Wiltshire hospitals are victims of NHS 'constant revolution'

10.23.00pm UTC (GMT +0000) Wed 21st Jun 2006

Professor Steve Webb MP, Lib Dem Shadow Secretary of State for Health, reminds the NHS Confederation of the growing number of community hospitals being closed in Wiltshire and Gloucestershire, in a speech to their annual conference:

Steve Webb MP: "Even where there is near universal opposition - as with the mass closure of community hospitals in places such as Gloucestershire and Wiltshire - the system seems to plough on regardless."

Steve Webb MP: 'We need evolution. Not constant revolution.'

It gives me great pleasure to speak for the first time to the annual conference of the NHS Confederation. As the health spokesman for one of the two principal opposition parties, you might expect me to spend my time this morning criticising the Government. And if you listen carefully, the odd slightly critical remark might slip out.

But actually those of you who are on the front-line trying to deliver quality health care don't need me to tell you what the problems are of the NHS. You know how difficult it can be to cope with an ever-changing environment where the rules of the game seem to change with little notice but with alarming regularity.

So what I want to do instead is to set out an alternative vision of how the Liberal Democrats want to health care healthcare developing in the future.

As an opposition politician, it is very tempting to stand up and say that everything is going wrong with the NHS and what is needed is - wait for it - REFORM. But I suspect that that would probably be the best way to get the NHS Confederation to come out in sympathy with the Royal College of Nursing in the slow-handclap stakes.

In fact, my view is quite the opposite. In my view, the NHS is actually suffering from too much reform, too fast. There seems to be a lack of a clear long-term direction, and reforms and restructuring pile up one after another with little time for each to bed in or for any to be properly evaluated. So much for evidence-based policy. You could be forgiven for thinking that the Government is making it up as it goes along?.

But whilst I don't believe that we should simply be calling for yet more root and branch reform, nor do I believe that the status quo is an option. To say: "Vote for me and I won't change anything" is hardly a cry that stirs the soul or drags voters out to the polling station to put their cross against the Liberal Democrats.

What I believe that we need is evolution. Not constant revolution. I believe that NHS managers need to know that the broad financial and regulatory framework that they will be operating in will not change for several years. I don't imagine that as Secretary of State for Health I would be able to resist totally the temptation to meddle, but the presumption has got to be to leave people front line the frontline the time and space to adjust to the new NHS and to plan ahead, instead of constantly having to respond to headline-grabbing initiatives.

One of my biggest concerns about what is happening in the NHS at the moment is not that change is happening but rather that it is being driven by short-term financial crises. The changes that are made all too often have to be those that will yield a "quick win" in terms of financial balance, rather than those that necessarily represent the best long-term strategy for delivering improved patient care and greater efficiency.

Rather than constantly moving the goalposts, what government can and should do however, is to set a long-term framework and direction of travel.

Which aspects of the current direction of travel should we be most concerned about?

With regard to "payment by results" - or "payment by activity" as perhaps it should be better named - I have no problem with the principle of identifying the cost of a procedure and starting to think about why costs and processes vary so much from one institution to the next. But I do have reservations both about the speed of change and about the scope of tariff-based payments. Where long-term conditions are concerned, in particular, I very much doubt that a "piece-work" based system of payment is really the best way to proceed. I am very much attracted to the idea of a pooled budget for a "year of care", to which different agencies might have access, and which might make it more realistic to deliver patient-centred care largely outside an acute hospital setting, and with full involvement of social services as appropriate.

We should also be concerned about an ideological preference for independent sector providers over NHS providers. Whilst the Government's rhetoric is that they want a "level playing field", the reality is that in many cases the private sector has effectively been bribed to be part of the NHS market with guaranteed volumes of business and above-tariff prices. Incidentally, I have asked in Parliament for information about how much money ISTCs get for each procedure they carry out compared with the going rate for the NHS but have been told that I cannot be told because this information is commercially sensitive. Something tells me that if the playing field was truly level, the information would not be sensitive.

So what would be the key features of that direction of travel in a Liberal Democrat world?

The first goal would have to be progressive decentralisation of decision-making in the NHS. Despite the Government's rhetoric, the reality is that the NHS is still a hugely centralised organisation.

Earlier this week I chaired a health conference address by health minister Lord Warner. In his biography it said that he was "responsible for cleanliness in hospitals". I had a picture of the noble lord clad in ermine with a mop and bucket in his hand! Surely, there is no meaningful sense in which one minister in Whitehall can or should be responsible for cleanliness in literally hundreds of NHS hospitals?

We need to get away from the notion that Whitehall knows best or that a massive organisation, employing 1.3 million people - or 1 voter in 30 as I prefer to think of it - can be well run from the centre. For as long as individual hospitals and GP practices are so constrained by what central government and strategic health authorities will allow, we will never achieve the benefits of allowing innovation and creativity to flourish.

The second feature of the Lib Dem evolutionary approach would be greater local democratic accountability.

The truth is that the people who pay for the NHS no longer feel that it belongs to them. In Parliament, it is now impossible to talk about "consultation" about local NHS changes without adding the adjective "sham". As someone once said, never in the field of human history have so many been consulted by so few to so little effect. Up and down the country you hear tales of people being consulted to death about local NHS changes, and then what actually happens is what the SHA originally proposed. Even where there is near universal opposition - as with the mass closure of community hospitals in places such as Gloucestershire and Wiltshire - the system seems to plough on regardless. As a result, people feel increasingly disenfranchised and increasingly disinclined to engage with future consultations. This cannot be a healthy trend.

I imagine that for some in this audience today, the prospect of more public involvement - perhaps even by directly elected representatives - fills you with horror. Clearly there are dangers that populist politicians will scupper necessary but difficult changes to local health services on the back of knee-jerk "save our hospital" campaigns.

But much depends on exactly how people are engaged in the process. For me, there are a number of key elements in effective consultation.

First, people need to be involved early on. Rather than wait until a decision has been made and be asked to rubber stamp it, the public should be involved at the stage where a problem has been identified and should be engaged in trying to develop a solution. Second, the views of clinicians should be given considerable weight and public exposure. Where people can see that changes are being made because clinicians believe it will deliver a better quality of service, rather than simply because of the latest financial crisis, they are far more likely to buy in to those changes. Clinicians do have a credibility with the public to which managers - and politicians - can only aspire. I know of one former Health Secretary who would happily go on Newsnight at the drop of a hat to debate issues with fellow politicians but who had a policy of never going on if he was opposite a man in a white coat!

Not only do the public need to be engaged early and genuinely, but their elected representatives also need to have a key role. One of the things that makes the public feel most enraged and impotent about NHS reform at present is that if they disagree with a decision they have no control over the people who make that decision. The only elected person to whom the decision-makers are ultimately responsible is the Secretary of State. It makes a complete farce of local democracy when councillors who scrutinise local health decisions can only get a decision over-turned by begging the Secretary of State to refer the decision to a quango - the Independent Reconfiguration Panel.

The exact way in which local democracy should interact with the NHS is a subject on which the Liberal Democrats are currently consulting - and on which I would value your views. We are just in the process of establishing a year-long health policy working group, to be chaired by my colleague in the House of Lords, Baroness Julia Neuberger, which will review our whole approach to health policy. One of the key issues for that working group to discuss will be how you can give local people real ownership of their NHS, through a system of proper local democratic accountability, whilst retaining the ability of the NHS to make difficult decisions in the interests of health care delivery of healthcare.

The third key strand of the evolution that the Liberal Democrats want to see is much closer working between primary care and social services. I very much welcome the fact that the new structure of PCTs now means that roughly two in three are co-terminous with local social services authorities and I believe that those structures must now be given time to settle down and start building new partnerships. In the interests of avoiding yet more turmoil, I won't advocate here and now the complete merging of primary care and local authority social services budgets, but again, that does seem to me to be a direction in which we ought to be travelling. Much progress has been made in joint working in recent years, but there are still too many artificial distinctions between health and social care and too much shifting of people from one budget to another when it is not necessarily in their best interests.

These then are the three key features of the direction of evolution that the Liberal Democrats would like to see - steady decentralisation of decision-making, greater local democratic accountability and a progressive removal of the barriers between health and social care.

Together, these strands would produce an NHS which would be more responsive to local needs, more innovative and creative, and more able to meet the needs of the whole person to whom care was being provided.

A great deal of good work is currently going on in the NHS and there is much that can be built upon. But those who run the NHS need to know the direction in which the NHS is going, and that direction needs to be settled - not changing by the week.

Far from speeding up the pace of NHS reform to deliver the Prime Minister a legacy before he goes, the Government should be slowing the pace of change, giving front line people on the frontline in the NHS the time to adjust to the new environment in which they find themselves. The NHS should not be set in stone. But it must be set a clear and consistent direction of travel and must be given time and space in which to evolve in that direction. The era of permanent revolution must end.