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Wednesday, December 15, 2010 

Opaque consultations and Andrew Lansley's NHS reforms.

As political U-turns go, the Liberal Democrat about face on tuition fees has absolutely nothing on the promise made in the coalition agreement that the new government would not indulge in top-down reorganisations of the NHS. The full pact between the Lib Dems and the Conservatives was published on the 20th of May; on the 12th of July the government published the Liberating the NHS white paper, advocating the abolition of strategic health authorities and primary care trusts. If you were feeling cynical you might fall into the belief that the two parties had no intention whatsoever of honouring the pledge made in the agreement, and had been planning all along to do exactly the opposite. Appropriately enough, the website setting out the coalition's Programme for Government has already been closed down, and is now only available through the National Archives' cache.

Today the government published its response to the consultations launched by that previous health white paper. Considering how quick the coalition was to abandon its opposition to carrying out the kind of top-down reforms which had so angered and demoralised NHS staff during Labour's years in power, you'd expect it to at the least recognise or catalogue just how many responses were either in favour of their proposals and how many were against. While this would be time-consuming as there were over 6,000 submissions, it would not only signify this government's dedication to transparency but also enable us to ensure that they aren't misrepresenting the overall tone of those responding.

Instead the document cherry picks from this vast cache of opinions, and while it does provide a small amount of space for trenchant criticisms of the original plans (paragraph 1.15, page 10), it quotes at far greater length those who were supportive, which it describes as coming from "across the spectrum". It's impossible to know whether this is an accurate summary of the consultation submissions for the simple reason that the only thing we have apart from the tiny pieces directly lifted from them littered throughout the paper is the names of the organisations that took part. These are listed in this highly professional 58 page PDF file (original mirrored here in case it's replaced), 27 pages of which are either completely blank or have what may have been the remnants of earlier edits to the document strewn across them.

This wouldn't be so bad or so hilariously hypocritical if the document itself didn't propose an NHS "information revolution" (paragraph 2.23, page 22), the kind where "information can drive better and safer care, improve outcomes, support people to be more involved in decisions about their treatment and care, and, through extending opportunities for people to provide feedback on their service experience, improve service design and quality". Such as by perhaps asking whether those responding to consultations would mind having their submissions published alongside the official government paper, ensuring that their own objections and proposals can be used to hold the department to account? A further consultation was incidentally launched on this "Information Revolution", alongside another on greater choice and control, with very little fanfare back in October (an introduction to the "IR" on the DoH website has so far received only 18 comments). Most will only now be learning of them, with the consultations closing on the 14th of January, leaving little real time for many to respond.

It may well be the case that the responses to the consultation have somewhat altered the government's plans, as it sets out (paragraph 1.13, page 8), although you certainly wouldn't know if from the way it's presented the opposing submissions. For instance, while the summary of how the government has listened suggests that it's changed its view on the commissioning of maternity services due to the response, a look at the actual relevant section (paragraph 4.97, page 79) sees four different organisations quoted as supporting the original plan while another four, described as representing the majority view, differed. Here's where it would have been incredibly useful to have the full submissions to be able to see the real strength of opinion. Without them you're left to take the Department of Health's word for it, which judging by previous performance would be a very foolish thing to do indeed.

As with so much else the coalition is proposing, speed is being favoured over properly thinking through the possible consequences of such rapid and untested reform. The response given in the white paper to those arguing that the proposed changes are a "revolutionary" leap in the dark (paragraph 1.20, page 12) is that they would be better characterised as a logical evolution of the reforms put in place by the last government, with it commenting that practice-based commissioning and GP fundholding have been around for 20 years. This is despite Andrew Lansley previously arguing that comparing the former and GP commissioning is meaningless as they are completely different things. It also doesn't make clear that £80bn of NHS funding will be going straight to the new GP consortia to allocate and spend, a truly massive change, and one which the government is yet to prove the majority of GPs actually want. The cost of this reorganisation, yet to be revealed despite the health secretary apparently knowing the figures, comes as it seems unlikely the government will be able to keep its other promise of a real terms increase in spending on the NHS without making further cuts in other departmental budgets. If no one other than NHS staff originally cared about the breaking of the "no more top-down reforms" pledge, millions of voters will come to if it leads inexorably to Cameron's "cutting the deficit rather than the NHS" policy becoming just another election soundbite.

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