The Coalition were the future once.
Matthew d’Ancona, a pretty formidable intellect himself, has been publicising his excellent book, “In it together – the inside story of the Coalition.” Britain actually had had no recent experience of coalition government, so this work of scholarship is a very useful one. d’Ancona found that it wasn’t the fevered days following the Coalition which determined most the coalition. d’Ancona felt, however, that behind the scenes of their election campaign, it was known that the Conservatives knew that they couldn’t win the 2010 general election (for a period of months before the election.) At the time, David Cameron was producing a ‘moderate’ offering, and the Orange Bookers were dominating the Liberal Democrat Party.
d’Ancona feels that it was possible to draw together common strands from the Conservative and Liberal Democrat manifestos. It was very difficult to forge together the parties, despite commonalities in approaches from their grassroots memberships. Having the Liberal Democrats inside the Coalition was seen as a useful way of ‘taming the Tory right’, such as Peter Bone MP and Bill Cash MP, and it turns out that the major impetus for the fixed term Government was from the Conservatives who felt the Liberal Democrats might have bailed out.
It’s said that the coalition government is run by the ‘quad’ – David Cameron, Osborne, Nick Clegg and Danny Alexander. Osborne invariably chairs this meeting of the most senior officials and advisers because of his political skills. The expertise regarding the NHS is pretty small. In fact, the expertise in the current Coalition leadership is pretty poor. In comparison, the expertise of an incoming Miliband government will be quite great in comparison. d’Ancona has usefully likened it to a traditional ‘oligarchy’ – to be contrasted with the “sofa government” characterised by Tony Blair’s approach. Blair himself had had very little experience himself of senior offices of state prior to being Prime Minister.
Boris Johnson is alleged to have said that the formation of the Coalition was a ‘triumph of the public school system’. Indeed, it is reputed that George Osborne MP and David Cameron MP saw themselves as the antithesis of the dysfunctional Blair-Brown relationship. Clegg and Cameron had both come from a public school background, been through the Oxbridge mill, were at ease with modernity and “at ease with affluence” (according to d’Ancona). In keeping with this, Rafael Behr in the New Statesman comments:
D’Ancona describes a tight social circle running the Tory side of the coalition – old friends, their wives, ex-girlfriends, all joining each other for holidays and dinner parties and sharing childcare, now all ministers or Downing Street staffers. He draws the contrast with the New Labour elite who took charge of the country in 1997. Tony Blair’s clan started life as a political project and only later evolved into a governing family before splitting into mafiosi tribes. Cameron’s was a clique before it thought of running the country. That makes it more affable than the Blairites but also lacking in purpose. The Cameroons had an easy ride to power before they had thought enough about what power should be for.
The book by d’Ancona also comes warmly recommended by Nick Cohen, writing in the Guardian:
No journalist has better access to our rulers than Matthew d’Ancona. As a liberal conservative, he is at ease with the Conservative-Liberal Democrat coalition, and it is at ease with him. Just about everyone in power spoke to him for In It Together, and as a result, I doubt there will be a better insider’s account of the coalition for years. If you want to understand today’s high politics, you should read him.
Ideally, one should check progress against the Coalition Agreement which is in a non-legal sense a compromise agreement of its own. Even that agreement is fraught with blind alleys, notions such as ‘we will give enhanced powers to the PCTs’ and the such like. However, d’Ancona says that going through the two manifestos became a textual exercise, where they arguably saw areas of overlap. What we have therefore seen in the last three years represents this area of overlap. Indications are with an emphasis on patient safety, 24/7 and ‘out of hours’ care, no more maternity and A&E closures what was promised was very far from reality.
No more top down reorganisations?
The curious starting point of the Conservative manifesto is that David Cameron and his party wish to protect the NHS from top-down reorganisations. This is blatantly a lie as anyone who has read ‘NHS SOS’ will clearly conclude.
“more than three years ago, David Cameron spelled out his priorities in three letters – NHS. Since then, we have consistently fought to protect the values the NHS stands for and have campaigned to defend the NHS from Labour’s cuts and reorganisations. as the party of the NHS, we will never change the idea at its heart – that healthcare in this country is free at the point of use and available to everyone based on need, not ability to pay.”
Conservative Party Manifesto 2010
Only this afternoon, Dr Sarah Wollaston MP was asking the current NHS England CEO, Mr David Nicholson, about whether the English law was a ‘barrier to reconfiguration’. Of course, the essential issue is NOT whether the law is OBSTRUCTIVE to the NHS carrying out reconfigurations. Reconfigurations must be led by proposed benefits or improved outcomes in quality of care locally, at a clinical level, and should not be merely seen as a cost-cutting exercise to deliver the £20bn or so McKinsey ‘efficiency savings’. The Conservative Party manifesto therefore takes the position of MPs wishing to save their seats in such reconfigurations, rather than the national stance it later adopted over Trust services. The Lewisham campaign has recently won a second victory at the Court of Appeal, and the decisions of the Trust Special Administrator (TSA) in Staffordshire have yet to be published.
“We will stop the forced closure of A&E and maternity wards, so that people have better access to local services, and give mothers a real choice over where to have their baby, with nhS funding following their decisions.”
Conservative Party Manifesto 2010
And this even appears to be an area of agreement between the Conservatives and Liberal Democrats. However, in the drive for the NHS ‘efficiency savings’, as part of the austerity aka ‘cuts’ national interest narrative, this could have been a firm commitment for this Government. Most people agree that this Government has conducted backdoor reconfigurations of the NHS in a cack-handed manner, though it is unclear precisely what Labour wish to legislate regarding this, currently?
“The NHS often feels too remote and complex. Local services – especially maternity wards and accident and emergency departments – keep being closed, even though local people desperately want them to stay open.”
Liberal Democrat Manifesto 2010
And the creation of NHS England is at least signposted in the Conservative Party manifesto.
“We will make sure that funding decisions are made on the basis of need, and commissioning decisions according to evidence-based quality standards, by creating an independent NHS board to allocate resources and provide commissioning guidelines.”
Conservative Party Manifesto 2010
This – at first blush – seems contradictory to the Liberal Democrat version, although the LibDems also concede a need to stem management costs. The creation of NHS England might conceivably be considered an area of commonality between the two parties, depending on your perspective.
“We have identified specific savings that can be made in management costs, bureaucracy and quangos, and we will reinvest that money back into the health care you need.”
Liberal Democrat Manifesto 2010
The ensuing ‘Coalition agreement: A programme for government‘ makes numerous references to PCTs, which were also ultimately scrapped in the NHS ‘reforms’.
However, at least the Liberal Democrats do throw forward to the concept of abolishing PCTs. It might be argued that the Liberal Democrats at this stage were still living in ‘cloud cuckoo’ land, with making all sorts of pledges and promises believing that they would never come into government (as per the tuition fees debacle.) And yet it is the Coalition government that implemented the Health and Social Bill as it was going through parliament, and beyond after it obtained Royal Assent. Had the Liberal Democrats been at all serious about government, irrespective of whether the general public took them seriously or not, they should have attempted to budget the opportunity cost of dismissals and subsequent re-appointment elsewhere in the system.
David Nicholson, current NHS England chief, explained today that he does not have this information about dismissals leading to reengagement, although he claims to have the figure for redundancies etc. overall. This is something which the Conservative government, and presumably David Baumann, the Chief Financing Officer, could have budgeted for. Of course, the current Government prides itself on fiscal responsibility, having never clearly stated as to whether they too would have bailed out the investment banks to the tune of £860bn thus massively increasing the deficit.
The Liberal Democrats’ plan to scrap PCTs is clearly stated here:
“Empowering local communities to improve health services through elected Local Health Boards, which will take over the role of Primary Care Trust boards in commissioning care for local people, working in co-operation with local councils. Over time, Local Health Boards should be able to take on greater responsibility for revenue and resources to allow local people to fund local services which need extra money.”
Liberal Democrat Manifesto 2010
Resource allocation problems
There have been thousands of nursing staff cut under the Conservative-led government, with parts of the capital relatively shielded from the effects of the cuts.
“We all know that too much precious NHS money is wasted on bureaucracy, and doctors and nurses spend too much time trying to meet government targets.”
Liberal Democrat Manifesto 2010
The ‘pledge’ made by the Conservatives for allocating resources in the NHS responsibly is of course hugely laughable, with the benefit of hindsight of a reorganisation estimated at £2.4 bn.
“as a result, we will be able to cut the cost of NHS administration by a third and transfer resources to support doctors and nurses on the frontline.”
Conservative Party Manifesto 2010
John Appleby from the King’s Fund in the lifetime of this Coalition government has written in the BMJ on how the issue of ‘increased health spending’ has been mischievously addressed thus far.
“We will back the NHS. We will increase health spending every year. We will give patients more choice and free health professionals from the tangle of politically-motivated targets that get in the way of providing the best care.”
Conservative Party Manifesto 2010
Jeremy Hunt has indeed announced to limit the pay and bonuses of NHS managers, indeed referring also to how such pay shouldn’t exceed that of the Prime Minister announced in the Liberal Democrat manifesto. The problem with this argument is that it is alleged that Jeremy Hunt’s personal income for various reasons is quite large, compared to the income of the nurses he is currently sacking.
“We will cut the size of the Department of Health by half, abolish unnecessary quangos such as Connecting for Health and cut the budgets of the rest, scrap Strategic Health Authorities and seek to limit the pay and bonuses of top NHS managers so that none are paid more than the Prime Minister.”
Liberal Democrat Manifesto 2010
Health and Social Care Act (2012)
The Health and Social Care Act (2010) created the largest QUANGO in the universe, some allege, though commissioning power has been devolved locally to clinical commissioning groups (CCGs). However, it is still a moot point whether CCGs are genuinely clinically-led.
As CCGs are state insurance schemes, there’s actually no obligation for them to have much clinical input, so that they can ascertain the pooling of risk competently. No formal stipulation has ever been given on the optimal size of the CCG, interestingly.
Possibly the most significant line however is the comment that the NHS puts ‘targets before patients’. Whilst it is claimed that the targets introduced by the Labour administration improved patient care, e.g. waiting times, only this evening we had yet another report of performance figures being gamed by a English NHS Trust (Colchester).
“We have a reform plan to make the changes the NHS needs. We will decentralise power, so that patients have a real choice. We will make doctors and nurses accountable to patients, not to endless layers of bureaucracy and management. We can’t go on with an NHS that puts targets before patients.”
Conservative Party Manifesto 2010
The Health and Social Care Act (2012) does, however, have three primary aims of legislation, despite the enormous volume of it at 493 pages.
The primary aim of it is to pivot the NHS on price competitive tendering. This was of course the famous section 75 which we all warned about. I was one of the first people to warn about the cost about this for resource allocation, in fact, in an article on this blog at the beginning of January 2013. David Nicholson, in contrast, appears to have been totally oblivious to the costs we had all warned him about, in his evidence to the Health Select Committee this afternoon. I wonder if he is fully aware of the extent of the failure of this showpiece plank in this policy, as I wrote about on this blog recently too.
The second arm of the legislation is a redefinition of the failure regime. This clearly has not gone according to plan from the Coalition’s point of view, with the present Government having hurriedly legislated for an amendment in the Care Bill (2013) to extend the powers of the TSA, as described here.
The third arm of the legislation is to put in place the regulator for this competitive market, Monitor. This has necessarily meant re-allocation of scarce resources away from frontline care into the regulator’s processes. But even in 2010, the Conservative Party gave a clear warning shot that they wished to extend the scope of the NHS market. Online reports of the performance of healthcare providers, in promoting ‘customer choice’, are in fact mentioned in the second set of regulations for section 75 (the revised statutory instrument – No 500 – after the first one – No 257 – had to be discarded due to popular criticism.)
“We need to allow patients to choose the best care available, giving healthcare providers the incentives they need to drive up quality. So we will give every patient the power to choose any healthcare provider that meets NHS standards, within NHS prices. We will publish detailed data about the performance of healthcare providers online.”
Conservative Party Manifesto 2010
“We will set NHS providers free to innovate by ensuring that they become autonomous foundation trusts.”
Conservative Party Manifesto 2010
The drive towards integration became particularly apparent when the first set of section 75 NHS regulations had to be scrapped, with Norman Lamb ferreting around for a compromise which Baroness Williams and partners-in-crime could sell to their Lordships.
It is hard to when at what stage the Liberal Democrats will begin their process of ‘differentiation’ from their partners, the Conservative Party, in the coalition, as described famously by LibDem strategist Richard Reeves. With the introduction of Norman Baker at the Home Office, it is conceivable that the Liberal Democrat Party will wish to make its mark on policy sooner rather than later.
The problem with integrated bundles is that it has just kicked the competition law football down the line, and this will have to be picked up again by Andy Burnham MP in the latest incarnation of integrated shared care packages, “whole person care”.
Integrated packages, especially if delivered through the ‘prime contractor model‘ where legal liability is currently unclear, may offend competition law in this jurisdiction.
The danger for Burnham of course is that by picking up the ball he might create a foul under the rules of football, unless he suddenly changes the rules to rugby; or, in political terms, changes the narrative to whole person care, which a sovereign parliament has legislated for.
“Integrate health and social care to create a seamless service, ending bureaucratic barriers and saving money to allow people to stay in their homes for longer rather than going into hospital or long-term residential care.”
Liberal Democrat Manifesto 2010
Personal budgets
The Conservative Party (just) have been marginally more open about personal budgets for social care. However, I have previously argued in my ‘OurNHS’ article called “Shop til you drop“, that this is a narrative that has gone on relatively unnoticed from all parties, and is likely to be an important policy issue in the near future in England, at least. This is set to become an explosive issue in the next parliament, with likely attempts to merge the healthcare and social care budgets. If these budgets get merged with universal credit, thus far scuppered by a poor NHS IT infrastructure, amidst a drive towards NHS data sharing (see this article from Tim Kelsey from today), this is a policy area which deserves special scrutiny.
“Where possible we want to devolve control over health budgets to the lowest possible level, so people have more control over their health needs. for people with a chronic illness or a long-term condition, we will provide access to a single budget that combines their health and social care funding, which they can tailor to their own needs.”
Conservative Party Manifesto 2010
Public health
The Conservative-led government in the end rejected minimum pricing of alcohol and standard packaging of cigarettes.
I discussed some of the furore over standard packaging of cigarettes here, in relation to alleged “The Wizard of Oz effect” of Lynton Crosby.
A powerful criticism of the Health and Social Care Act (2012) was that it represented the end-point of powerful secret lobbying on behalf of the private healthcare provider corporates; and thus represented rent-seeking behaviour from the private sector in a pretty obvious ‘corporate capture’.
An interesting article on the phenomenon of corporate capture in public health in recent years was produced in the BMJ.
Nonetheless, the following bold, and now meaningless promises, are made in their manifestos.
“Reduce the ill health and crime caused by excessive drinking. We support a ban on below-cost selling, and are in favour of the principle of minimum pricing, subject to detailed work to establish how it could be used in tackling problems of irresponsible drinking. We will also review the complex, ill-thought-through system of taxation for alcohol to ensure it tackles binge drinking without unfairly penalising responsible drinkers, pubs and important local industries.
Liberal Democrat Manifesto 2010
“We will turn the Department of health into a Department for Public health so that the promotion of good health and prevention of illness get the attention they need. We will provide separate public health funding to local communities, which will be accountable for – and paid according to – how successful they are in improving their residents’ health.”
Conservative Party Manifesto 2010
“Lifestyle-linked health problems like obesity and smoking, an ageing population, and the spread of infectious diseases are leading to soaring costs for the NHS. at the same time, the difference in male life expectancy between the richest and poorest areas in our country is now greater than during victorian times.”
Conservative Party Manifesto 2010
Primary care
The future of general practice is a huge area, as I have previously given a brief account of.
‘Out of hours’ care has been a huge issue in the last few years. In April 2013, NHS England directors admitted that patients have been “let down” by the “unacceptable” failure of some NHS 111 services.
Prof Clare Gerada is about to step down as Chair of the Royal College of General Practitioners. She gave a brief account of what had to be done about out-of-hours care in her wide-ranging speech for the RCGP in October 2013:
Further details, published in the Guardian, are here.
The idea that GPs are directly involved in providing out-of-hours care was dealt a heavy blow in 2012 when it was reported that the Harmoni out-of-hours service was ‘putting patients at risk’.
“Ensuring that local GPs are directly involved in providing out-of-hours care.”
Liberal Democrat Manifesto 2010
And in June 2013, it was described that ‘out of hours, out of GPs’ hands‘.
The “24/7 narrative” has nonetheless continued, and I have blogged on the feasibility of this here quite recently.
“People want an NHS that is easy to access at any time of day or night. We will commission a 24/7 urgent care service in every area of england, including GP out of hours services, and ensure that every patient can access a GP in their area between 8am and 8pm, seven days a week.”
Conservative Party Manifesto 2010
And, finally, it’s no particular surprise that the issue of GP records ending up in a national state information database, with flimsy valid consent if at all, did not appear in either manifesto.
Patient safety
It is impossible not to be affected by the sheer horror of Mid Staffs (I have previously blogged on toxic cultures), though it is important to acknowledge that staff in the Staffordshire area have been successful, it is argued, at turning this organisation around in recent times.
It is a significant tragedy of the Health and Social Care Act (2012) that there is not a single clause on patient safety, save for one clause on the abolition of the National Patient Safety Agency.
“We all need to be assured that, if we become unwell, the care we get will be of good quality. Most of all, we need to be confident that our safety comes first, and that the treatment we get doesn’t put us in more danger. We will introduce a series of reforms to improve patient safety.”
Liberal Democrat Manifesto 2010
The Government has been slow to legislate for a ‘duty of candour’, after the Francis reports, save for an amendment in the Care Bill (2013).
“We will require hospitals to be open about mistakes, and always tell patients if something has gone wrong.”
Liberal Democrat Manifesto 2010
Prof Sir Mike Richards has been appointed as a new Chief Inspector of Hospitals, Prof Steve Field has been appointed as Chief Inspector of General Practice, and Andrea Sutcliffe has been appointed as Chief Inspector of Social Care.
There is still a concern that the provision of social care will be through ultimately a mandatory insurance system. There is also a concern that this discussion will not be laid out openly by any political party ahead of the May 7th 2015 general election.
Conspiracy theorists have held that ultimately integration of healthcare and social care, if enabled through a competent national IT system, will ultimately lead to integration of personal healthcare and social budgets; and even possibly with the private insurance system.
The ‘data farms’, which Tim Kelsey speaks about, could also be a source of entities denying healthcare, social care or benefits from entities in the public or private sector, in future, if not adequately regulated.
“We reject Labour’s plans for a compulsory ‘death tax’ on everyone to pay for social care, regardless of their needs. We want to create a system which is based on choice and which rewards the hundreds of thousands of people who care for an elderly relative full-time. So we will allow anyone to protect their home from being sold to fund residential care costs by paying a one-off insurance premium that is entirely voluntary. Independent experts suggest this should cost around £8,000. We will support older people to live independently at home and have access to the personal care they need. We will work to design a system where people can top up their premium – also voluntarily – to cover the costs of receiving care in their own home.”
Conservative Party Manifesto 2010
Where now?
And so in the words of Shirley Bassey history is repeating itself…
The Conservative Party know that they will need a miracle to win the 2015 general election on May 7th 2015, with Nick Clegg having delivered a fatal blow through the lack of boundary changes, perhaps in retaliation for AV.
The 493 page Health and Social Care Act (2012) did not deliver a single clause on patient safety.
And yet there is unfinished business there, with a possible statutory duty of candour for organisations and individuals; and a strengthening of the law on wilful neglect building on the Mental Capacity Act.
Whistleblowing against unsafe cultures is also a fertile area for legislating anew. I have previously argued that the Public Interest Disclosure Act is not currently fit-for-purpose. I have also emphasised that it may not be possible to legislate on everything to do with culture, but we should try to advance a culture which promotes ‘speaking out safely‘. It may also be necessary to revisit the issue of ‘safe staffing‘ soon.
Burnham intends to introduce the ‘NHS preferred provider’ approach, but this still perpetuates the market. It could still run into trouble if the US-EU free trade agreement comes in on the sly (I mentioned it here previously). Now that this government has firmly nailed its colours to the EU competition law mast, some drastic action is going to have to be taken by Burnham and Labour in repealing the Health and Social Care Act (2012). It is also critical that Part 3 of the said Act is reversed, so that not all the ongoings of the NHS are seen in the prism of the EU ‘economic activity’ prism, or else mergers proposed on the basis of clinical decision-making but blocked on the basis of legal competition law considerations will continue to be blocked.
Finally, no party wishes to mention PFI in its manifestos at all, although the policy think-tank behind this can be traced very accurately to the Major government as I explained here. Labour’s relative silence on this is troubling, not least because it gives uncertainty about the future of the NHS and what to do about ‘failing hospitals’. Labour does need to clarify the law on this in some way, if it disagrees with extending the powers of the TSA.
Labour claims to aspire for a comprehensive, free-at-the-point-of-need service, and, if it wishes to do this, if it believes in billions of efficiency savings and if it believes in a need for reconfigurations, it may well need to go further than simply aspiring to repeal the Act.
The strange thing is that Andrew Adonis’ version, “Five days in May: the Coalition and beyond“, paints a rather different picture, which emphasises more the commonalities in policy between Labour and the Conservatives.
If the general election of May 2015 delivers a ‘hung parliament’ comprising Labour and the Liberal Democrats, the person the Liberal Democrats wish to work with Ed Miliband is going to be critical for determining the outcome of a second coalition, if Matthew d’Ancona’s observations are correct.
What Labour writes in its manifesto is therefore going to be analysed in great detail – especially the bits about the market, gaming the system, and patient safety I should imagine.
