For the last year, whenever two or three NHS leaders have gathered together, one of their political truths has been the certainty that there will be no new legislation on the structure of the NHS until after another election.
A government without an overall majority is not going to introduce legislation which that lack of majority would prevent it from controlling. Putting legislation before a hung Parliament is one thing but getting it through, in any semblance of order, is quite another.
Or so they thought.
Theresa May’s speech on Monday began to lay out some of the wider changes she is thinking of developing with the NHS. But it was very much with the NHS and not to the NHS.
Her willingness to get rid of the internal market will have been a surprise to those that haven’t been paying close attention to the 2017 Manifesto.
Let’s not forget that when this Manifesto was published the Conservatives were way ahead in the polls. As it was being put together by her team at number 10 they must have believed that these were more than just mere words on paper. The Civil Service would have read the manifesto (as they did with the Labour’s) and begun to think through what it meant for a legislative programme.
Given that her speech re-energised the ideas it is worth returning to the words of the Manifesto,
“We will hold NHS England’s leaders to account for delivering their plan to improve patient care. If the current legislative landscape is either slowing implementation or preventing clear national or local accountability, we will consult and make the necessary legislative changes. This includes the NHS’s own internal market, which can fail to act in the interests of patients and create costly bureaucracy. So we will review the operation of the internal market and in time for the start of the 2018 financial year, we will make non–legislative changes to remove barriers to the integration of care.”
Page 67 Conservative Manifesto 2017
For the Conservative Party to be prepared to unravel the internal market was a surprise last June and it was again a surprise when in her speech on Monday she made these points again – word for word.
Within the politics of the NHS, it is no secret that there is a feeling that commissioning has not done the job that it was intended to. Rarely are commissioners reshaping care in, for example, terms of outcomes for patients and the public. Most commissioners spend most of their time recreating last year’s contracts – plus or minus a few percentage points.
Neither has the market been used as a tool for patient-led change. There are very few of the real markets that commissioning needs.
Similarly the market has rarely been used as a tool for integration. There are very few contracts forcing providers to come together to provide person-centred, coordinated care. The logistics that bring private sector companies together in other industries have not been yet been produced in the NHS.
I remember, during the 2010-2015 Parliament, appearing before Stephen Dorrell when he chaired the Health Select Committee and trying to make the case for outcome-based commissioning to a very sceptical chair. He pointed out that over his long experience the internal market had not had many chances to succeed and it was always – as I was saying – likely to succeed in the next few years. But it never did.
Perhaps the most interesting political issue of 2018 would be what Jeremy Corbyn’s Labour opposition might do if the Government introduced legislation – with the agreement of the NHS leadership – to dismantle the internal market.
Would they, in order to oppose anything the Government proposes, support the NHS internal market? Politics is a bit weird at the moment and one needs to be be prepared for anything. But a Conservative Government proposing to dismantle the internal market and Labour voting to stop them would be one of the weirder. Watching the left wing of the Labour PLP going through the lobbies in favour of NHS commissioning would be very unlikely.
So a Conservative Government might just introduce legislation and dare the Opposition to vote against it. This would provide great political theatre, but on balance it looks unlikely. The Lansley Act pieces together a lot of different issues. Undoing any one of them would mean that a whole range of other issues would need unravelling. It would end up with a very big bill.
Another, even odder, alternative would be for the NHS to publicly approach the Health Select Committee with a request for two or three very small changes – perhaps concerning NHSE and NHSI at their centre. And the excellent Sarah Wollaston taking charge of some of the legislative process to put through what was a clearly NHS sponsored bill.
Or maybe they’ll opt for muddling through – pushing the law to breaking point.
Given how dangerous whole-scale reorganisations have been in the past this is probably their preferred strategy.