Analysis: Where will the NHS reform concessions come from?

Partial retreats on NHS reform may not be a viable option
Partial retreats on NHS reform may not be a viable option

The ideology of competition pervades the government's NHS reforms. So where can concessions come from?

By Alex Stevenson

One thing is certain - something has got to give. Health professional groups, thinktanks and a large chunk of Liberal Democrat backbenchers are deeply concerned about the health and social care bill's unremitting backing of competition. The King's Fund, one of the most respected health thinktanks, argues that people with long-term conditions are the biggest challenge to the health service. These require a health service based on cooperation and collaboration between different services - what the jargon calls 'integrated care'. What happens when the different parts of the health service start vying against each other?

All agree that competition in some areas can be useful. But this bill places too much emphasis on it, opponents say. The sheer weight of their opposition means concessions are going to have to be made - from somewhere. But as the government's 'pause' of its divisive health and social care bill continues, it's still not clear how far the government will retreat.

Policy experts following the legislation confess themselves baffled as to what will happen next. They're left trying to work out whether there's a difference between David Cameron promising "substantial" changes and Andrew Lansley only going as far as "substantive". As much as anything else, this is about the dynamics of power within the coalition as it is about the ins and outs of health policy.

One of the handy side-effects of the sheer unwieldy bulk of this bill is there are real areas where climbdowns are possible without ministers losing too much face. Among them are concerns about accountability. More could be done, for example, to ensure the autonomy of the proposed national NHS Commissioning Board from interference by the secretary of state. Health groups want a guarantee that national oversight of medical education and training will be maintained. Even the independence of directors of public health is viewed as so important it deserves to be protected by legislation. Making these concessions could help weaken resistance without watering down the basic ideological thrust of the bill.

Another option is to make undertakings to slow down the pace of implementation. The headache of where to find £20 billion in efficiency savings means most NHS managers feel they've got enough on their plate. So it could help to abandon some of the arbitrary deadlines contained in the bill - by which GP consortia have to be set up, or primary care trusts and strategic health authorities have to be wound down. Staff want the opportunity to "learn from mistakes" and the chance to do some diluting of their own, too.

Even if ministers do cave in on the less divisive bones of contention, and agree to pilot schemes here and there, it probably still won't be enough to placate the concerns of most critics.

The biggest single issue, after ministers abandoned price competition during the bill's committee stage, is the role of the healthcare regulator Monitor. Under coalition plans this would have a statutory obligation to encourage competition, and not much else. It's a "counterweight" which nurses are looking for, according to Howard Catton of the Royal College of Nursing. Would it also block the sharing of good practice, or research and development?

"They're very concerned that the bill completely takes the brakes off and lets the market rip." The fear is this could fundamentally threaten the NHS.

It's up to ministers to add in enough safeguards to allay these fears - without completely destroying the competition element of the bill.


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