Anyone Listening?

In September the Liberal Democrats had a conference in Liverpool when they spent five days congratulating themselves that the Tories had failed to get a majority and that they had lost 5 seats but not too many to allow them to put a right-wing Conservative government in power.

However, a few Lib Dems (just ten of them) realised that being in government was more than just propping up Conservatives who could not get the country's support, and they expressed their worry over the government's policy on the NHS. The conference was just under two months after the NHS White paper had been published, but this was enough time to read the policy document, yet it appears that only ten did. They proposed the following Emergency Motion (22 September 2010):

Emergency Motion 4: NHS White Paper

10 conference representatives

Conference notes the recent government white paper Equity and excellence: Liberating the NHS.

Conference further notes that existing Liberal Democrat policy:
A. Proposes increased local accountability for the NHS through directly elected Local Health Boards.
B. Supports empowerment of patients and equity for patients, particularly those with mental health problems.
C. Acknowledges the risk of destabilisation of NHS services through the use of private sector providers and sets criteria to minimise this risk.

Conference believes that:
i) The NHS is best served by co-operation and collaboration between hospitals.
ii) The patients with some of the most difficult healthcare requirements, such as elderly patients with multiple medical conditions, are likely to benefit the least from a competitive market, and suffer most where there is lack of co-ordination between providers of services.
iii) GP-led commissioning consortia are unlikely to have sufficient expertise in negotiating contracts to eliminate the risk of exploitation by corporate suppliers, and will need to procure specialised and often more expensive commissioning support, creating significant potential for conflicts of interest.
iv) A more fragmented health service often leads to poor opportunities for clinical training.
v) The white paper proposals will tend to increase choice and service provision in affluent and densely populated areas, and by attracting more services to the centres of population will reduce or remove services in poorer and more sparsely populated areas.

In particular conference restates the principles that every provider should:
a) Meet all NHS standards for Quality, Information and Communication.
b) Demonstrate that it provides value for money and does not undermine the local health
economy.
c) Ensure that no NHS patient shall receive a diminished service as a result of the introduction of a new provider.

Conference therefore urges the Coalition Government to:
1. Legislate to ensure that no company or organisation that offers services in support of the commissioning process should either provide healthcare services directly, or have commercial links to a company or organisation that provides healthcare services.
2. Include in their plans explicit powers for local authorities to intervene if local services are at risk.
3. Ensure that any contract with a provider that does not train clinical staff should include a levy to support training of clinical staff in NHS facilities.

Conference also calls on all Liberal Democrat-led local authorities to use the proposed strategic role given to them in the white paper to protect the sustainability of an integrated health service, and to improve cooperation and communication between providers.

Applicability: England.

This points out problems in the white paper of conflicts of interest in commissioning, problems arising from using the private sector, highlights that the white paper proposals may increase health inequalities and provide worse care for people with complicated health needs, and it points out that training was at risk. This was a warning, but was anyone listening?

It seems not. The Lib Dems then passed a motion at their Spring Conference (12 March 2011) expressing concerns about the Bill (bear in mind that this motion was a toady motion proposed by Paul Burstow the Minister of State and then amended to change its tone from congratulatory to condemnation):

Conference believes that the NHS is an integral part of a liberal society, reflecting the social solidarity of shared access to collective healthcare, and a shared responsibility to use resources effectively to deliver better health.

Conference welcomes our Coalition Government’s commitment to the founding principles of the NHS: available to all, free at the point of use, and based on need, not the ability to pay.

Conference welcomes much of the vision for the NHS set out in the Government’s White Paper, Equity and Excellence: Liberating the NHS which commits the Government to an NHS that:

i) Is genuinely centred on patients and carers.

ii) Achieves quality and outcomes that are among the best in the world.

iii) Refuses to tolerate unsafe and substandard care.

iv) Puts clinicians in the driving seat and sets hospitals and providers free to innovate, with stronger incentives to adopt best practice.

v) Is more transparent, with clearer accountabilities for quality and results.

vi) Is more efficient and dynamic, with a radically smaller national, regional and local bureaucracy.

vii) Gives citizens a greater say in how the NHS is run.

Conference particularly welcomes the proposals to introduce real democratic legitimacy and local accountability into the NHS for the first time in almost forty years by:

a) Extending the powers of local authorities to enable effective scrutiny of any provider of any taxpayer funded health services.

b) Giving local authorities the role of leading on improving the strategic coordination of commissioning across the NHS, social care, and related childrens’ and public health services through councillor led Health and Wellbeing Boards.

c) Creating Health Watch to act as a local consumer champion for patients and to ensure that local patients are heard on a national level.

d) Returning public health duty to local government by ensuring that the majority of public health services will now be commissioned by Local Authorities from their ring-fenced public health budget.

Conference recognises however that all of the above policies and aspirations can be achieved without adopting the damaging and unjustified market-based approach that is proposed.

Conference regrets that some of the proposed reforms have never been Liberal Democrat policy, did not feature in our manifesto or in the agreed Coalition Programme, which instead called for an end to large-scale top-down reorganisations.

Conference therefore calls on Liberal Democrats in Parliament to amend the Health Bill to provide for:

I) More democratically accountable commissioning.

II) A much greater degree of co-terminously between local authorities and commissioning areas.

III) No decision about the spending of NHS funds to be made in private and without proper consultation, as can take place by the proposed GP consortia.

IV) The complete ruling out of any competition based on price to prevent loss-leading corporate providers under-cutting NHS tariffs, and to ensure that healthcare providers ‘compete’ on quality of care.

V) New private providers to be allowed only where there is no risk of ‘cherry picking’ which would destabilise or undermine the existing NHS service relied upon for emergencies and complex cases, and where the needs of equity, research and training are met.

VI) NHS commissioning being retained as a public function in full compliance with the Human Rights Act and Freedom of Information laws, using the skills and experience of existing NHS staff rather than the sub-contracting of commissioning to private companies.

VII) The continued separation of the commissioning and provision of services to prevent conflicts of interests.

VIII) An NHS, responsive to patients’ needs, based on co-operation rather than competition, and which promotes quality and equity not the market.

Conferences calls:

1. On the Government to uphold the NHS Constitution and publish an audit of how well organisations are living by its letter and spirit.

2. On Liberal Democrats in local government to establish local Health and Wellbeing Boards and make progress developing the new collaborative ways of working necessary to provide joined up services that are personalised and local.

3. The government to seize fully the opportunity to reverse the scandalous lack of accountability of publicly-funded local health services which has grown up under decades of Conservative and Labour governments, by:

a) Ensuring full scrutiny, including the power to require attendance, by elected local authorities of all organisations in the local health economy funded by public money, including Foundation Trusts and any external support for commissioning consortia; ensuring that all such organisations are subject to Freedom of Information requirements.

b) Ensuring Health and Wellbeing Boards (HWBs) are a strong voice for accountable local people in setting the strategic direction for and co-ordinating provision of health and social care services locally by containing substantial representation from elected local councillors; and by requiring GP Commissioning Boards to construct their Annual Plans in conjunction with the HWBs; to monitor their implementation at meetings with the HWBs not less than once each quarter; and to review the implementation of the Annual Plan with the HWBs at the end of the year prior to the construction of the Annual Plan for the forthcoming year.

c) Ensuring commissioning of health services has some degree of accountability by requiring about half of the members of the board of commissioning consortia, alongside GPs, to be local councillors appointed as non-executive directors.

d) Offering additional freedoms only to Foundation Trusts that successfully engage substantial proportions of their local populations as active members.

Applicability: England.

It does not appear that the government (nor Paul Burstow) listened to the Lib Dem conference in September 2010. The Lib Dem Spring conference were still complaining about issues that they highlighted in their Autumn conference.

Now the Social Liberal Forum have launched a petition to demand changes to the Bill.

Liberal Democrat members and activists – Demanding changes to the Health and Social Care Bill
Our Federal Party Conference last month overwhelmingly backed a call from Shirley Williams, Dr Evan Harris and 150 others, calling for Andrew Lansley’s health reforms to be significantly amended to bring the policy back in line with the agreed Coalition Agreement and with Lib Dem principles.

Specifically we seek amendments to:

a) ensure the Health Secretary has a duty to provide a fully comprehensive and free health service, with no gaps and no new charges
b) provide more local democratic accountability for the health service
c) curb the market obsession of the proposed reforms to prevent quality being relegated behind price and prevent the cherry-picking of profitable services by the private sector undermining and fragmenting existing provision
d) slow down the pace of change so that the NHS, facing its toughest settlement for decades, does not implode from the stress of another massive reorganisation

The changes to the health bill required by conference are set out in full here. They do not preclude other changes that may be needed but which were not covered by the conference motion as amended.

We are calling on our party’s leadership to fully respect the declared view of the Party on this matter and insist on all these changes in the health policy in any discussions with the Conservatives.

We believe it would be unacceptable for Liberal Democrat MPs and peers to be whipped to vote against conference policy and to vote in support of Tory policies that were not included the coalition agreement and that we have democratically rejected.

The Spring conference was during the time that the Bill was passing through the committee stage in the House of Commons, with ample time for the Liberal Democrat minister, Paul Burstow to amend the Bill according to his party's wishes. Did he? No, this is why the Social Liberal Forum had to launch their petition (and the pointed statement at the end about whipping Lib Dem MPs to vote contrary to Lib Dem policy).

Now the Bill has been  delayed (Lansley: "during the natural break"; Clegg: "for two months"; HSJ: "for one month"; in other words for very little time at all). Is it likely that the Bill will be changed "substantively" as Clegg suggests? Well, judging on past performance, the answer is No.