Crunch time for the Liberal Democrats –The NHS Bill and electoral oblivion

The tuition fee debacle was bad. But at least there was a reason, if not an excuse. Neither major party was committed to removing tuition fees. So whoever the Liberal Democrats ended up in Coalition with it was unlikely that the party was going to be able to honour its pledge. The hand was no doubt badly played, but the outcome was going to be nothing other than politically damaging.

This time there is no excuse. The Conservatives may claim that their manifesto refers to extending GP commissioning. But this passing reference is a threadbare justification for the enormous changes being proposed. And how many electors actually read the manifesto? If they bought the story at election time then it was more likely to be Cameron the compassionate Conservative reassuring them that the NHS was his top priority, that it was safe in his hands, that there would be no top down reorganisation, that it wouldn’t be privatised, etc., etc., etc. That these reassurances were not worth the breath required to produce them seems increasingly apparent. Significant chunks of the electorate have interpreted the Government’s plans as taking an axe to their beloved NHS.

We can quibble about whether the plans being rushed through the Commons this week actually constitute privatisation. But that is largely irrelevant. The PFI was not technically privatisation. But it has resulted in commercial interests taking large amounts of money from taxpayers in the good times, while leaving the taxpayers to pick up the bill when things don’t work out. And, in many cases, for the provision of a poorer service. That is what people object to.

Liberal Democrats may well consider a version of the GP commissioning approach – including stronger local democratic accountability – to be desirable. The party may well have a model of commissioning that would be both democratically acceptable and prevents commercial interests running rampant. But attempts to graft that on to Andrew Lansley’s original proposals have resulted in a dogs’ breakfast of a proposal. Many informed observers think is unwieldy and inefficient. The chances of these precipitous reforms delivering the sort of cost savings the Government promised were always miniscule. If these proposals go ahead then the prospects look vanishingly small.

Shirley Williams’ intervention over the weekend will further fuel concerns that buried in the 1,000 pages of this Bill are provisions that are going to lead to the progressive privatisation of the NHS. That may be through bad drafting and inadvertence – the protections needed to stop it are not there. But the evidence, brought to light by Spinwatch through FoI requests, that talks are already well underway between the Department of Health and multinational providers rather suggest that this is intentional.

Andrew Lansley might seek to write off this evidence as scaremongering. There have been comments from senior politicians, including Liberal Democrats, that continuing to debate these issues is creating uncertainty and delaying the cost savings that need to be made. The time has come to move on, it is suggested. I am reminded of some of Bob Diamond’s comments that the time for remorse over the banks’ role in the global financial crisis is over and we should get back to business. Only the bankers think that is the case.

These manoeuvres which attempt to silence critics of the NHS reforms are similarly crass. I hope that backbench Liberal Democrat MPs will be having none of it. The changes proposed to the NHS are momentous. They deserve as much scrutiny as possible and they need to be given as much Parliamentary time as possible, rather than being railroaded through Parliament in time for conference season.

Among the Liberal Democrat membership there are significant differences over whether introducing commercial providers into the NHS is desirable. Those who start from a stronger economic liberal orientation seek to separate means from ends and argue that as long as the service is free at the point of use and taxpayer funded there isn’t a problem. The full force of domestic and EU competition law will be a welcome spur to efficiency. Those with a stronger social liberal orientation argue that means are important if you want to achieve the ends of equality and cohesion – that pushing for privatisation and marketisation will have negative effects on access that will fall differentially upon the least advantaged. Attempts to counteract this tendency will require systems of targets and regulation which not only tend to set up distortionary incentives but also can absorb all the resources that are “saved” by introducing competition in the first place.

But these are technical discussions. They are largely irrelevant to the electoral consequences of the next few days.And being against these reforms is not to be against reform per se.

The NHS reforms will be constructed by their opponents as privatisation. The Coalition is the government that killed the NHS. And this is how large chunks of the electorate will interpret them. It may not be rational. But that doesn’t mean it isn’t the case. The killing the NHS will be the part of the legacy that enters the history books, as much as its success or otherwise in taming the budget deficit.

Many people did not vote Liberal Democrat seeking or expecting that outcome. Indeed, many voted Liberal Democrat for precisely the opposite reason. The NHS was a Liberal creation. Surely its future would be safer with the Liberal Democrats than with the Tories? Supporting this Bill in its current form will be seen by many as betrayal too far. And, unlike tuition fees, this time there will be no excuse. If we take that direction then electoral oblivion awaits.

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    • To be honest, that seemed largely rhetoric to me. Ultimately, in the UK we are lucky enough to have a health system that is more cost efficient than those of our continental neighbours and, according to the Commonwealth Fund we have the lowest proportion of people wanting any change (particularly substantial change) to the NHS of any of the countries they polled, which included some continental countries, Canada and Australia.

      Fundamentally, people, by and large, don’t want big changes to the NHS, and myself, as a by and large Lib Dem leaning voter, agree. Adjustments can be made, nothing is ever perfect and it’s better to tinker than to let it stagnate. Fundamentally, the current model is working pretty well though, and I see no reason for large changes. Yes, modifications on the current system to make x,y,z improvement would be fantastic but I see no need for any fundamental changes.

      Even if I did, GP commissioning would not be my answer. I would be fine for doctors to effectively run the NHS (though perhaps with someone higher up to keep the budgets in check as an overseer), provided there was a recruitment drive so that the same amount of actual medical work was done by the doctors as a whole.

      However I think that restricting this to GPs is, quite frankly, ludicrous. Perhaps it’s my biological sciences background but I’m aware that there are many very wonderful but hideously expensive drugs in the pipeline that will hit the clinic but never the GP’s surgery. I’m concerned that in the near future, more than ever, GPs will not see the most expensive procedures and treatments on the NHS first hand and that they are in fact singularly the least suited of all the doctors to be in charge of the NHS budgets. If the NHS were to be run directly by the doctors, I would in fact be inclined to include everyone but the GPs in budgetary decisions.

      The quality of GPs is also highly variable, I used to live in Oxford, in one surgery a GP was unable to diagnose a concussion (!) after seeing a patient I know. In another surgery, with a different patient, a GP was able to diagnose a very specific problem of the middle ear after a single visit that took an ENT specialist a few months to figure out. I would trust the second doctor with commissioning all my medical services, not so much the first one.

      As an aside, it’s all very well to talk about democratic accountability, but how far does this extend. If patients want more single sex wards, rooms instead of wards, cheaper parking, better transport to hospitals et cetera, that’s all very good and attempts to make the system more responsive to these concerns are to be lauded. This is the customer service side.

      The medicine side however deals a lot more in evidence and science than in opinion – and the truth is not a democracy and the truth (certainly in medicine) is more important than democracy. It is completely right that if the people want, say unhealthy food served in hospital or the NHS to spend a lot of money on homeopathy, that the NHS should completely ignore these requests, no matter how many people make them. This is a matter of principle rather than a specific concern at this bill or your post, but despite being a liberal, rhetoric about making the NHS more democratically accountable just makes me suspicious.

      I hope that my post has been appropriate in tone, but quite frankly, I disagree with you as much as is humanly possible and I would take great pleasure in seeing these ill-thought out, potentially harmful schemes rightfully shot down in flames.