vallierojas: Forget the debate about the health bill ? we must focus on how to implement it

Tuesday, September 6, 2011

Forget the debate about the health bill ? we must focus on how to implement it | Sarah Wollaston

The health bill will not privatise the NHS ? but it is flawed. MPs must focus on its real problems

Does Hamish Meldrum, chair of the BMA, really believe that NHS hospitals will be treating "wealthy Arabs" rather than their NHS patients? To claim that private income generation will be prioritised disregards one of the key protections in the revised health bill; their decision-making will be far more open to public scrutiny.

To those who want to see the bill scrapped, the problem is that the structural changes to the NHS have passed the point of no return. Many of the reforms that were needed, such as clinical leadership, greater transparency and choice, not to mention a focus on outcomes, could have been achieved without massive structural upheaval. But now that the changes are so advanced, even before the passing of the bill, the NHS will need a new legal framework and that needs proper scrutiny. Consequently, it is better to focus on where we go from here rather than how we could have arrived by a less contentious route.

There are those who believe that the secretary of state seeks to wash his hands of the NHS. The reality is that he cannot and nor does he wish to do so; over �100bn of public money and an area as important as healthcare will always beat a path to his door. We could have an argument about the difference between his duty to "secure that services are provided" in the current bill as opposed to a duty to "provide or secure the provision of services" in the 2006 act. Either way, he still carries responsibility and the public will hold this coalition to account for his actions. The key difference is who, for practical purposes, will be planning and commissioning those services and what powers the secretary of state will retain to intervene.

For years the NHS has complained of undue interference. This bill hands the reins to the NHS Commissioning Board, (NHSCB), and the secretary of state will have a duty to promote their autonomy. Little of the debate has focused on this board, yet it is one of the most significant of all the changes. Accountable to the secretary of state via an annual mandate, the NHSCB will be an independent, statutory body, free to determine its own structure. Even before it has statutory status, it has an interim chief executive, Sir David Nicholson. We need far more clarity about the people who will be taking on the major roles at this vast organisation and how they will be appointed.

The debate has, unfortunately, fallen victim to hyperbole and some of the real issues have become clouded by political opportunism. This is not the "privatisation of the NHS" and it is inappropriate to use the issue of abortion counselling to distract from the bill. Nonetheless, we may find the two days of Commons debate hijacked by the usual point-scoring or single-issue lobbyists.

We should instead be focusing on areas like the NHSCB and the complexity that we are imposing on those "buying" care on behalf of patients, the Clinical Commissioning Groups. How are we to establish the right balance between local accountability and freedom for CCGs? At what stage will the NHSCB be able to step in to overrule decisions if local flexibility results in too much deviation from national standards? One person's local decision-making is, after all, another's post-code lottery.

Will these reforms open the NHS to the full blast of European competition law, as critics have suggested? The reality is that the NHS would be prone to legal challenge whatever the changes contained within the bill. The problem is with the competition law itself. Monitor's wings have already been clipped, but this health sector regulator can at least provide some guidance for commissioners to help protect them from legal challenges. Private companies will, however, find it hugely expensive to mount legal challenges ? and why would they do so if commissioners were complying with expert guidance?

The role of Monitor has been amended following the listening exercise and anyone who reads part 3 of the bill will find little to support the claim that it will promote privatisation. The real debate is around how it will achieve the efficiencies of �20bn that were set out before the general election.

The secretary of state should follow the BMA's advice in at least one respect by putting in place additional safeguards to limit private income generation by foundation trusts. This would reassure those genuinely concerned and silence those using it as a political football. I also hope that we will retain a nationally consistent system for medical training.

It remains an issue that for this most complex of bills, so little time has been allowed for Commons debate and that most of the serious discussion will take place in an unelected House of Lords.

Sarah Wollaston

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