Andrew Lansley, secret radical - and the risks and opportunities of his healthcare revolution (Part Two)

by Paul Goodman

I described yesterday how -

• David Cameron's instinct is to leave the NHS much as it is.
• Andrew Lansley's intent is to reform it radically...
• ...At a time when the rise in health spending is subject to an unprecedented squeeze.

So what will happen? 

• At some point within the next eighteen months, there'll be an "NHS crisis".  The system, we'll be told, has "run out of cash".  Health bosses will warn of closures.  Patients will be photographed lying in corridors.  "Bedblockers" will be unable to leave hospital due to "local authority cuts".  Nurses will protest.  Shrouds will be waved, stumps brandished, scars exhibited.  Local papers will go doolally.  So will Labour.  At the moment, Brown's plane-loads of borrowed money are still washing through the system.  And at some point, Osborne's turning-down of the taps will be followed by the "crisis".  Some experts believe that this will happen as early as next autumn.

• It will probably happen after the health bill's passed the Commons.  The reforms will be well under by then.  Indeed, they're already taking place.  GPs have already taken charge of commissioning in Cumbria.  In west London, there's a Great Western Commissioning Consortium.  Bexley has a shadow GP consortium waiting to go.  It's chaired by Howard Stoate, a former Labour MP, who came to the defence of Lansley's plans in the Guardian in an article headed: "GPs do not fear the chance to reshape NHS services, they welcome it."

• If enough doctors take against the reforms, they'll run into political difficulty...  As Stoate's piece demonstrates, some doctors are enthusiastic about change.  But others aren't: they include, for example, the Conservative MP Sarah Wollaston, who's painted a picture of new commissioners privatising the NHS by stealth.  (A striking instance of political role reversal.)  However, most GPs' will want not so much to express a view on change as to get on with their lives.  If one's cynical, this means guarding their incomes and taking no blame for problems in the system.  If one's not, this means carrying on their work and caring for their patients.

• ...Because doctors are articulate, energetic, and - as interest groups go - respected.  There are unanswered questions about the reforms.  How large will the commissioning groups be, and will happen if GPs in a particular area want to shut surgeries?  Who will decide if hospital services are to close?  (The Coalition Agreement says that "We will stop the centrally dictated closure of A&E and maternity wards.")  My sense is that doctors won't want to take responsibility for moving services from one place to another, or for closing them down altogether. The long and short of it is that the doctors will certainly guard their contracts and will be resistant, surely, to being exposed to patient choice themselves.  This may help to explain why the BMA said that the changes are "potentially damaging".  It resisted Ken Clarke's fundholding reforms vociferously.  And his scheme - unlike Lansley's plan - was voluntary.

• The Treasury is watching the healthcare reforms anxiously.  The Coalition Agreement commits the Government to cutting the costs of NHS administration by a third.  Lansley wants to save £4 billion a year by 2013.  Stephen Dorrell, the former Health Secretary who now chairs the Health Select Committee, describes this as "a huge ask".  It can be argued strongly that the best time to reform a system is when spending's being scaled back, and better value for money's urgently required.  But it's uncertain whether commissioning will have that effect.  The practices could turn out to be very large, and simply re-absorb the PCT staff left jobless by their abolition - creating a revolving door and costing more money.  Civitas thinks that the Lansley plan is a distraction from driving up NHS productivity.  The Treasury's worried that no system will be in place to control GP spending, and that Downing Street hasn't had the policy expertise to question Lansley's assertions.  This may be part of the reason why Letwin was drafted in and the Policy Unit's being beefed up.

All in all -

• In the medium term, the reforms should improve services and save money.  They're worth a shot.  It can be maintained that with schools, welfare and the police being radically re-shaped, and that to take on health reform too is one major change too many.  Certainly, the results of commissioning will at first be patchy.  In some areas, GPs will rush in with enthusiasm.  Mistakes will inevitably be made, but patients will, on the whole, like the results, even if the Treasury doesn't.  In others, doctors will sign up under protest.  The BMA and others will probably utilise this discontent to water down any patient choice of doctors.  If results are variable, that's localism for you - but many voters cling stubbornly to the belief that the NHS should provide a uniform service, and there'll be cries of "postcode lottery".  But remember: the "NHS crisis" will happen anyway, as the supply of money to the service tightens.  Ken Clarke's fundholding experiment was denounced virulently at the time, but helped to empower doctors, improve choice, drive up standards and improve NHS productivity.  So should Lansley's, if he and Letwin get it right.

• But in the short term, the Treasury will probably have to stump up more money.  I may be wrong, but suspect that the political story of healthcare during this Parliament will fall into three parts.  First, the rush of money into the system will slow, and Lansley's NHS Bill will pass.  Second, the "NHS crisis" will take place, the BMA will protest and George Osborne will then - with a flourish - produce some more cash to grease the wheels of reform.  Finally, the resulting flow of money will quieten the whole system down just in time for the election.  By which time some improvements will show, David Cameron will have had his mid-term reshuffle, and Lansley will either be moved elsewhere, or be preparing to run Mammon Healthcare Enterprises Inc.  And Nick Boles will be Health Secretary.  I'm making that last bit up (I think).  But the rest is more likely than not.