So Dave, What is the Big Idea for the NHS in 2015?

Guest Blog by Stuart Carroll, Senior Health Economist and Epidemiologist

It has been a political summer of seismic proportions. We have seen a full scale Cabinet reshuffle complete with promotions and demotions, hirings and firings, and the odd important retirement.   The egregious and woeful “election” of Jean Claude Juncker as the President of the EC Commission.  The continued persistence (I think “rise” is hardly the right word now) of the unflappable Nigel Farage’s UKIP and the continued evisceration (I think “decline” does not quite do it justice!) of the hapless Nick Clegg’s Liberal Democrats.  An escalating international crisis in Russia, Ukraine, Syria, Iraq and the Middle East to name but a few.  And, perhaps most disturbingly of all, the ongoing public meltdown of Tony Blair.  Our former Prime Minister has not only shown that delusion is most certainly the servant of ignorance as far as Iraq is concerned, but he has added some credence to Mayor Boris Johnson’s theory that Tony Blair has actually “gone mad”.  In his extraordinary role as Middle East envoy, which given his toxic legacy on Iraq makes about as much sense as employing Ryan Giggs as a marriage guidance counsellor, Blair has been telling anyone who can still be bothered to listen that the furnace of chaos, death and destruction in Iraq is all a direct consequence of the international community not firing enough guns and bombs at Assad’s Syria!  The man once touted as the JFK of British politics has rendered himself totally ludicrous and politically pie-eyed.  No wonder some people are hellbent on impeachment.

Turning to doDavid Cameronmestic matters, we are now less than a year away from the general election scheduled for May 2015.  Back in 2010, although the economic crisis naturally predominated electoral proceedings, it was the health service that remained David Cameron’s officially pledged number one priority.  Announcing in 2006 that he could surpass Tony Blair’s “número uno” in just three letters – N H S – thereby defeating the nostalgically vacuous Blarite trio of “education, education, education”, the imperative that is health policy has proven to be a rocky and exigent challenge for the Prime Minister.

Cue the Health and Social Care Bill (now Act); the Future Forum exercise; the appointment of Steve Field as the Ole Gunnar Solskjear of health politics;  the boos, the cries and the moans (that is being polite); and the eventual removal of Andrew Lansley as Health Secretary.   The ministerial health team, as it stands today, only retains one member from the 2006 speech and, more to the point, the 2010 Coalition Agreement: the indefatigable and much respected Lord Howe (Freddie has actually been in the Conservative Health Team since 1997; #make the Earl a Knight for all his service – what a man!).  When all the management are shipped out, that is a tell tail sign something has gone wrong.  Indeed, it is difficult to believe this is how David Cameron dreamt it when declaring his number one priority over eight years ago.   Moreover, it is noteworthy the Prime Minister cites spending on international aid as his proudest achievement since occupying Number 10; not his reforms to his “number one priority”.

Since assuming office, the politics and policy of the NHS have been a reputational thorn in Cameron’s side.  Of course, Prime Ministers should expect the former – after all, the NHS is a potently political and stirringly emotional business – but it is the latter that has reinforced the former and harmed the Cameron strategy of “detoxification” designed to put the Conservatives at the zenith of trust on the NHS and reposition the Tories as the party of the NHS.

As I have blogged previously during this Parliament (Depressed Reformers and Field vs. Gerada), the over-arching essence and general thrust of the HSCA are, I believe, sensible following sound principles of devolving local decison-making; increasing patient choice and concreting the patient voice; and seeking to reform an overly centralised and unwieldy service that was too clunky to effectively respond to rising demographic demand, ageing populations and concomitant increases in chronic long-term conditions.  When looking at the history of the NHS from 1948 onwards, many of the reforms are more evolution than the widely denunciated revolution – something governments of all colours have concluded is necessary and unavoidable  – albeit parts of the new NHS are, without question, “up in the air”.  Furthermore, the amplified emphasis granted to public health through the creation of Public Health England (PHE) and local health and wellbeing boards (HWBs) is progressive despite it being very early and hestiant days in this new system design.

Of course, there is no denying that the HSCA = a top-down reorganisation of the NHS.  Fact.  Period.  In the spirit of Daniel Pink’s YouTube summation of “Drive”, the King’s Fund’s cartoon delineation of the English NHS confirms as much.  It is quite simply a case of quod erat demonstrandum (QED).

Moreover, there is no doubt that significant parts of the system are struggling to find their feet.  One noteworthy example is the role of NHS England as a de facto “commissioning board” and how in turn it should be interacting with Monitor and the Care Quality Commission (CQC).  The size of these close concentric circles and their attendant organisational roles and responsibilities remains sketchy and unclear, as does their intersection in any notional NHS Venn diagram.  In addition, it is apparent parts of the NHS are simply not skilled and resourced to accommodate some of the changes.  Monitor is hawkishly trying to recruit as many health economists as it can in a sure-fire signal it was not prepared for what was coming, which in turn confers important questions about organisational skill mix.  This all points to an important aphorism.  As Alfred Chandler once advised, structure should follow strategy.  There are parts of the NHS that feel a bit like an architect’s wet dream lacking due consideration for the practical feasibility (and desirability) of implementation and, more to the point, the “human resource” question and skill-mix imperative.

The reforms might be following a natural historical trajectory of travel and might actually be the right thing to do, but the Prime Minister should concede that his original pledge on structural preservation and reorganisation has not been delivered. Despite initial scepticism and criticism, Cameron’s appointment of the emollient and pragmatic Jeremy Hunt has been a master stroke and much needed.  The Health Secretary, who arguably has been the quiet unsung hero of the Coalition, has done a superb political job of taking the “sting out of the tail” with many in the NHS acknowledging he has steadied the ship.  It has allowed him to get away from the Murdochs!  Having been locked sedulously in implementing his predecessor’s plan with an essential preoccupation doing the political equivalent of “crisis management”, we are yet to really know and hear what Hunt’s vision is for the future NHS.  This is also true of the Prime Minister and Conservative leadership more broadly.  As the clock ticks closer towards May 2015, the business of health policy, ideas and politics will become evermore important should the Tories harbour any real chance of winning an outright majority.  It is my intention to blog my thoughts over the next few months on what I think should feature in a Conservative manifesto.

Opinion polls consistently place the NHS within the public’s “Champion League” of priorities and, moreover, concerns.  Although an inevitable part of the Cameron health strategy will be to defend the HSCA and his Government’s record, outlining a positive vision for “Parliament 2” is just as important.  Where does the Prime Minister see the NHS in 10 years?  What key policies are needed to deliver those values and that vision?  Does he have any further reforms up his sleeve?

Concreting a genuine promise about no more top-down reorganisations will surely need to be a keystone.  It is difficult to believe the public, or the NHS itself, could take any more major structural reform or “organisational surgery”.  The electorate will want, and need, to know where the Tories plan to take the NHS next.  A central plank will surely need to focus on funding and how to make the NHS truly sustainable; and by funding I don’t just mean ring-fencing more money from an increasingly limited national pot.  There are very tough decisions that need to be confronted.  Sooner rather than later, politicians are going to have to recalibrate what the NHS can afford to provide as a universal, comprehensive and free at the point of need service.  Regardless of what Ministers might say, there is a funding challenge – arguably crisis – that is only going to get worse due to demographic pressures, rising healthcare demand and the increase in chronic long-term conditions.  Politicians must not shy away from being upfront, candid and clear about the challenges confronting the public’s most cherished institution.  A failure to do so is tantamount to a dereliction of duty.

The Conservatives have a bit of an advantage in the form of an Opposition struggling to politically and, as we have seen so far, electorally breakthrough.  Moreover, Labour’s shaky performance on the NHS remains a problem for Ed Miliband.  Despite his human touch and accessible style, Andy Burnham has resorted to the politics of scorn, acidity and negativity.  This has been centrally epitomised by blindly opposing anything that comes out of the mouths of Ministers and playing the increasingly unconvincing “only we care about the NHS” card.  There is little sign this regressively tribal approach has positively persuaded a tired and suspicious public that Labour is best placed to run the NHS.  Moreover, some “on their watch”, and frankly outrageous, failings that occurred during the Labour and Burnham years render recent Opposition attacks politically hollow and do little to reassure weary voters that Labour has adequately rehabilitated itself during its time shadowing the Coalition.

NHS logoNonetheless, Cameron’s vision for the NHS cannot rely on Labour’s inadequacies and incompetencies, but must rather be a vision of positivity, clarity, reassurance and, this time, definitely preparation. Manifestos might not win you elections outright, but history shows us they can certainly lose you elections.  So Dave, what is the Conservative’s big idea on the NHS for 2015?

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