Watching Andrew Lansley at the Nuffield Trust Summit last week was to watch a man surprisingly at ease. The Health Secretary is at the centre of a huge media storm, surrounding an enormously mangled bill, decried by all and sundry in the medical profession and beyond.
But he started his talk with a joke, he hung around for questions (which he answered directly if a little technically), and at the very moment the Lords were figuratively dismembering his offspring, he seemed a man unexpectedly relaxed.
The explanation for his good-temper is a simple one: this bill will become law. The prime minister is now on board, the cabinet are falling into line, and it is being debated rather than pulverised by the Lords this week. Plus, as Ben Page of polling group Ipsos MORI told the summit, as concerned as you lot are, the bill is barely on the general public’s radar at present.
For doctors this means it’s time to draw a line.
Like or loathe the bill (and the majority view seems rather self-evident…), it’s time to start thinking about how to make the present reality work in the best interests of patients.
Given the trouble this bill is already causing on the ground, that will be no small ask of many doctors, but it’s imperative to deal with the reality we now have.
And there is an upside. Ironically it is their very critique of reform that now puts doctors in a strong position. Medics are a diverse bunch and getting them to collectively engage in anything can be tough. Getting them to engage en masse with the politics of structural management in the NHS is unheard of. And yet from Royal College to Royal College, organisations normally known more for education than evisceration, there has been a groundswell of fury over health policy.
Central pleas for doctors to engage with management and leadership have for years been a minority interest met by most professionals with a shrug of impotency. But now doctors the country over are demanding that their colleagues, colleges, and representatives show leadership and voice their concerns.
This momentum must be maintained and mutated if the ire of the response is to turn into a more practical outworking. The colleges must work to ensure that the fears of their members, dismissed by politicians, do not come to pass. Individual doctors now campaigning over the potential harms to their given specialty (and the multi-signatory letters to a multitude of newspapers suggest these number in their thousands), must maintain their focus to ensure that no such harms happen.
If even half the professional heat around the bill can be transferred to light in its enactment, then patients in England are about to see some real improvements.
But also to date the debate has focussed on the problems of the bill. Now is the time to take stock of any opportunities. For example, whether or not you believe CCGs are needed to enable real clinical commissioning or like many believe that the same could have been better achieved with GP-majority boards on PCTS, what we are now left with is GPs in the legal driving seat of commissioning. This is something that groups opposing the bill from the BMA to the RCGP welcomed when it was but a mere White Paper.
Of course there are real problems with what is emerging around commissioning – unrealistic sizes, pressure from above, and a resentful workforce. GPs are concerned about conflicting interests, imposed competition, and the situation on the ground is putting them under enormous pressure: it’s not much fun out there right now. But when the dust has settled it will be the same doctors who are given the opportunity to rectify fears and build new systems – it will be the very doctors now campaigning against the bill now who can take hold of the keys to what happens in the future.
Likewise in public health, Health and Wellbeing Boards could become an underfunded sop to social care integration and at worst a massive drain on the NHS. But given the right direction, and particularly given good data, they could become a serious force for good at a population level and bring better integration between health and social care. Doctors need to ask how they can ensure the latter rather than the former.
The bottom line is that this bill will pass and then we are where we are. Maybe it’s time the combined brains of the nation’s doctors stopped talking about what is wrong with the new landscape and asked how they can make it work for patients.
Edward Davies is editor, BMJ Careers