Edward Davies: NHS Reforms – be careful what you wish for

Edward Davies David Cameron’s speech on NHS reform this week should have marked a substantial victory for doctors’ leaders. In recent months they have been even more outspoken than usual in their opposition to whatever it is the government’s saying this week and David Cameron let them know he was all ears. “I’ve heard the passion of our… doctors,” “I’ve heard doctors tell me,” “I’ve heard our hospital doctors,” “Doctors said we should,” “It’s what doctors and nurses want.” “How high should I jump?” Only one of those may be fictional.

Let’s be in no doubt that Mr Cameron has a bit of a thing for doctors. So why shouldn’t doctors, or indeed the public, be loading the PM or themselves with plaudits after he announced several concessions at their request?

Take the reinstatement of waiting targets. “Yes, we’ll continue to measure how long people are kept waiting in A&E. Nurses and doctors said we should – and that’s what we’re doing.” Is that the sound of a BMA fist punching the air with delight? No, what you are hearing is the dull crack of palm slapping forehead. Because you only have to go back one government to hear doctors saying the direct opposite.

This report from the BBC is just a few years old: “But throughout recent years, government targets – including those for waiting and A&E treatment – have been attacked for distorting clinical priorities. Jonathan Fielden, chairman of the British Medical Association’s (BMA) consultants committee, said: ‘The biggest problem is that the government has not engaged with doctors. “They have imposed these targets from the centre which have interfered with clinical judgement.’”

But there are arguments both ways for these targets so maybe that’s an unkind example.

What about the other splendid victory on scrapping the ridiculously tight 2013 deadline on forming GP consortia. There’s near unanimity on that. “I’ve heard the concern that the direction is right but the pace is too fast,” said Mr Cameron, all ears again. “What if some places, some practices aren’t ready? Will we just let them flounder as others prosper? No. We will make sure local commissioning only goes ahead when groups of GPs are good and ready.”

So GPs can take their foot off the gas. Phew. No pressure. We’ll sign up when we’re ready. All is well. Except we’ve been here before with practice based commissioning and an awful lot of GPs didn’t feel ready to commission. In fact they never felt ready. In fact the lack of urgency around the situation was so profound that it led David Colin-Thome, the government’s own Primary Care Tsar to describe the policy as “a corpse not for resuscitation.” As any editor will tell you, no deadlines means no journal. If you set a tight deadline, people may bitch, curse, and even fail to meet it, but at least there is an expectation to work to.

But actually it’s worse than that. Some areas are already doing GP commissioning very well thank you, while others do not as yet even have any provisional structures in place. What we can expect is some savvy and committed GPs to run with this while others hang back and wait for the next government reshuffle. There will be a two tier system of commissioning for patients. Sound familiar? Fundholding anyone?

And throughout the shenanigans that have played out over the 12 months since Lansley presented his White Paper, there has been a sword of Damocles hanging over the health secretary’s head. Whether it’s at a nursing conference passing a vote of no confidence in him or a doctors’ one narrowly failing to do so, you really don’t have to look far to find voices demanding he be sacked. But who would replace him? Enter stage right Stephen Dorrell.

If Lansley should go Mr Dorrell now appears liked and hotly tipped to fill the seat – indeed even Dorrell himself wouldn’t reject the notion last week.

So just how short is the human memory? Rewind to the eve of 1997’s general election and Tony Blair staked his entire election on the soundbite “24 hours to save the NHS.” The following day’s landslide victory, the most seats the Labour Party had ever held, showed him a keen judge of the public mood. And who was the health secretary from whose clutches the service needed saving? The very same Stephen Dorrell.

This is not a critique of the just criticism thrown at the bill nor any particular advocacy for it, but one of its few merits was the nod to some historical problems in the NHS and an attempt to correct them – the two- tiered system of fundholding, the distorted priorities of targets. So before the UK sashays elegantly back into waiting times, fundholding, and the mid-90s in general, we might just want to be a little bit nuanced about what we wish for.

Edward Davies is editor, BMJ Careers