got the Royal College of GPs, the physicians, the nurses, people working in the health service supporting the changes we're making"
This was disputed, but the damage was already done.

Furthermore, Andrew Lansley then used this in defence of his no confidence vote at the RCN conference.

So, these 3 core principles which were made clear in the foreword of the White Paper have served Mr Lansley and the coalition very well. It is imperative that leaders of the professional health organisations take more care in understanding political rhetoric. Once again the political class has run rings around a politically naive medical and nursing establishment. They need to wake up now and defend the NHS, before it’s too late.
The RCN, RCGP, Royal College of Midwives, and other professional organisations should sign a joint statement with the BMA as soon as possible to get this bill withdrawn.

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