As the dust settles following the passage of the Health and Social Care Act, one of the most absorbing questions for health policy watchers (apart from the process of implementation) will be how Labour responds, having fought so hard and long against the Bill. 

Should their policy be to repudiate the entire Act, or are there in fact elements which are sound and should be kept? This and other questions are now absorbing Labour’s Health Policy Commission, which is aspiring to build policy by consulting a broad base of Labour supporters. 

A few hints about how things might develop were dropped by Ed Miliband in his speech to the annual congress of the Royal College of Nurses last week. Miliband unequivocally embraced one new element of the Act’s architecture – Health and Wellbeing Boards – which he suggested could be used as a tool to counter Government policy on competition. 

This reflects an enthusiastic response by local government to the new structures created by the Health and Social Care Bill and the move of public health into local authorities.

For those in local government with a desire to tackle the upstream determinants of ill health – poor quality housing, domestic abuse etcetera – this is an element of the coalition’s reform that makes absolute sense. 

Miliband unequivocally embraced one new element of the Act’s architecture – Health and Wellbeing Boards – which he suggested could be used as a tool to counter Government policy on competition 

There are plenty of enthusiasts – including Labour-led councils – for the potential for Health and Wellbeing boards to create a powerful vehicle for mobilising local government, local GPs and hospital trusts to work towards a shared set of objectives.

It is not clear how powerful Health and Wellbeing Boards will become – real power lies with the NHS Commissioning Board (now NHS England). As local government budgets tighten, successful local partnerships will also encounter some underlying snags in the system. 

First, an enlightened and engaged local government can potentially save the NHS a considerable amount of money with upstream investment in preventative work.  But these savings will not accrue to local government, which is faced with ever higher bills for adult social care amongst other pressures, but will return (generally speaking) to the NHS.  

In addition, in the public’s mind, an engaged local government will be seen as increasingly responsible for local health services. But the largest savings for the NHS are likely to come from shifting care from acute hospitals and closing all or part of a hospital down – also known as political suicide for locally-elected officials.  

Labour politicians, both national and local, will be very tempted to cash in on the anti-closure sentiment that builds up whenever hospitals are threatened. But Labour must not fall into the easy trap of opposing all NHS reconfigurations as a vehicle for local support, however powerful the views expressed to campaigners on the doorstep.   

Miliband was – unsurprisingly – coy on this point. He recognised that longer lives and more chronic conditions will bring ‘service change’ in the NHS, but at no point spelled out what that might mean.

Labour’s position on the increased use of competition and market forces in the NHS appears to be more clear cut. Miliband promised he would repeal the ‘free market free for all’ contained in the Act.

But, even if Labour were to find a (legal) way of neutralising the threat from new, for-profit entrants wanting to get access to the NHS, it would be interesting to see if they develop an approach to public sector improvement that is not dominated by ideas from markets and the private sector.

Labour’s previous term in office was notable for its reliance on two contradictory approaches to change: top down, ‘command and control’ techniques using targets (effective but often unpopular with clinicians) and quasi markets, using financial incentives to motivate individual clinicians (particularly GPs)and the promotion of competition between NHS trusts. 

These were set up and subsequently incentivised to behave like income-maximising businesses, based on contractual relationships with primary care trusts (PCTs).

In the language of economics, Labour’s policies appealed increasingly to the extrinsic rather than intrinsic motivations of public sector workers, as the motor for change in the NHS. 

Is this still at the heart of Labour policies or will Labour try to develop an alternative, non-target driven, vision of what will persuade or enable NHS professionals to improve the quality of care in the midst of financial constraints?  

This is not a doorstep campaigning issue. But any discussion about the ends of new policies will be incomplete without a debate about the means.    

This blog was also published on Progress online.     

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