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Unravelling Lansley:- Will it affect public and patient engagement?

The weekend speculation is that the Government will legislate to re-organise the NHS in England over the coming months. An inspired leak has allowed Ministers to test public reactions, and hopefully to avoid the debacle that surrounded the Coalition’s NHS reform package almost a decade ago.

The history of the changes which brought CCGs into existence and changed many of the decision-making structures has settled on a narrative that George Osborne claimed to have been taken by surprise. He had masterminded the 2010 election around Cameron’s pledge “We will stop the top-down reorganisations and pointless structural upheavals that have done so much damage to the NHS …”  But silently, Andrew Lansley had held the Shadow health brief for years, delved into detail and had nurtured his own plan. According to Matthew d’Ancona’s 2013 book[1] on the early years of the Coalition, one adviser had noted that “He’s like a mad professor in the shed.”  A home-worker before his time, perhaps!

Many twists and turns occurred before the changes became enshrined in the 2012 Health & Social Care Act. Primary Care Trusts were abolished. Managers who knew their jobs inside-out were made redundant, and there was a huge haemorrhage of expertise. These included hundreds of public engagement specialists. Instead, General Practitioners were prised away from their patients to become bureaucrats commissioning services from Hospitals with budgets infinitely greater than the doctors had ever experienced. The changes had few supporters, but with typical British talent for muddling-through, somehow it was made to work. The NHS is a tremendous learning organisation. It is a tribute to thousands of dedicated people that the service managed to survive despite inadequate funding and a statutory framework that’s a mixture of Alice in Wonderland and Uri Geller trying to do the Rubik cube.

So, unlike 2012, this legislation will not be a surprise. It will be a case of Parliament playing catch-up with the realities of managing the service. So unwieldy was the Lansley model that Sir Simon Stephens and his colleagues have had to devise workarounds to make the system work. Jeremy Hunt, who inherited this institutional chop suey actively connived with its non-statutory modifications. The bizarrely-named STPs (Sustainability and Transformation Plans) had to be created just to counter the fragmentation of the management and resurrect some roles of the previous Strategic Health Authorities. (During the pandemic, many have lamented their absence!). We even had a bright new idea called Accountable Care organisations – as if the rest of them had never been intended to be accountable!

Until we see the White Paper, we should treat many of the current stories as kite-flying.

However, the Consultation Institute and its Associates are acutely aware that the structure and legislative framework for the service has a significant bearing upon the conduct of public engagement. So here are five brief pointers on what to look for as more information drip-feeds into the public domain in the coming weeks.

  • Expect the abolition or emasculation of CCGs and a move away from their commissioning role, especially the need to consider what was once called ‘any willing provider’. This has the potential to destabilise valuable community relationships work that has gradually been re-built by public engagement professionals, but much of this has already been absorbed by Integrated Service providers and similarly named consortia of organisations.
  • Ministers seem quite keen to take charge of major changes to Hospital services, and, one suspects, to take credit for new builds and visible investment in them. One report stated that they wanted a role in determining hospital closures and reconfigurations, but in a sense they already have it through the Local Government legislation by which they refer contentious proposals to the excellent IRP (Independent Re-configuration Panel). They should beware of what they wish for. It is uncomfortable for Ministers to have to square the circle between the logic for change and the public’s opposition. If in doubt, ask SNP Ministers – who once got elected on a promise to save a hospital that professionals to a man and woman felt needed replacement.
  • We should assume that no Government would be foolish enough to water down the requirements for public and patient involvement, but we know from experience that tinkering with the words can have unintended consequences. We will watch this issue carefully and seek to influence Parliamentarians and major stakeholders to preserve and enhance the role of the public; if this were threatened, it would be a major political tussle and would win the Government few friends … even amongst its own supporters.
  • Assuming that the much-needed requirement to consult remains, replacing the CCGs could serve to improve such consultations in one important respect – by removing some of the confusion as to who is running such exercises, and who takes the decisions. Insiders may know the answer, but consultees have frequently been bemused about the distinction between the CCG – as the lawful consultor, and the local hospital Trusts whom they commission, and who appear, too often to call the shots when eventual decisions are made. We may also be spared some of the unseemly manoeuvring as clinicians fight it out at options-development stage.
  • Little of this can be done quickly. Sir David Nicholson, the former head of the NHS described the Lansley plan as ‘So big you can see it from space’. If the Government wants to move quickly – and one newspaper said they wanted changes in place by April 2022 – its only chance is to make it so small that very few people notice. A technical tidy-up might therefore be prudent, but who knows if this administration will quite see that as sufficient.

There is one other major reason to make haste slowly. The elephant in this particular room is Social Care, and until decisions are made about its post-pandemic future, so much of any new legislative framework remains uncertain. Unlike the devolved administrations in Edinburgh, Cardiff and Belfast, the integration of health and social care in England remains a long-standing item on the ‘to do’ list. Covid-19 has taken it close to the top of that list.

Whatever happens, the Consultation Institute will monitor the situation closely, provide commentaries on emerging developments and continue to advocate best practice public engagement and consultation in the belief that the NHS, its patients and the communities it serves are so much better as a result.

[1] In It Together. The inside story of the Coalition Government by Matthew d’Ancona, published by Viking, 2013

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