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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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The White Paper – Some issues (Introduction)

Filed Under (GP Commissioning, Health Policy, Reform of the NHS, Secretary of State, White Paper) by Paul on 13-07-2010

How does the political philosophy of “Liberating the NHS” work and where are the limits of this new liberation theology?

Over the next few days I will outline some of the problems that come from each of the main architectural themes of the White Paper reforms and hopefully some possible solutions.

  1. What is the responsibility of the National in the English NHS?
  2. Who is commissioning health care and how are they doing it?
  3. Who is providing health care and how are they organised?
  4. What are the transactional relationships between commissioners and suppliers and how are they organised?

But first in today’s post I want to outline what the basic political philosophy of the White paper is, and then to show where the failure of nerve of the Government in carrying out that philosophy will undermine the whole reform.

The straightforward clue to this philosophy is in the title ‘Liberating the NHS’. This Government believes that the state in general, and ‘NHS bosses’ in particular, are stifling people and stopping a considerable upsurge in clinical led activity and entrepreneurialism. Therefore, it reasons, in order to unlock all this activity the main action a Government needs to take is to withdraw the state from as many places as possible.

The Government believes that this is the case in a wide range of areas of our society. Remove the state from the situation and civil society will do what the state has been doing, and more. So the NHS White Paper needs to be read as a set of activities from which Government removes itself and its organisations. By removing itself from as many areas as possible it “liberates” actions previously prevented. As the state removes itself from on top of us, lots and lots will happen.

This is a coherent political philosophy and has a long track record in both the Conservative Party and the old Liberal Party (the Manchester Liberals believed strongly in this). The philosophy has its greatest weight and power in the relationship between the economy and the economic market. The phrase ‘laissez-faire’ was used in the 19th century by people who wanted the state to leave us alone so that we can get on with creating wealth.

The philosophy has a strong history and is, in its own terms, coherent. Applying it to public services as this Government intends to do will be a different matter. In many economic areas history shows that over time economic markets do emerge as the state steps back. But in others the state has to intervene to help to make a market – as many independent sector providers to NHS services look to the state to help make that market.

But in civil society the answer to the question of whether the public will step into the void left as the state withdraws is less certain than in some aspects of the economy. This real political problem for the Government will run through my thoughts in the next few posts.

For those that work for and in the “NHS state” this new philosophy will be puzzling. Those of us that worked as ‘NHS bosses’ have worked in an organisation that believes that its interventions are in some way stopping chaos from being unleashed upon the world. Without the steadying influence of NHS bosses it’s not that good activity will be unleashed upon the world but financial chaos will be. If the holy line of the Treasury, the Chief Exec of the NHS the SHA and the PCT accountable officer do not keep a tight control anarchy is unleashed upon the world.

I don’t write this post with any sympathy for the old world of NHS bosses. But I do think the new liberation theology when applied to the NHS runs into some important contradictions.

The reality of the NHS is that it only exists because the state takes money from all of our wallets. It does this through the crudest of and most interventionist of all state activity – taxation. So the principle of the NHS that this Government agrees with is based upon national taxation and there are real problems about liberating state funding from the state.

Unless the Government gets on top of this, these contradictions will destroy their reforms. I just want to take a few examples from the White Paper which betray the contradictions of the fudge that has failed to really stand up for this liberation philosophy.

  • Withdrawing the SoS from day to day responsibility for the spending of £110 billion is a part of the overall laissez-faire philosophy. But this £110 billion is taken every day from every tax payer and they, as tax payers, will demand some accountability for that money and how it is spent. At the moment every Friday and Saturday people go to see their MPs about the NHS and expect their MPs to intervene. The public do so because they are paying for their NHS with their taxes. This accountability means that MPs ask more written questions of the Secretary of State than on any other issue. If the Secretary of State believes that from the 1st April 2012  this will have nothing to do with him – as the State – I think English MPs and their constituents will disagree with him. They expect the state to be accountable for the money that it takes from people.
  • The creation of GP commissioners and the abolition of PCTs is a powerful example of removing the state and NHS bosses from the work of commissioning. One of the reasons why it is thought that GPs may be good at commissioning is that they have developed their work within a small business framework. They know about business economics. But the White paper will force GPs who want to lead commissioning to become members of a statutory organisation. Making small business people become part of a state organisation is a very strange way of limiting the power of the state. How does this liberate GPs? It comes about because the Treasury will not allow the SoS for Health to give state money to small businesses. Whether they are right or wrong about this, the Treasury intervention is a blow against liberation theology.  You cant liberate GPs from the oppression of the state by nationalising them. You really can’t.
  • Again the political philosophy of liberating the NHS from the state is to unleash the enthusiasm and energy that they have to commission care. The Government has obviously heard GPs arguing that they are being held back by State commissioners. They have been told that getting rid of PCTs and SHAs will be the liberation that GPs need to make them successful commissioners. But if that is really the case why then does the State have to force every GP to become a commissioner? There is something very weird about the state making people do something that apparently they want to do. Conscription is hardly a voluntary civil society sort of intervention. It’s the raw power of the state intervening with GPs much more strongly than PCTs ever did.
  • Given the political thrust of liberating the NHS from the interference of the Secretary of the State, one of the limitations to the liberation has been in the interference that the Secretary of State feels free to make in the clinically agreed processes of hospital reconfiguration. Before the General Election he told the people of Bury that he would have the power to reopen a part of their hospital. Since the election rather than saying ‘this is political interference’ he has been opening parts of hospitals that clinicians felt should be closed. The White Paper secures this role for him into the future.
  • There is an interesting ambivalence about how the state and NHS bosses are going to ensure that there is value for money over the next few years. The White Paper is clear that it looks to this central control in order to make sure that money is not wasted. In fact it wants to go further  – “The Department will not hesitate to increase financial control arrangements during the transition, wherever that is necessary to maintain financial balance; in such instances, central control will be a necessary precursor to subsequent devolution to GP consortia”. So we want to liberate people so much that we are going to increase financial control over them and then when we have done that we are going to release them from control more than ever before. This is the only bit of the White Paper that verges on the dishonest. The Treasury will not allow statutory organisations of GPs not to be under central control – that is why they are statutory organisations.

This post does not argue that liberation theology is wrong. Democracy means that the politics that wins a general election has the right to implement its philosophy. But the Secretary of State is just that – the secretary of STATE. What he does is the state. He appears to be wishing himself away from the job he has been trying to get to for the last 6 years. He has been left with problems that will undermine his White Paper.

These contradictions show that it’s just not possible to liberate a state-funded service from the state without a lot more courage and determination.

Comments:

3 Responses to “The White Paper – Some issues (Introduction)”


  1. GP commissioning bodies as statutory organisations begins to sound like the old PCGs. I wonder if GPs, having been told they are the bosses of the new system, will begin to get frustrated at the checks and balances, and partnership obligations placed upon them. The NHS moves in cycles. One cycle is that of freeing the market and letting the patient choose. This then runs up against some painful consequences for hospitals, and the NHS reverts back to “managing” markets.

    What doesn’t seem to have got much attention is the NHS Commissioning Board- wasn’t it originally called the NHS Management Board? The White Paper makes clear it is not to be the headquarters of the NHS, and its role is an unusual combination of system management (holding the GP consortia to account) and commissioning a mix of services, most importantly primary care. One wonders if this is going to be active commissioning, like the better PCTs do, or passive commissioning, like the old FHSAs. If the former how many staff and offices is it going to have? The White Paper is silent on the number of regional offices. If it is as few as four (as Polly Toynbee seems to think) one wonders at its ability to actively manage very localised services.


  2. The issues that I see arising…

    1. Duplication, the splitting of PCT’s into 2 or more Consortia will increase the number of professional skills being employed by the Consortia exercising its function as there are less economies of scale. GP’s will need this support as in their spare time they will still need to see patients (sarcasm intended)

    2. Who will commission Specialist Services (Med-High Sec MH)? GP’s aren’t MH clinicians, if they were they would be Psychiatrists. How will commissioning decisions be made? Spot contracts = Bad Value.

    3. We will go through a pointless cycle of diluting decision making so that the free market can end up eventually for sound business decisions merge organisations into a similar structure that we see at present.

    It seems to me that this “Shoestring Govt” is undertaking the biggest exercise in public spending we will see in a long time, at a time when we cannot afford it.


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