{"id":18759,"date":"2012-07-17T10:40:02","date_gmt":"2012-07-17T09:40:02","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=18759"},"modified":"2012-07-17T10:40:02","modified_gmt":"2012-07-17T09:40:02","slug":"anna-dixon-evolution-or-revolution-the-story-behind-the-health-and-social-care-act-2012","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2012\/07\/17\/anna-dixon-evolution-or-revolution-the-story-behind-the-health-and-social-care-act-2012\/","title":{"rendered":"Anna Dixon: Evolution or revolution: the story behind the Health and Social Care Act 2012"},"content":{"rendered":"

\"AnnaIt was often difficult to know who to believe during debate about the Health and Social Care Bill<\/a>. 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.<\/p>\n

In his account of the story behind the bill<\/a>, published yesterday by The King\u2019s 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<\/a>. 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 \u201cmistakes\u201d have been avoided if lessons had been heeded from previous major reforms to the NHS?<\/p>\n

Ken Clarke introduced the purchaser provider split to the NHS with the 1989 White Paper Working for Patients<\/em>. These ideas had much continuity with Labour\u2019s attempt at the market. The names were different\u2014foundation trusts, practice based commissioning, payment by results, and patient choice\u2014but the elements were very much the same and all have been reflected again in the current reforms. Indeed the coalition government\u2019s 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 \u201cchallenging and far reaching set of reforms\u201d in the government\u2019s own White Paper? A puzzle indeed from a political point of view.<\/p>\n

It was David Nicholson who vividly characterised the enormity of the reforms\u2014\u201cso big you could see them from space.\u201d 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\u2014a mongrel created from the Conservative ideas of markets and the Liberal Democrat commitment to local democracy\u2014were unworkable. The solution\u2014hand over public health to local authorities, devolve commissioning to groups of GPs and abolish PCTs.<\/p>\n

In our account of Labour\u2019s health reforms<\/a>, 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 \u201cHave a clear narrative about the reforms and make sure their purpose is clear to those responsive for implementing them.\u201d 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.<\/p>\n

Our other lessons were around the implementation phase. This story is yet to unfold and, unlike Nick\u2019s lessons of the policy making process, there is still a chance for the government to learn. Three are worth repeating here.<\/p>\n

Firstly \u201cBe open to adapt and refine policies in response to the changing context.\u201d 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.<\/p>\n

Secondly \u201cDo not assume that passing new legislation will change the behaviour of those within the system.\u201d 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.<\/p>\n

And a final note of caution: \u201cExpect there to be unintended consequences, amplify the positive, and mitigate the negative.\u201d 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.<\/p>\n

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\u2019s hope we don\u2019t repeat the same mistakes over implementation.<\/p>\n