How the Lib Dem fixation with the powers of local government lead to a radical and unnecessary restructuring of the NHS
Never Again by Nicholas Timmins is generally accepted to be the best account so far of the Health and Social Care Act 2012, Andrew Lansley’s massively controversial overhaul of the NHS. I’d been meaning to read it for quite some time and deciding whether or not to write a thesis on the Act’s implications for competition law gave me a pretext to do so.
It does not make comfortable reading for a Liberal Democrat. It is true that Timmins’ book is a good corrective to wilder theories about there being a Conservative conspiracy to privatise the NHS – a scheme which if real would have made Lib Dems at best dupes. And it is clear that the rejection by Lib Dem conference in March 2011 of Lansley’s proposals as they then stood was pivotal to delaying and mollifying what eventually emerged. Norman Lamb and Shirley Williams also come out of the story well. However, that is about where the things we can be proud of end.
For starters, Timmins is pretty unsparing about just how thin Lib Dem ideas on the NHS were. Beyond support for more ‘local accountability’ we had no real vision for Britain’s largest public service and no coherent answer to quite basic questions like what role competition should play in it.
There is also the rather dubious ‘programme for government’ drawn up by in large part by Danny Alexander, who alongside Oliver Letwin at great haste and with little consultation produced this document in the days after the coalition agreement. Regarding health this wound up amounting to an attempt to “a cut and shut” together Conservative and Liberal Democrat manifesto commitments which Lansley was able to rapidly jettison.
It is also clear that Nick Clegg and his entourage failed to recognise there was a problem until very late in the day by which point Clegg concluded that so many changes had already been implemented that it was impossible to drop the Bill.
Most worrying, however, is Timmins suggestion that:
“without the Liberal Democrats…[i]t [the Act] would almost certainly have involved less immediate structural upheaval.” As he tells the story:
As the department [of health] sought to unpick the programme for government, and as they sought to meet the Liberal Democrat demand for more local democratic accountability, a logic emerged.
“We were in a world where we were going to reduce expenditure on SHAs and PCTs by more than a third – by something like a half – and so what Andrew and colleagues had to face up to was ‘what were these PCTs actually going to do?’,” one official says.
“They had nothing left to do. What they were going to do was possibly a little bit of public health. But they were going to be bossed around by a public health department and by the local authority which still actually had most of the stuff that makes a difference on public health at local level. They were going to hold the contract for pharmacy and for the GPs.
And we had already agreed that community services were going to be split away’ (the completion of a Labour policy)”.
Paul Burstow, the Liberal Democrat minister at health, helped drive that argument. A former deputy leader of Sutton council, a leading light in the party’s councillors’ association, and the party’s health spokesman between 2003 and 2005….Burstow is a long-standing advocate for transferring all of NHS commissioning to local government. His primary concern was to get local government a bigger role in health – and in a way that would integrate health and social care more closely.
Unlike the department and Lansley, he had not greeted the programme for government with “a sucking of teeth” as he puts it. Its proposal for part-elected/part-council-appointed PCTs fitted his wish to deliver the long-standing Liberal Democrat goal of a bigger role for councils as part of its desire to devolve power from Whitehall.
But he rapidly came to see the problems with the idea. And, he says, he “certainly argued very strongly [about] what were PCTs going to do in this new world? All they were going to be left with was a residual role in public health”. Why have that, Burstow says, “when it makes more sense for the public health role to be put into the local authority?” Local government has “more of the levers for driving the wider determinants of health”.
At the same time, the parallel idea that was being developed of health and wellbeing boards – aimed at bringing GP commissioners and councillors together. Again an idea that Burstow promoted. That offered a chance of better integrating health and social care together with prevention, and in a way that might give local authorities at least some influence over NHS commissioning,
Once it was determined that GPs were to be required to do the bulk of the commissioning, that public health was to go to local government, and that community services were to be separated out, there was indeed nothing, or virtually nothing, left for PCTs to do. “They were a shell,” one official says. There was no need for them.
The deal came out of “Andrew’s black and white approach to commissioning” – that all GPs would be required to be involved – and Paul Burstow’s and the Liberal Democrats demand for more local democracy. “So the PCTs death warrant was signed by that, really.
But this decision was problematic. Scrapping PCTs (and SHAs) was what moved the situation from “we will stop the top-down reorganisations of the NHS” to launching precisely just such a restructure. In addition, PCTs were the bureaucratic underpinning of the old system. As they were already substantially wound up by the time Lib Dem conference turned on the plans, Nick Clegg found that it was impossible to abandon the plans because there was no one to administer the status quo if it was left in place.
I am afraid to say I don’t think this sorry story is just about health. Rather it reflects a general weakness in how the party approaches policy making. In a thoughtful piece for Liberal Democrat Voice from 2011, Stephen Tall argued that “Local government is to the Lib Dems what the unions are to Labour.” The role of the party in general and Paul Burstow in particular in the passage of the Health and Social Care Act does unfortunately seem to fit this pattern.