Analysis: Health white paper struggles to square the circles

NHS set for major restructure
NHS set for major restructure

In a time of cuts and "unprecedented" efficiency savings, questions about money are never far away for Andrew Lansley's groundbreaking reforms of the NHS.

By Alex Stevenson

Today marks the culmination of six years' work as shadow health secretary for Lansley. He is finally implementing many of the ideas which have underpinned much of his rhetoric during that time - scrapping targets, increasing choice, "liberating the NHS from the old command-and-control regime".

Lansley could never have anticipated the wider environment within which those reforms would take place. Yes, the Department of Health is spared the budget cuts of other departments. But there are still up to £20 billion of cuts scheduled for the next four years. There is much pain to come.

"The reality is there is no more money," the white paper says. "Difficult local decisions" will be required. Net cuts in terms of total staff are "inevitable" in the next five years. There will be "significant disruption".

At the same time, the NHS faces many challenges as it confronts its weak spots. It scores "relatively poorly" on customer service and has poor mortality rates when it comes to respiratory diseases, some cancers and some measures of stroke. MRSA infections, together with diabetes and asthma admissions, are disappointing.

How are these problems to be solved with less money? The health secretary thinks he knows how.

At the centre of this white paper are proposals to sweep away the "top-down" superstructures currently controlling the NHS. Both strategic health authorities and primary care trusts will be phased out in the coming years. In their place is a market-driven world where GPs are king; or, more accurately, consortia of GPs which "have sufficient freedoms to use resources in ways that achieve the best and most cost-efficient outcomes for patients".

Making the GPs get on with their own management is a bold, simple stroke. Under Lansley's plans management costs will be culled by an enormous 45% in the next four years. "The NHS simply cannot continue to afford the costs of the existing bureaucracy," the white paper says simply. "The government has a moral obligation to release as much money as possible into supporting frontline care."

Lansley's predecessor in the Department of Health, Labour leadership contender Andy Burnham, is unsurprisingly incensed. "What he calls pointless bureaucracy we call essential regulation," he hissed in the Commons.

That is not how the coalition government sees it. The white paper presents this set of proposals as being so efficient an improvement they will save money by themselves. Patients, more involved in making decisions about their own health and care, will cut costs by doing so. There will be no more "inefficient micromanagement" when it comes to meeting targets. And local authorities, filling in the blanks which GPs cannot help with, are expected to "help unlock efficiencies" through "stronger joint working".

Lansley's agenda slots perfectly into the need to make savings; if anything it encourages the trend. The same measures which, it is hoped, will win over those working in the NHS will help save costs and improve the nation's health.

Patients aren't left out either. A raft of changes giving them better choice - including the ability to register with whichever GP they like and choose where they receive treatment - are designed to improve wider efficiency, too.

Will it work? As always, the devil is in the detail. In markets there are always winners as well as losers. After the teething problems will come the rise of postcode lotteries as the new hands-off approach becomes entrenched.

"Our goal is an NHS which achieves results that are amongst the best in the world," the white paper states. Lansley's reforms must be judged by this standard in the years to come.


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