Sound out

One bright Tuesday morning back in April, Health Secretary Andrew Lansley did something unexpected. At a point in a Bill’s passage through parliament when it’s normally ‘full-speed ahead’, he announced that he would take advantage of a “natural break” in the legislative process and press the pause button on his NHS-shaking Health and Social Care Bill. The government, he said, wanted to “listen, reflect and improve”.

That listening exercise turned out to be in the form of the NHS Future Forum, a panel of 45 doctors, nurses and other experts in the smooth workings of a modern health service. Over the course of two months, and under the leadership of Professor Steve Field, a former Chair of the Royal College of GPs (RCGP), the panel were to hold public meetings, hear the evidence, examine the Bill and generally come up with ways to make things work better.

The exercise prompted a certain degree of cynicism: for all the talk of a natural pause, after all, it is very unusual to radically alter a Bill after its second reading. In the normal course of things, the Bill should have gone to committee, where individual clauses would be scrutinised but the broad sweep of the new laws left unchallenged. Stopping a Bill dead, and gathering a committee of experts to look at it again, was almost unprecedented.

More cynical observers noted that the decision to pause the legislation coincided neatly with threats of rebellion from the Liberal Democrat half of the coalition. The pause, many assumed, was a way of backing away from unpopular and coalition-splitting reforms: the real decisions would be thrashed out behind closed doors between the Tories and the Lib Dems. Others suspected it was a PR exercise, allowing the government to look like it was listening, before it ploughed ahead anyway. Either way, the whole exercise was political.

Considering all that, though, the listening exercise may have actually succeeded in turning an embarrassing legislative hold-up into something positive. Talk to those involved in the process and they’re brimming with praise for the experience.

“It’s frankly been a rough and ready exercise,” says  Sir Stephen Bubb, Chief Executive of the charity leaders’ representative body ACEVO (Association of Chief Executives and Voluntary Organisations), and one of the Future Forum’s members. “But despite that I think it’s been really productive.”

The statistics suggest an impressive level of engagement from the public, too: 6,700 people, more than 200 events and 25,000 emails. “At the start of the exercise there was, understandably, quite a lot of cynicism,” says National Voices’ Chief Executive Jeremy Taylor, another panelist. “But the exercise itself hasn’t felt at all cynical. People have been very keen to have their voices heard.”

The Forum’s members describe the listening events as lively, engaged and crowded affairs (so crowded, in fact, that there are anecdotal reports that many clinicians couldn’t get in at all).

The patient involvement strand, unsurprisingly, had a fair share of input from patients. Many events, though, tended to be dominated by NHS staff, professional bodies or other interest groups. This, say the more reformist members of the Forum, has presented an excellent opportunity to explain what the Bill was actually for. “The initial response was, ‘Why are you doing this?’ People started off very negative,” recalls one GP who contributed to the Future Forum. “By the end of the event, though, people were very, very positive.”

Not everyone was quite so taken with the Bill, of course, and criticism seemed to focus on a few recurring themes. One is a concern that the Bill was a little too fuzzy on matters of accountability. It wasn’t clear whom the new GP commissioning groups (GPCCs) would be answerable to for their use of public money, or how transparent their decisions would be.

“From GPs we were hearing, ‘Please don’t create too many layers in the system’,” says the unnamed family doctor. “But from everyone else we were hearing: ‘Who are they accountable to?’”

A second big concern surrounded the issue of choice. Choice, the consensus seems to be, is good: but it’s also widely misunderstood by the politicians. Patients want to have options around the treatment they are given, and how they can access them. What they don’t want is to be treated like consumers. “People are saying they want the choice, for example, to die at home,” says Taylor. “What they’re not saying is that they want a choice of where to have their new hip.”

And then there’s competition. As originally constituted, the Bill promised to turn the NHS into a market, in which “any willing provider” could offer health services. Foundation Trust regulator Monitor would act as the ‘economic regulator’, with a duty to promote competition.

This didn’t go down very well – and the complaints weren’t just ideological. A large chunk of NHS funding, after all, goes on long-term conditions. That generally means giving patients care packages, involving both primary and acute services. Wouldn’t Monitor’s new remit treat these as collusion, and be forced to break them up? And in an open market, what was there to stop private providers from offering only the profitable services, leaving hospitals short of vital income?

“You have to leave the rules loose to create a market,” says the unnamed GP. “But the acute sector were very, very worried about cherry picking.” What’s more, Lansley had promised that competition would be based around quality, not on price – but quality is famously difficult to measure, raising fears of a health service in which new providers drive down cost at the expense of outcomes. (Death rates, after all, went up in the early nineties when the NHS internal market was introduced.)

Perhaps most worrying was the fear of the damage competition could do to existing services. The Bill, Professor Field himself warned, would “destabilise the NHS [and] lead to some hospitals not being able to continue as they are. We need some significant changes,” he concluded, “in how the role of Monitor is described and enacted.”

Such changes feature heavily in Field’s final report. It supports the case for reform, and backs the idea of devolving funding and commission power to GPs. But it stresses, too, that competition should not be an end in itself, and calls for more integration of services. (One quote Field borrows from the NHS Constitution, beginning, “The NHS belongs to the people”, is a marker in the sand against cherry-picking profiteers if ever there was one.)

Other key proposals included widening the membership of the commissioning groups to clinicians besides GPs, making their work more transparent, greater accountability for the health secretary, and a slower transition to the new arrangements, particularly on training.

The government, contrary to what some feared, looks unlikely to ignore the recommendations. Its suspiciously speedy response, in fact, came just 12 hours after Field published his report, and accepted many of his suggestions. GPCs are to be broadened out into “clinical commissioning groups” involving nurses and hospital doctors, while stronger safeguards against marketisation and privatisation, and a new duty for commissioning groups to promote joined-up services, will all be added to the Bill.

What’s more, Prime Minister David Cameron was making recommendations along these lines a good month before the Forum completed its work. A charitable reading of the situation is that there were real and clear problems with the Bill: anyone who went through it with a fine-tooth comb would come to the same conclusions. The more cynical reading, of course, is that the exercise was all about politics, providing cover for the government to back down from reforms it no longer felt sure of.

Those who took part in the panel, though, remain very proud of their work. “I made it clear when I started I wasn’t getting involved in a PR exercise, but I think the process has turned out to be a good one,” says Bubb. “Who knows. They might think it’s been so useful it’ll happen again.”