Anna Dixon: Evolution or revolution: the story behind the Health and Social Care Act 2012

Anna DixonIt was often difficult to know who to believe during debate about the Health and Social Care Bill. The public were faced with baffling technocratic details from government with no accompanying compelling narrative to explain the need for such significant reforms, alongside sensationalised claims from some who opposed it that the bill spelt the end of the NHS as we know it.

In his account of the story behind the bill, published yesterday by The King’s Fund and the Institute for Government (IfG), Nick Timmins sets the record straight. Through interviews with key players involved in the action, analysis of public speeches and documents, and his own personal observations as a journalist reporting on the bill, Nick has produced an illuminating account of the policy making process and suggested some lessons for government. The IfG have elaborated on some of the wider lessons for policy making. But how revolutionary were the reforms? Were they just a continuation of the market reforms begun in the early 1990s? And could any of these “mistakes” have been avoided if lessons had been heeded from previous major reforms to the NHS?

Ken Clarke introduced the purchaser provider split to the NHS with the 1989 White Paper Working for Patients. These ideas had much continuity with Labour’s attempt at the market. The names were different—foundation trusts, practice based commissioning, payment by results, and patient choice—but the elements were very much the same and all have been reflected again in the current reforms. Indeed the coalition government’s reforms were seen by some as completing the unfinished business of the new Labour project. So why, as Nick describes, were these reforms presented as a “challenging and far reaching set of reforms” in the government’s own White Paper? A puzzle indeed from a political point of view.

It was David Nicholson who vividly characterised the enormity of the reforms—“so big you could see them from space.” The reason they were seen as so revolutionary was the extent of structural change they brought. The programme for government had not signalled the abolition of Primary Care Trusts (or Strategic Health Authorities, which got no mention), but the proposals it contained—a mongrel created from the Conservative ideas of markets and the Liberal Democrat commitment to local democracy—were unworkable. The solution—hand over public health to local authorities, devolve commissioning to groups of GPs and abolish PCTs.

In our account of Labour’s health reforms, published after the publication of the White Paper but before the bill, we set out some of our own lessons for government. One of these was “Have a clear narrative about the reforms and make sure their purpose is clear to those responsive for implementing them.” Yet clinicians, and particularly GPs who were always going to be critical to the success of these reforms, were some of those who most actively mobilised against the bill. Managers who traditionally saw NHS policies get implemented were under fire and many were working for organisations that were marked for abolition.

Our other lessons were around the implementation phase. This story is yet to unfold and, unlike Nick’s lessons of the policy making process, there is still a chance for the government to learn. Three are worth repeating here.

Firstly “Be open to adapt and refine policies in response to the changing context.” When faced with a radically different financial context, Andrew Lansley made little change to his original ideas formulated in a time of plenty. It is vital that policies are adapted as the needs and demands on the system change.

Secondly “Do not assume that passing new legislation will change the behaviour of those within the system.” The focus of Andrew Lansley and senior civil servants has been on getting the bill through. The issues of implementation have been left to David Nicholson to take care of. Delivery needs as much attention as design.

And a final note of caution: “Expect there to be unintended consequences, amplify the positive, and mitigate the negative.” As we, and others have highlighted, there are both opportunities and risks inherent in the current reforms. They could play out very differently in different areas and for different services. Careful attention will need to be paid to the impacts of these reforms in order to identify where things are working well and where they are not. If we are to learn lessons, there is an urgent need for the government to commission evaluations of the key components.

The art of good policy making is now well documented. And yet despite knowing how to do it, we seem to keep on forgetting. Let’s hope we don’t repeat the same mistakes over implementation.

Anna Dixon is director of policy at the King’s Fund