Andrew Lansley's woes are multiplying by the hour this week as efforts mount to block the Health and Social Care Bill.

Resistance might be expected from the British Medical Association (BMA) and the Royal College of Nursing (RCN) and other unions, but it is now more widespread and even reported from deep in his own party, among cabinet colleagues. The public are bewildered and staff in the service doing a difficult job while debate rages and the restructuring proposed by the Bill has already begun.

It's all a long way from the proud unveiling of the White Paper back in July 2010. Where did it all go wrong? As some now suggest, should the Bill be ditched?

It's a story in two parts. The first is the political process of reforming the NHS. The second is the substance of the Bill – despite everything, is it along the right lines?

The keen irony is the Secretary of State is highly knowledgeable about the NHS, appears to be well meaning, supportive of its ethos and wants to end political interference and micromanagement. And every minister naturally wants an administration-defining policy and to be first off the marks in implementing it. Thus incremental change is favoured less than bold visible, speedy and larger scale reform, with a White Paper and a Bill.

With public satisfaction levels at an all time high, creating a mandate for change on the huge scale envisaged by the White Paper was always going to be hard

But the NHS is large, operationally and technically complex, close to the public's heart and contains ranks of organised stakeholders with diverse views. With public satisfaction levels at an all time high, creating a mandate for change on the huge scale envisaged by the White Paper was always going to be hard.

Add in the bomb of explicitly promoting more competition and the backdrop of a very challenging budget settlement for the NHS, a coalition Government, and the difficulty multiplies. And the keener irony was the coalition agreement statement: 'there will be no major top down reorganisation'.

The result has been to an extent predictable. The case for change, particularly legislative change, has not convinced the public or key groups. The focus on structural change and promoting competition has divided rather than united opinion on the important question of how the NHS can develop in the face of budget squeezes and rising demand.

That stakeholders are in no mood to trust, is evidenced by the trouble there has been over the wording of the Secretary of State's precise duties towards the NHS, which must seem arcane to the public.

The Bill itself has been scrutinised for longer (40 sessions) than any other Public Bill in the whole period from 1997 to 2010. Nearly 2000 amendments have been moved by the Opposition in the Commons and the Lords, and 600 or so by the Government itself. The opportunity cost of this effort is worth sober reflection.

Politics aside, what of the Bill's substance? Should it now be scrapped? The three main elements are attempting to end political micromanagement, handing more budgetary responsibility to groups of GP practices to buy hospital care for their patients and encouraging competition between NHS facilities as a means to improve quality.

The first is laudable, but almost impossible while the NHS remains a tax-funded service. Witness the Prime Minister as late as 6 January this year telling an audience at Salford Hospital that nurses should make hourly ward rounds. The last two are in keeping with the longer run direction of health care policy not just in England under Labour, but also across Europe.

Competition has its place to improve performance, and it could be argued that the dose currently in the NHS in England is sub-therapeutic and should be upped. Is competition the main means of motivating professionals to do better? Probably not, but it is a means worth trying alongside others given the evidence of its impact.

As for giving budgets to groups of general practices, we've tried some of this before with some positive results. The rationale is that the trajectory of health care spending is mainly down to decisions by clinicians. This is behind attempts across countries within the Organisation for Economic Co-operation and Development (OECD) to align this power with the responsibility of holding a budget and other financial incentives.

So again the broad direction of the Bill is not wrong. Broad direction is one thing, but whether a policy is workable depends on detail especially with such sweeping and interconnected changes. And politicians, or officials for that matter, may not have time to work out enough detail with the current penchant for over-rapid policy-making.

The answer in future may be to load less into Bills, and move forward more steadily with changes to regulations. This might result in greater and more thoughtful progress, albeit perhaps less politically visible – therein lies the rub for governments.

The answer to whether this Bill should be dropped is more a political one, than a substantive one for the NHS, since regulations can achieve most of the changes without legislation.

Whether or not the Bill limps to the finish, it should be a text book case study for new ministers.

This blog is also available to read on the Huffington Post website. For a longer analysis of the NHS reforms, see Jennifer Dixon’s essay ‘Reform and the National Health Service’, published in the latest edition of Political Quarterly.

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Comments (4)

Ooooh, you lead me up the garden path with your excellent analysis - especially about trust. But, like borrowing a novel from a book rack on holiday- the last page was missing. Bill or no Bill? Yes it can all be done by regulations; so speak the words, whisper them. It's valentine's day; 'shhh; kill the bill'!

Roy Lilley
14 February 2012

Roy Lilley is right, Jennifer: the logic of your argument is unassailable, but you don't deliver the conclusion. You say, airily, legislation is excessive and unnecessary, but don't utter the words. Nuffield Trust trustees might not like it, but why not be wise before rather than after the event?

David Walker
17 February 2012

Thanks for an interesting piece Jennifer though I am with Roy and David as well. The answer is to drop the HSC Bill. Also you say that the extent of competition is sub therapeutic (nice term) but I would argue that other more effective interventions are also very much lacking such as; staff being given the time to do their job properly and valued for their work rather than treated as cyphers in the race for easily measurable 'performance indicators', staff being empowered to make decisions at the front line and given opportunities for learning and development. The NHS undervalues and under invests in its staff and I don't mean salary. These aspects are very boring to policy people (nothing personal) because getting human is to get complicated and diverse, but if we took the NHS workforce more seriously people would be even more productive and hard working than they are now.

Sarah Corlett
17 February 2012

Roy, David, and Sarah V sorry for the delay responding - half term. M

any thanks for yr comments.

I don't favour dropping the Bill, for three reasons.

The direction for the NHS set out in it is broadly right (operative word being broadly). Dropping the Bill now would give a signal that it is not.

Many changes are underway and the disruption of stopping (and trying again) would be worse than continuing. There are separate important questions as to why the changes started without the Bill being passed (and worth a formal review).

Most (not all) of the key changes can be made through regulations without the need for legislation. They will happen/are happening anyway. Calling for the Bill to be scrapped seems to me to be more a political decision based on yr trust in/view of the performance (or political stripe) of the Secretary of State and team.

Dr Jennifer Dixon
20 February 2012

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