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Stephen Dorrell Interview

Stephen Dorrell Interview
22 July 2011

As Andrew Lansley faced increased public anger over the health reforms and a critical media spotlight, interviews with Stephen Dorrell, Conservative MP and Chairman of the Health Select Committee (HSC) since June 2010, always ended with the same question: "Are you going to be the next health secretary?"

As Andrew Lansley faced increased public anger over the health reforms and a critical media spotlight, interviews with Stephen Dorrell, Conservative MP and Chairman of the Health Select Committee (HSC) since June 2010, always ended with the same question: "Are you going to be the next health secretary?"

Appearing to support Lansley on the one hand, while heavily criticising his bill on the other, Dorrell – who has already served as the health secretary under John Major's government from 1995-97 – denied he was making a play for a repeat performance in ever-decreasing tones.

In May he said: "I don't answer questions about that. I do a job on the health committee for which I was elected by my peers and that's what I intend to do."

Then in June, he told The Guardian: "I was selected to serve four years as the chair of the HSC and the prime minister has made it crystal clear he's planning to carry on to the end of this parliament with this cabinet and he has my full support in that." Reading between the lines suggests the prime minister would also have Dorrell's full support had he been asked to play the protagonist.

Speaking to GP Business in May, Dorrell says: "What I am interested in is a system. Andrew has been a huge success in opposition. He was a success in getting public trust for himself and the Conservative Party around the health policy. He's been a great success in raising public health up the agenda.

"In both cases he bears comparison with any of his predecessors. What I hope will emerge from this is a structure that creates a commissioner-led health service more effectively than any of his predecessors. Then, I guess, he will have the position as long as he wants to hold it," he said.

Although some may raise a cynical eyebrow when, in the current context, the words 'Andrew Lansley' and 'success' are put together, it looks as though Lansley is safe for now: the Future Forum has reported its findings following the listening exercise and the government has largely accepted the recommendations.

Even Dorrell agrees the bill could have been communicated better. So what would he have done differently had he been in Lansley's shoes?

The miscommunication of the bill is something Dorrell feels quite strongly about and, had he been in charge, he says, he would have communicated the end game and benefits the reforms would bring to the NHS and patients from the very start.

"Where was the vision?" he asks. "I do think things were missed out of the bill, which left it open to misinterpretation – all the stuff about governance that has been put in the HSC report, for example.

"I understand the argument around 'don't let's be over-prescriptive', and that's why the HSC recommends that the precise membership of boards and so forth isn't a matter for primary legislation. It is a matter for law makers, which is why the appropriate way to deal with that is through secondary legislation."

What did he make of the prime minister wading in to front the health reforms?

"David Cameron is involved because if you are going to achieve successful change in the NHS you do have to take people with you. There's a tendency – and quite a broad one – to underestimate what the government has taken on here. I don't mean GP commissioning, but 4% efficiency gains in four years running: this is a change in the way healthcare is delivered in Britain at a pace, and on a scale, which has never been seen anywhere in the world. It's a monumental undertaking. I think it's doable but it won't happen unless people focus on doing it."
But that's not to say he does not see the need for the reforms, even if the speed is troubling. "I don't need any persuading of putting the economic and clinical responsibilities alongside each other. I was the junior minister who promoted fundholding and, as Secretary of State, we got roughly half the GPs in the NHS engaged with the fundholding model. And what I was seeking to do was to broaden that kind of primary-care led commissioning process."

Dorrell was proved correct in his prediction in mid-May that the listening exercise would not take the policy off in a "fundamentally different direction".

"Andrew Lansley is absolutely in the line of health ministers who have pursued what is fundamentally exactly the same health policy since Ken Clarke in 1990, with the single exception of Frank Dobson, who wasn't regarded as a huge success at the time," he says.

"The proposition that what we should have is independent providers, so you shouldn't try to centrally manage providers, that you should identify the objectives based particularly on outcomes and that you should drive those through the health system through effective empowered commissioning – those are ideas first legislated in 1990.

"At the heart of that view of how the health service should be managed is the critical factor of effective powerful commissioning. That's the thing that's failed under successive rounds of changes, that we haven't yet succeeded in delivering effective commissioning that's up to the job of holding the providers to account, driving necessary change in the system and driving quality through the system, in particular through challenging practice variation.

"Are we going to move away from a commissioner/provider concept of how we manage public-service health delivery? The answer is: 'I don't think so'. The question is how you deliver something we have talked about for 21 years."

But while in favour of the broad sweep of the reforms, he would not have branded it 'GP-led commissioning', a title that has led to much criticism.

"I am in favour of practice-based commissioning when it comes to prescriptions… referrals for physiotherapy [or] referrals for elective surgery. I am in favour of GPs being able to act as the powerful advocate of their patients' interest. What I am not in favour of is the illusion, and that's what I think it is, that reshaping the entire clinical model of the health service is something that only needs a GP perspective. And I don't meet very many GPs who agree with that either."

He says that falling into the trap of saying GPs will make all the commissioning decisions in the NHS "is not what the white paper says and it's not what would be the consequence of the structures that would emerge from the bill".

"Like so much public discourse around this project, we are talking about something which no one is proposing," he said, echoing other health commentators.

"When it comes to reshaping hospital services in order to deliver more integrated collaborative care pathways, less reliance on the acute insurance policies, more focus on the integrated pathway in the community, of course the GP has a key role to play. I need no persuading of that. But it isn't just about GPs."

The Future Forum reached a similar conclusion, leading to a name change now adopted by the government, from 'GP consortia' to 'clinical commissioning groups', to allow for nurses and hospital doctors to be involved.

"It's certainly true that the way the bill has been presented has been 'GP commissioning'. If there were a single headline around the bill it would be 'GP commissioning'. But actually, if you look at it, it was 'GP-led commissioning consortia'. I understand that's a bit of a mouthful," he says, again highlighting the poor communication of these reforms.
Accountability of consortia was another issue raised by detractors of the reforms who said the bill was unclear in this area. The Future Forum addressed this by recommending that commissioning groups should be required to meet in public and that providers of care to the NHS should make board papers public.

"Part of the frustration of working with public money is that you have to be accountable for the uses to which it's put… and £60bn of public money [divided across commissioning groups] is a quantum that taxpayers will take an interest in. And it isn't just a set of private decisions by GPs or anyone else about how that money is used," he says.

"I also think there is a degree of unreality on both sides of the argument here about what is deliverable. This project, as launched in the white paper, was never 'fundholding plus'. It was never intended to be a structure where these decisions were to be made by GPs acting in their practices. It was always going to be a public authority spending public money with a different form of accountability."

This brings Dorrell onto another "big issue" – collaboration and integration, something he and the HSC were particularly concerned about.

"If you see these commissioning groups more as commissioning authorities and less over-dependent on GPs, what you also then move away from is one of the problems the white paper grappled with, but did not really resolve, which is: 'Who commissions the primary care services in an age where we should be trying to get rid of silos in the health service?'"

"Reintroducing a different commissioning structure for primary care – in the form of the commissioning board responsible for primary care, which is what the white paper and the bill proposed – I think is a step away from collaborative integrated commissioning, which is certainly what I want to see and I think it's what most health professionals want to see," he says.

Now that the listening exercise is over and the majority of those opposed to the reforms seem to have been appeased, perhaps the show is over for the short term. It certainly doesn't look as if we'll get to see Dorrell centre stage anytime soon – but he is waiting in the wings.

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