LibDems get tough

Is it possible for the LibDems to get tough?

The Sunday Express (yeah, stop laughing, but honestly there is nothing in the article about Princess Diana) reports that Simon Hughes saying that the LibDems are now going to get tough with the Tories and insist only on policies mentioned in the Coalition Agreement. (For politicians who are supposed to be experts at coalitions - it is, after all, their only chance of power - they do seem to have made a complete mess of keeping the Tories to the Coalition Agreement, but I digress...)

The Express reports that Hughes is upset that the No2AV campaign fought a

"fundamentally fallacious campaign" which would affect the way the coalition partners behaved in Government.

"The effect on the coalition is it will reduce trust in the Tory party among our members and amongst colleagues. The coalition is a five-year deal. That won't change, because that is in the national interest. We did a deal and we will keep to that deal. But it will mean, from now on, we are very clear that we will keep to what the coalition has agreed in the Coalition Agreement - that other stuff will not be allowed in as policy unless our party has agreed to it, and I guess that the same will apply for the Tory party."

GP online are rather optimistic about this, saying

Much of the Health Bill could now be rejected by Liberal Democrat MPs, including the plans to abolish PCTs and SHAs.  The Coalition Agreement, released in May last year, did however moot plans for GP commissioning and the development of Monitor to oversee ‘competition and price-setting in the NHS’. It also said an ‘independent NHS Board’ will be created to allocate resources and provide commissioning guidelines.

Such a pick and mix approach to the Health Bill will be completely bonkers: you simply cannot pick which parts you want and drop the rest. However, if the LibDems do get tought, and do stick to the word of the Coalition Agreement it should affectively kill the Health and Social Care Bill because the types of amendments it would suggest would be too wide scale for the Bill to be workable.

Coalition Agreement

It is interesting to see what the Coalition Agreement says, so here are the important points:

1. Real terms increase in health spending
2. Stop top-down re-organisations of the NHS.
3. Significantly cut the number of health quangos. 
4. Stop centrally dictated closures of A&E and maternity wards
5. Enable GPs to commission care.
6. Directly elected boards to PCTs, PCTs to "champion patients" and do the commissioning not done by GPs. PCTs will be responsible for public health.
7. Right to a choice of GP.
8. 24/7 urgent care service
9. Develop Monitor into an economic regulator that will oversee aspects of access, competition and price-setting in the NHS. 
10. Create NHS Board to allocate resources and provide commissioning guidelines
11. "reform" NICE and move to value based pricing
12. Allow patients to choose any healthcare provider that meets NHS standards, within NHS prices (independent, voluntary and community sector providers) 
13. Cut the cost of NHS administration by one third. Various stuff about "reducing duplication and administration". 

What is in the Bill?

So what has been delivered? "Real terms increases" is specious. There are still Tories who will argue until the cows come home that Osborne gave the NHS a generous settlement, and there are even some Tories who believe in the virtual money that will be created as "efficiency savings" (here's the clue, the money will not be there, the efficiencies have to be made to make up for the lack of funding, in any other government department such changes in funding would be called cuts).

The number of health quangos has been cut (this is also a LibDem manifesto pledge) and the health bill does give patients the right to choose a GP (even if it is a daft idea), another LibDem manifesto pledge. The 24/7 urgent care service is the 111 service and is a consequence of allowing patients to register with any GP (otherwise, how do you get home visits if your GP is in another part of the country?). NICE has been neutered (the Daily Mail will be happy) and VBP will be implemented. Although Lansley has pledged to stop the central closure of A&E and Maternity units, in practice he has gone ahead and closed some (for example, Maidstone's maternity unit), so it is debatable whether he can be said to have implemented that part of the agreement.

A substantial part of the Health Bill is about changing the role of Monitor and its role in promoting competition. This part of the Bill has upset a lot of LibDems because they do not like the idea of competition being forced upon hospitals (particularly the cherry-picking of services). They should have made their concerns more explicit during the Coalition Agreement negotiations, because points 9 and 12 certainly indicate that competition will be king. Indeed, the policy of patients being allowed to "choose any healthcare provider" was named Any Willing Provider in the white paper and is now called Any Qualified Provider, and will still go ahead.

Commissioning

That then leaves commissioning. The Coalition Agreement does not describe the type of commissioning that is introduced in the Bill. The version in the coalition agreement is:

We will strengthen the power of GPs as patients’ expert guides through the health system by enabling them to commission care on their behalf. 

This is very different to handing over £60bn of NHS funds to GP consortia and telling them to go ahead and do it. Indeed, the implication of the agreement pledge is that GPs will have only some commissioning responsibilities and only in the context of a patients' expert guide. The white paper makes it perfectly clear that GP commissioning is not about patient care, it is about raw, hard-nosed, cost cutting:

"GP consortia will align clinical decisions in general practice with the financial consequences of those decisions." (section 5.12) 

Nowt in there about commissioning care as a patient's expert guide.

Further, the Coalition Agreement says that some of the PCTs board should be directly elected (with the remaining members appointed by local authorities and the Secretary of State). Of course, this assumes that PCTs will exist! But the current Bill abolishes them. The level of GP commissioning suggested in the Coalition Agreement would allow a role for PCTs and it specifically says that they will "act as a champion for patients". There is no patients' champion in the Health Bill. Further, the Coalition Agreement says that PCTs will be responsible for public health (as they are now) but the Health Bill has given this to local authorities to the disdain of public health experts.

The agreement also says that PCTs will "commission those residual services that are best undertaken at a wider level, rather than directly by GPs" and presumably this means that they would commission GPs as primary care practitioners. In the Bill, both of these actions (specialist commissioning, and commissioning GPs) will be carried out by the NHS Commissioning Board. So rather than merely producing commissioning guidelines the NHS Commissioning Board will actually perform 40% of all NHS commissioning (twice as much commissioning as is carried out by the Department of Health!) This is a huge change because it centralises a lot of power and does a lot of commissioning (GPs, opticians, dentists etc) that should be commissioned locally.

What Does the Bill Add?

So what does the Health Bill do that is not in the Coalition Agreement? There is no mention in the agreement about abolishing SHAs (this is, however, a LibDem manifesto pledge) and the agreement explicitly says that PCTs should exist and that GP commissioning would be a very different to what has been offered. Significantly, the Coalition Agreement does not say that the Secretary of State for Health will no longer be responsible for the universal and comprehensive healthcare provision in England, yet clause 1 of the Health Bill repeals that responsibility.

But the most important bit is that the Coalition Agreement says

We will stop the top-down reorganisations of the NHS that have got in the way of patient care. 

This is not a throw-away remark. It is meant to be a significant tenet of the new government's health plans, and it is a pledge that has been completely, and utterly ignored.

Conclusion

If the LibDems get their way, and only the NHS policies mentioned in the Coalition Agreement will be implemented, the Bill will effectively be killed. The changes to the Bill will be to substantial and the type of commissioning (and the LibDem approach to competition) is very different to that proposed in the Bill.

If the LibDems stick to the spirit of the agreement, then the Pathfinder consortia will have to be re-configured, not least because they will have to work with the directly elected PCTs and thus the GP consortia will have to be aligned to PCT boundaries.

So will the LibDems act tough? Let's hope so, because the very existence of the NHS is depending on this Bill being killed.