Health Lexcomm: Finding The Right Remedy

20/07/2011

A continuous flurry of activity since the General Election in 2010 has made health one of the key bellwethers for the success or otherwise of the Coalition. The track record so far has been less than convincing. The publication of an ambitious reform programme by a new Government is not without precedent, but the energy with which the Coalition has gone about attempting to reform public services has been impressive, with difficulties in achieving the overall vision perhaps inevitable.

The health reforms initiated a concerted campaign of opposition by a diverse range of vested interests and others, resulting in public humiliation for the Health Secretary and concessions on key parts of the Health and Social Care Bill. The Liberal Democrat party faithful will undoubtedly look back on the debate over the legislation as a strategic victory; revenge for the painful concessions made to the Conservatives on tuition fees and the outright defeat faced in the AV referendum. For their part, Conservative backbenchers found an unlikely hero in the form of Andrew Lansley who held firm under a relentless barrage of criticism from the junior coalition partner. Health became a test of what the Tories were willing to concede in order to get their plans onto the statute book within the constraints of the Coalition.

Despite the political horseplay there are still doubts that the Bill has indeed changed substantially and if the NHS Future Forum report and subsequent modifications of the legislation were largely a change of rhetoric to help satisfy opposition. Political anger toward the reforms has dissipated but the major premise of the Bill has not. The concept of devolving purchasing power to the front line, of expanding choice of provider, of shifting more care into the community and of separating out the delivery of public health policy by local authorities and Public Health England all remain.

Concerns over the sweeping away of bureaucracy and the development of a knowledge gap have now been replaced by fears that the compromise will result in a confusing mishmash of responsibilities, increasing costs at exactly the time that the health service needs to produce unprecedented savings. A creeping timetable for implementation and the development of further ‘transitional’ arrangements give weight to the argument that reform will fail if costs begin to impact on service delivery.

When the Bill returns to Report Stage in the Commons in September and is then debated by the House of Lords in the autumn session, the Government can expect numerous grievances to be aired by Peers keen to influence the final measures. The vast majority of political opposition to the reforms has come from those most affected at an operational level – trade unions, NHS organisations, patient groups and to varying degrees from health policy think tanks. Patient groups in particular will be seeking more clarity on how the commissioning of services in their disease area will be managed under the new system.

Labour has not been at its most effective when dealing with the Government’s difficulties on health, but there are signs that this is changing. David Cameron has been forced onto the defensive over waiting times by Ed Miliband, a classic Labour tactic straight out of the healthdebates of the 1990s where waiting time soared due to a lack of investment from the then Conservative administration. The charge that the present Government was elected on a premise of ‘no top down reorganisations of the NHS’ has also frequently come back to haunt it.

Aside from the battles over the flagship piece of legislation that will continue until it eventually becomes law, expected in April 2012, the Coalition is continuing with its plans for the implementation of a Value Based Pricing regime for the pharmaceutical industry. This far reaching attempt at redefining the cost of medicines and their societal benefit has not yet hit the political headlines but tough negotiations lie ahead.

On social care, grand reforms of the existing political settlement are also in the offing following the conclusions of the Dilnot Review. Whilst a Bill has been promised for next spring, the Department of Health will have its work cut out in convincing the Treasury that such plans are affordable at a time of severe constraint and a lack of growth in the economy as a whole. Progress in this area of policy will depend on whether the promised all party talks turn out to be something more substantive than cover for acting on the Review’s findings further in the future.

The major political battles over the NHS appear to have subsided for now. The Government has settled on a compromise (some might say compromised) piece of legislation that has satisfied its junior partner and a proportion of the many groups that joined the bandwagon of opposition to the original proposals. The essence of much of what was contained in the original plans remains but there can be no doubt that health has acquired a degree of toxicity for the Conservatives and for Andrew Lansley in particular. He has, however, shown resilience and has proved those predicting his demise wrong, for now.

The House of Lords committee stage could be a lengthy drawn out process where interest groups spot a further opportunity to thwart the policy process. Front of mind for those at the top of Government will be the potential cut off of April 2012 when the Queen’s Speech will effectively guillotine all remaining outstanding measures. When the grandstanding, resignations and inquiries into events in Wapping fade from the headlines, we are likely to once again face the prospect of health policy having a major role in influencing the Coalition’s success or failure.


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