My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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…Coming home to roost

Filed Under (Conservative party, Health Policy, Secretary of State, White Paper) by Paul on 22-11-2010

I may be wrong but I am pretty sure that Jim Callaghan, when he was in opposition to the Conservative Government from 1979, was one of the first to use the phrase that “the sky was dark with the wings of chickens coming home to roost.”

But that is now what’s happening in regard to Government policy of keeping parts of hospitals open against the previous advice of clinicians. As I posted at the time of the election, Andrew Lansley, after he became Secretary of State for Health, made an immediate tour around hospitals where significant services were being closed. During the election campaign he had said he would reopen these and would ask clinicians to look again at their plans for closure. His tour provided photo opportunities to stand in front of these hospitals and say that he was keeping his and the new local MPs promise to reopen the ward/A&E/maternity unit.

Given everyone’s cynicism about politicians this was hardly seen as news by most in the NHS. Of course that’s what politicians do. During election campaigns they join local populist fights to keep hospitals open in order to win marginal seats.

But, as I said in May, I think this goes beyond an electoral tussle with Conservative politicians being populist in wanting to be part of “save our hospitals” campaigns. In fact what I think this exemplifies is the dilemma of policy and practice of Conservatives in Government since 1979.

From 1979 the Conservatives rediscovered with a passion the power of introducing markets as a method of rapid change and have believed in creating a set of economic conditions where markets are used to force change through our society. Margaret Thatcher was very successful with this policy and her Government changed our society not at the point of a sword but at the point of a market. Her governments were successful in using markets to force social and economic change.

But then, since they are after all called Conservatives, the impact of these markets was worrying since it was full of change. Where these changes interfered with the community that conservatives wanted to conserve, they were to be resisted. As the corner shops closed in the market town centre because of the hypermarkets that were opened at the edge of the town, it was often the Conservatives who helped lead the campaign against the impact of their own market forces. When the bank closed its branch in the village there was the local Conservative Party trying to conserve the nature of the local community by trying to keep it open.

It was unfortunate for local communities that the markets that the Conservative Government had unleashed were the cause of these closures. On the ground the policy never really felt very successful as the pillars of local communities were closed. Many people who were passionately in favour of the cause of markets were very unhappy about the outcome when those causes ripped through their town.

No one told them that the deregulation of the banking and retail market would lead to this happening. From 1990 onwards this has puzzled the political party whose name tells us it wants to keep things as they are.

We are now starting down that path with the nation’s NHS hospitals. The White Paper and a number of national Conservatives talk about the necessity of much greater market forces driving through the NHS. And indeed GP commissioning consortia look like the organisations to make that happen. As business people they will construct patient pathways, the argument goes, and that will be much better value for the patient. These will put patient choice in charge in the same way as they are in the grocery and retail banking trade.

But then, as with those other markets, the inefficient local hospital will be driven out of business by markets and we will all have to join a campaign to keep it open. The local Conservatives will have to face down those very market forces that other Conservatives have unleashed.

If the White Paper is enacted in some form similar to its intentions, this will be the main politics of health for the two years running up to the election. Local Conservatives will be running campaigns against the market forces that national Conservatives have unleashed in the health service. In suburb after suburb, market town after market town those conservatives that want to conserve will find themselves trying not to understand that those Conservatives that believe in the market have unleashed forces that have made their local hospital unviable.

I am a bit surprised that in the suburbs of London we have got there so quickly. The Tories entered the election with a view that those nasty NHS bosses had been trying to close their local hospitals and a new Conservative Government would stop them

As Nigel Edwards said in last Thursday HSJ, “It is regrettable that in the general criticism of management an assumption seemed to develop that there was somewhere a secret bunker with a Stalinist plot to close hospitals”

In fact of course it wasn’t Stalinism that was closing hospitals but the economics of a not very powerful market place that was leaving some parts of some hospitals with insufficient business to remain financially or clinically viable.

So the first few weeks after the election saw Andrew Lansley reopening bits of hospitals that previously clinicians had wanted to close.

The wings of the chickens coming home to roost that are darkening the sky are the outcomes of the reworking of the case for closure in the suburbs of London.

During the election when David Cameron said “We will immediately stop the proposed closure of vital local services” local campaigners did not read the small print which said “Unless local GPs think they should close”.  What local campaigners saw in opposition as a cast iron guarantee to keep open a part of their hospital has become, just 7 months later, a much less certain process. Apparently in the new way of doing things the SoS cannot keep to the promises that were made in April.

There is one significant problem with that. The Secretary of State has made it clear, far from not interfering in any hospital reconfigurations; he will take personal responsibility for arbitrating between different opinions about what should happen to the local hospital

“Arbitration: The SoS will have a statutory role as arbiter of last resort in disputes that arise between NHS Commissioners and local authorities for example in relation to major service changes” – Liberating the NHS, page 33

So if and when the Secretary of State listens to local GPs in Enfield and in Bexley that parts of the hospital that he reopened 6 months ago should now be closed, if he were to say to the people of those two boroughs “I am afraid this is nothing to do with me, it is down to your local GPs”, he will have made sure that this is not the case.

If the White Paper is implemented it means that over the next 4 years we will see a lot more of this.


One Response to “…Coming home to roost”

  1. When it comes to unleashing market forces on the NHS, New Labour and your good self were key players. In fact, New Labour took the market forward much further than Thatcher with the key policy levers of payment by results, patient choice, competition between a plurality of providers, Foundation Trusts and the P-P split. The Tories are simply accelerating and building on these market based policies.

    This is Schumpeter’s “creative destruction” in action, described by Simon Stevens (former advisor to Blair) as “constructive discomfort”. However, the costs of entering and exiting the healthcare market are substantial and not economically sustainable in a single payer system. For example there are the high costs of building new provider organisations kitted out with the latest technology. Mergers also have associated costs and also result in closures of many services for local people. In addition, “Exit” is particularly costly in terms of loss of services for local communities and loss of votes for politicians! (as you described very well above).
    Now add to the mix the concept of FTs becoming Social Enterprises. In effect, this will result in the Government selling off £16 billion of assets to the City of London. SEs will need to pay this back to the City investors with interest. This means taking advantage of the abolition of private practice income caps (aided by the abolition of waiting list targets and financial constraints on GP consortia, which will increase the number of people taking out additional healthcare insurance). Famous teaching hospitals in wealthier parts of the UK will have a competitive advantage for attracting private patients and corner the market, leaving smaller local hospitals in poorer regions at a distinct disadvantage and at high risk of being unable to pay off their debts. In fact, some will not even be able to attract investment at all. This will result in mergers and closures.

    The idea of a NHS as a single payer system that provides a universal service is finished. We are heading for a mixed funding system with massive private sector involvement. It is no coincidence that the WP used the term “comprehensive” when describing what the new health service will cover.

    If the public get wind of this, Cameron will have great difficulty securing a second term.

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