| Topic: | Shirley Williams article, The Observer, 4.9.11 | |
| Posted by: | Allison Franklin | |
| Date/Time: | 04/09/11 07:59:00 |
| Why this flawed bill threatens the very future of the NHS The new health bill displays an unhealthy fascination with the discredited US system reddit this Comments (81) Shirley Williams The Observer, Sunday 4 September 2011 Article history As the passage of the Health and Social Care Bill has ground on, the doubts and questions that accompany it have become ever more difficult to address. This is a bill that has been subjected to a listening exercise, extensive consultation and a report by Steve Field, chairman of the Future Forum, redrafting by Parliament, more than 100 hours of debate, and dedicated efforts by the deputy prime minister, Nick Clegg, and the Liberal Democrat minister of state for social care, Paul Burstow, to amend it to meet the worries Lib Dems expressed at their conference last spring. Now that 38 Degrees, a group of concerned citizens, has sought the advice of leading lawyers, the confusion thickens further. The central issue is whether, if the bill is passed without further amendment, there will be any legal duty on the secretary of state for health, Andrew Lansley, to provide and secure a comprehensive health service for the people of England, free at the point of need – the heart of what the NHS is all about. At present, the duty to provide and secure such a service has been delegated to the primary-care trusts and strategic health authorities. These commission the services that have to be provided, some of them listed in section three of the 2006 National Health Service Act. That section requires him or her to provide hospital and other accommodation, nursing and ambulance services and services for vulnerable groups such as children and pregnant women. But in the new bill, section three is repealed. Those responsibilities are no longer delegated; the secretary of state can set objectives and even intervene in the case of a significant failure by a commissioning body, but he is no longer legally and constitutionally responsible. That view, however, is not shared by the Department of Health's legal team. "The removal of the duty to provide," the department declared, "does not in any way undermine the secretary of state's accountability or responsibility for the health service which remains unchanged since the founding of the NHS." The opinion of the lawyer in the 38 Degrees case was equally unambiguous: "It is clear that the drafters of the Health and Social Care Bill intend that the functions of the secretary of state in relation to the NHS in England are to be greatly curtailed. The most striking example of this is the loss of the duty to provide services pursuant to section three of the NHS Act 2006." (The services I mentioned.) "Effectively," he continues, "the duty to provide a national health service would be lost if the bill becomes law." By passing these duties down to an unknown number of commissioning consortiums, the government, he says, will be "effectively fragmenting a service that currently has the advantage of national oversight and control, and which is politically accountable via the ballot box to the electorate". The Department of Health is inclined to dismiss such comments. The position of MPs who are not lawyers is made extremely difficult by disputes of this kind, which may reflect the politicisation of a civil service which is meant to give impartial and objective advice. Let's move on to the constitutional issue. More than £80bn pounds of taxpayers' money is poured into the NHS every year. Taxpayers have been willing to pay for a service most of them deeply care about and find satisfactory. But they expect the government, the minister and, ultimately, Parliament itself to be held accountable for the delivery and quality of the services for which they pay. Mr Lansley is right to want greater freedom for doctors to work with their patients and to restrain political interference in the NHS. But to throw out accountability in order to tackle petty interference is to undermine democracy itself. The conflicting interpretations of the secretary of state's responsibilities are made worse by an amendment to the bill, added after the recommissioning exercise, "the hands-off clause", which requires him to respect the autonomy of the National Commissioning Board and the commissioning bodies. The minister would have to show that any intervention by him was essential, a tough test to meet. He could be subject to legal challenge if he failed to meet that test, making "hands-off" a prudent path to follow. This is a provision that must be dropped, just as the reinstatement of the secretary's duty to secure provision of a comprehensive health service should be reinstated. There have been changes for the better. Nick Clegg's intervention ensured that the commissioning bodies will have lay people on them, will be much more transparent in how they act, and will consult HealthWatch and other local bodies. He managed to get the coalition to drop competition on price altogether and to make co-operation and integration objectives for Monitor, the independent regulator of NHS foundation trusts, alongside its duty to oppose anti-competitive practices. One thing that remains, however, is the decision to lift the cap on private beds in foundation hospitals. Not only could that mean that many of our finest hospitals would gradually become private, it also means that inevitably foundation hospitals would be subject to European and British competition law. It would be much better to amend the law so that no foundation hospital anywhere could have a majority of private and commercial patients, while leaving the exact figure to be determined by each within that ceiling. There is an even bigger question to which I have no answer. Why have so many of our politicians, Labour and Conservative, sought to introduce a market into health? I am not against a private element in the NHS, which may bring innovation and good practice, provided it is within the framework of a public service – complementary but not wrecking. But why have they been bewitched by a flawed US system? I worked in the US for a decade between the 1980s and 1990s and saw the misery of people who could not afford even to insure themselves against the catastrophe of serious ill health. The NHS is recognised by the OECD, the US Commonwealth Fund, most of our own medical organisations and many of those who use it as one of the most efficient, least costly and most effective in the world. It could become more productive and more innovative, especially through greater integration of services and sensitive reconfiguration, ensuring that treatment is undertaken locally or at home rather than in hospitals. But reform need not mean upheaval and disintegration. The remarkable vision of the 1945 Attlee government – of a public service free at the point of need for all the people of England – should not be allowed to die. |