A divisive NHS bill may end up being less alarming than its many foes predict

Difficult birth, slow recovery

NHS reform

A divisive NHS bill may end up being less alarming than its many foes predict

Feb 18th 2012 |From the print edition

THE coalition's health and social-care bill is a textbook example of how not to introduce major reform. A sprawling piece of legislation, it was launched at a bemused public without much preparation. Clumsy explanations by Andrew Lansley, the health secretary, did not help, especially when the Conservative and Liberal Democrat coalition partners have differing instincts on health in the first place.

These rifts have deepened since January 2011, when measures to change the way family doctors run their practices and referrals were announced along with plans to increase competition in a largely state-run system. Since then, the bill has been paused, amended, opposed by professional bodies and fiercely scrapped over. An online petition calling for a rethink has garnered more than 125,000 signatures. A mere 18% of respondents recently told YouGov pollsters that they think the proposed changes are right.

Still, barring last-minute upheavals the legislation will pass through the House of Lords in a few weeks. Some think that in practice it will prove less divisive than it looks in prospect. Nick Bosanquet, a health-policy expert at Imperial College, London, notes that the new system offers clinicians “a better grip on value, because they can arrange trade-offs and secure better deals for their patients”.

Language like this frightens those who see the NHS as a health-care system driven purely by response to need, rather than by hard calculation about cost. Yet the organisation's own chief executive has insisted on a hefty £20 billion ($31 billion) in efficiency savings by 2014. It was widely believed that productivity in the NHS had fallen under the last, Labour government as the health budget rose by around a third—one reason why the coalition's reforms were said to be needed. A recent analysis purporting to show the opposite has added to controversy over the bill.

Though turning family doctors into health-care commissioners was the early bone of contention, this aspect of the reforms is already under way. Well over 200 GP consortia have been set up and some are actually in operation, though many clinicians remain critical of the decision to disband the primary-care trusts, losing experienced staff at a time of upheaval. Local oversight committees will be set up to ward off anti-competitive practices, to the frustration of those who welcomed a drive to cut NHS bureaucracy.

Less settled is the role of private competition, which the bill is meant to promote. In truth, the public has long held contradictory views on this. Many private firms provide long-term care for the elderly. GPs are private contractors, and independently run treatment centres, introduced by Labour, provide around 5% of elective surgery requiring short hospital stays.

Last year cash-strapped Hinchingbrooke in Cambridgeshire became the first general hospital to be run by a for-profit health group, Circle, signalling that the private sector might well save others from closure. But Ali Parsa, Circle's chief executive, worries that the requirements imposed by Monitor, the health regulator, on those seeking to compete with NHS services have now become so demanding that only a state-backed company or very large private group could satisfy them. Excessive regulation, Mr Parsa says, means that “Britain can't emerge as a world-class private health care provider.”

Mr Lansley, meanwhile, compares current health-care provision with the music industry, speculating that changes in technology, like the move from compact discs to MP3 players, can “sweep away less effective services” and encourage better practice. This example has jarred with some (the health secretary is unlikely to win a communicator-of-the-year award.) But Britain's debate over health care is in danger of becoming parochial. In Germany, for example, over half of hospitals are now outside the public sector.

Alan Garber, a health-policy professor and provost of Harvard university, also concludes that the NHS would benefit from competition to “allow experimentation and variation”. Rising treatment prices, an ageing population and ongoing fiscal austerity mean that it will have to change if it is to keep pace with expectations. That will hurt—though not, perhaps, quite so much in practice as the screams of protest at the prospect suggest.

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