This is the latest article I have sent for publication to Liberator magazine.
"John Bryant argues that while the campaign led by the Social Liberal Forum has secured some significant changes to the Health and Social Care Bill there remain some lingering doubts...
Since my last article on the fortunes of the Health and Social Care Bill after the Liberal Democrats Spring Conference in Sheffield, we have had an official pause in the Bill’s legislative journey, a listening exercise, a report from the Future Forum, and publication of amendments to the Bill.
Liberal activists have also attended the Social Liberal Forum’s first one-day conference on 18th June, which received feedback from Evan Harris, one of the key campaigners for change.
My own modest role in the campaign for change was to convince Camden’s Health Scrutiny Committee to make a submission to the listening exercise, setting out support for the 25 amendments that the Social Liberal Forum was promoting at the time. Since then there have been various claims that the vast majority of these suggested changes have emerged as formal amendments to the Bill.
So that’s all right then?
Well I think the gushing self-congratulations that have been published in recent weeks need to be tempered a little.
Not everyone in the NHS family of interests has declared its happiness with the result of the listening exercise. For the second time this year the BMA voted at its annual conference (following a critical emergency meeting in March) to support a motion calling for the Bill’s withdrawal, despite a call from its leadership not to be too critical now the Bill was to be amended.
At the SLF Conference Evan Harris was critical of the Future Forum’s report as it was littered with anecdotal references without a coherent analysis of the feedback it received from the many respondents to the listening exercise.
There was also an example of the classic bureaucrats’ answer to every problem by creating more committees. The Future Forum argues that, “there should be a strong role for clinical and professional networks in the new system and multi‐speciality clinical senates should be established to provide strategic advice to local commissioning consortia, health and wellbeing boards and the NHS Commissioning Board.”
A clinical senate may well be a useful adjunct to the more formal commissioning landscape, but something similar already exists outside of formal NHS structures. One example is “UCL Partners” which is a research body bringing together clinical leaders in Foundation Trusts in my part of North London to think through the best way of providing clinical pathways for specialist acute services. Its work in helping to shape the development of Hyper-Acute Stroke Units has led to the new “HASU” based at University College London Hospital. This is now reported to be the third best performing HASU in the UK with rapidly improving survival rates compared to the old regime.
So while such innovations as “clinical senates” may be useful I am not sure that giving them a statutory role will make their contribution even more valid than it is at present. The key to progress here is to ensure that clinical recommendations on patient pathways from such informal bodies are given effective scrutiny in public by scrutiny committees either at borough or regional level.
I am not entirely convinced by the Future Forum’s statement “We have heard many people saying that competition and integration are opposing forces. We believe this is a false dichotomy. Integrated care is vital, and competition can and should be used by commissioners as a powerful tool to drive this for patients.”
In developing an integrated care pathway for Stroke patients in North Central London the clinicians presented a case for UCLH to be the HASU, while other hospitals such the Royal Free in Hampstead would develop and expand their rehabilitation service for supporting patients in the period following the first three critical days after a stroke. Had a competitive approach been followed both UCLH and the Royal Free would have had good claims to be the HASU and a lot of time and money would have been wasted to judge between competing bids. So in my own local example working together to create a well-organised integrated care model produced the desired improving health outcomes, without competition being involved.
The Future Forum report later backtracks on the competition issue with this -
“Most importantly, the Bill should be changed to be very clear that Monitor’s primary duty is not to promote competition, but to ensure the best care for patients. As part of this, they must support the delivery of integrated care.”
Without specifying clearly how integrated care models are to be created by using competition, it begs the question that this report was surely designed to please both Conservative and Liberal Democrat members by providing a fudge between the different forces in favour of either competition or integration.
The more detailed report on Choice and Competition sets out some principles for a new Framework which are - Delivering choice; Encouraging collaboration and integration; Market making; Improving outcomes; Personalising care; Reducing health inequalities; Enabling informed citizens.
The most worrying of these for me is the principle of “Market Making”. The later section devoted to this talks about new entrants to the market, but concentrates on the creation of new social enterprises rather than admit the existence of the elephant in the room - the possibility of many more services being commissioned from the independent sector.
The Government’s formal response to the Future Forum appeared to take on board of many of the fears of Liberal Democrats, ruling out cherry-picking and competition on price. However it is noticeable that the summary on Choice and Competition also states “we will phase in the extension of Any Qualified Provider”. What the “extension” might entail could be anyone’s guess, but if you are naturally sceptical of anything the Tories put forward with regard to competition in health services I would remain alert to future interpretations of this throw away line.
One of the big worries regularly expressed by both providers and patients is that competitive tendering by clinical consortia (even on quality rather than cost grounds) could put some well-loved institutions such as Foundation Trust hospitals out of business, because without a certain level of core business they may become unviable.
So even assuming that most of the new amendments to the Bill are supported across the Coalition and are welcomed in the Lords, there is still more that Liberals should be doing.
As this Liberator was being prepared, Liberal Democrat conference representatives were being urged by SLF activists to put their names forward in support of a new motion for the Autumn conference. This was drafted by Charles West and calls for all the new NHS structures created by the Bill to have a common duty when commissioning services to “avoid the risk of a transfer of such income or case-load as to undermine the ability of existing providers to provide emergency, complex case and intensive care services, and to provide education, training and research.”
It also suggests that Monitor's duty to prevent anti-competitive behaviour, which is against the interests of patients, is matched by a duty to prevent anti-collaborative behaviour for the same purpose.
So what else should Liberals be doing? Besides supporting SLF motions at conferences Liberals can be doing some useful work at a local level too. Many principal local authorities have created shadow Health and Well-Being Boards and it is through these that Liberal Democrat councillors can argue for better integration of health and social care providers as they redefine patient pathways. They can also argue for much greater transparency of decision-making by all local providers, including Foundation Trust Boards.
Members of Scrutiny Committees could also challenge Board members of emerging clinical consortia to avoid engaging arms length organisations from the independent sector to carry out commissioning functions. PCTs were forced to shed around half their staff this year because of Andrew Lansley’s decisions to cut management costs, but the remaining postholders should be those with the expertise to understand the intricacies of health contracts. Retaining the transactional task of commissioning as an in-house function of consortia by them directly employing their own (hopefully ex-PCT) staff is something that Liberal Democrat councillors could and should be arguing for.
Liberal activists not serving on Councils should continue to make their voices heard through their local press, urging local editors to spend some time on investigating the various interests that are hovering in every community to get a slice of the NHS cake.
I ended my last article on these issues by alluding to a “reasonably managed muddle”. I am not yet convinced we will achieve anything better than this, despite the good work done by campaigners on improving the Bill. The Future Forum report attempts to look in two directions at the same time and while many of the amendments to the Bill are welcome, it is the behaviour and motivation of the key players in every locality which will need to be closely monitored over the coming months.
JOHN BRYANT
(John has been a member of the Liberator Collective as “William Tranby” for about 20 years. He is currently a Camden councillor and Chair of its Health Scrutiny Committee, and is also Vice Chair of the North Central London Joint Health Overview and Scrutiny Committee.)"
