In the current fraught political climate when policy is rarely making the headlines and when there is great uncertainty as to the future direction of public services, Andrew Lansley’s recent lecture to the Royal Society of Arts (RSA) gave some clear insight into the Conservative Party’s vision on health.
His key message, which reinforced their recent policy documents, was that under the Conservatives the pace of current reforms will be stepped up. His main political point here was that the reforms set out by Alan Milburn and Tony Blair have stalled, and he went on to highlight the key objectives Tony Blair set out in 2006, with four central elements:
- Patient Choice
- Independent Sector involvement
- Practice Based Commissioning
- Foundation Trusts
His key themes were innovation, competition, efficiency, excellence, devolution, choice, maximising information, and encouraging responsibility.
Andrew Lansley has a public service background, and his father worked for the London County Council and then transferred to the NHS in 1948. He has been Shadow Secretary of State for six and a half years, quite a good run for a senior politician these days. If the Conservatives win the next election as seems increasingly likely, he will be made Secretary of State for Health, and in a much tougher financial environment.
He argued that the NHS provides social solidarity and is a source of cohesion. It belongs to us all and we are all stakeholders through the taxes we pay. He pointed out that Conservatives recently supported the incorporation of NHS core values into statute.
The Conservative responsibility agenda includes:
- Parents taking responsibility for their children
- Teenagers needing to recognise the rights of others
- Bankers managing our money properly
- MP’s acting properly over their expenses – they should behave properly and have high standards
Nothing too controversial there, I suspect!
His next key theme was a radical redistribution of power, and decentralisation. In the public services this would mean empowering Doctors, Nurses and teachers, and the scrapping of many targets. The focus should be on outcomes rather than making staff jump through hoops. In practice, their policy does not mean the ending of all targets but certainly the emphasis will be different.
Public health and inequality was covered quite a lot.
He highlighted again the need for efficiency and the role social marketing can play to improve diet, tackle heavy use of alcohol and encourage more exercise. However, he ducked the nanny state arguments. From previous Conservative positions we can assume that top down legislation is less likely and therefore persuasion will be the order of the day.
He suggested that public health needs to be ring fenced with separate funding, so that the money is not raided by other parts of the NHS. Moreover, he underlined increases in health inequalities in areas such as infant mortality, longevity and obesity.
He also made some criticisms on the lack of coverage on dentistry and suggested there was no adequate dementia strategy, or one for NHS research and development.
He then went in to more detail on his central themes, echoing Tony Blair’s and here are a few points worth noting.
GP’s still have fixed practice boundaries. This needs to change. The number of patients who said they had a choice of hospital was 46% in April 2008 and this only rose by 2% in the last year.
Treatment Centres were seen by the Government as an add-on, not on an integral part of the process. He felt that opening up the Health Service to the independent sector was about spurring competition and innovation, not about capacity, and this is expanded on in Conservative policy documents. The provider arms of PCTs will be competing against others from the private and voluntary sector, and increasingly providers from outside their geographic patch, as well as inside. Of course, much of this is in the Darzi reforms.
Practice Based Commissioning
He argued this has also stalled and that the GP is best placed and has the local clinical knowledge to commission. The number of GP practices holding notional budgets has dropped by 5% in the last couple of years.
These were supposed to be completed by December 2008, but again this has stalled. For 20 years the aim has been to move to a purchase and provider split, but we are still not there yet.
The Shadow Secretary of State then went back to his attack on targets, arguing they have created perverse outcomes, led to some cheating, and denied authority to front-line managers. As he put it “the process has become the target rather than the outcomes being the target”
As a result a Healthcare Commission report on staff opinion showed they thought caring for patients came second to target completion.
In summing up he emphasised that the NHS needs reform, not reorganisation, so thankfully he is not talking about structural changes. A focus on outcomes rather than targets would, he believes, lead to innovation.
In driving reform the Conservatives would keep what works and use choice, competition, devolution and professional responsibility to achieve accountability, equity and efficiency. People he said should be accountable for outcomes
Finally, he went back to his theme that it was time to accelerate Blairite reforms but in the context of a much tougher financial environment. Chief Executive of the NHS, David Nicholson has said it needs to make 15-20 billion worth of efficiency savings over the coming years, and the NHS Confederation has echoed this. The NHS will have to do more with less.
In questions he was asked about the competition agenda what happens to patients who are seldom heard and not able to articulate their case well, and he talked a bit about the need for patient advocates.
Of course, when you reflect on a speech by an opposition politician what is more interesting is what is not said.
Their job is to not get skewered on the details, and keep their options open a little. Ours is to understand what the detail will really be, and what the implications are.
He did not cover personal budgets and that is certainly a major area that the government is already piloting, and he did not spell out just how tough the innovation and competition agenda could be, particularly given the financial backdrop.
What happens if a provider PCT just does not win any contracts? Implicitly there is no reason why a particular PCT should survive in the long run, and mergers across boundaries and disciplines (with social services) are clearly on the cards.
There is also a debate to be had about the different models of purchaser provider split, with social enterprises popping up, as in Surrey.
To understand how radical change could be across the public services look no further than Essex County Council. In October 2008, the council placed a notice on the Official Journal of the European Union website asking for bids to run ‘any or all’ of its services for a period of 8 to 12 years, at a total cost of £5.4billion.
I think there is plenty of food for thought, and given the political environment at the moment there may not be much time to digest.
Published by Peter Watt, Chief Executive of The Campaign Company