McKee, Martin

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McKee, M (2012) Martin McKee replies to Andrew Lansley. BMJ,344. e921. ISSN 1468-5833 DOI: 10.1136/bmj.e921Downloaded from: http://researchonline.lshtm.ac.uk/20761/DOI: 10.1136/bmj.e921Usage GuidelinesPlease refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna-tively contact researchonline@lshtm.ac.uk.Available under license: Creative Commons Attribution Non-commercialhttp://creativecommons.org/licenses/by-nc/2.5/RESPONSEMartin McKee replies to Andrew LansleyMartin McKee professorLondon School of Hygiene and Tropical Medicine, London WC1H 9SH, UKI thank the Secretary of State for seeking to correct mymisunderstanding of the proposed NHS reforms.1 However, hisresponse has raised additional questions in my mind, not leastbecause in the 24 hours since his response was published he haspublished almost 140 amendments to the bill. I wonder if I amalone in struggling to keep up.I am reassured to know that the NHS will “remain free at thepoint of use” but am still unclear whether this covers thoseservices, such as sexual health, that are being transferred to localgovernment and therefore will no longer be “NHS.” Willcouncils be able to means test them, as they did with the longterm care services that they previously took over from the NHS?I welcome the description of who is responsible for variousthings but note that my confusion was shared by the House ofLords Constitution Committee, which stated that “it is not clearwhether the existing structures of political and legalaccountability with regard to the NHS will continue to operateas they have done hitherto if the Bill is passed in its currentform.”2I agree that there are certain things that would benefit by beingmade explicit but remain uncertain about why thesecomparatively simple matters require a bill stretching to severalhundred pages. The argument that the reforms will increase thescope for frontline professionals to make decisions seemsstrangely at odds with a commissioning structure that replacesthree management tiers with five3 and contains a series ofministerial injunctions to “make every contact count” and, fornurses, to undertake ward rounds hourly. It is also surprising toread that patient experience in the NHS is poor, given evidencefrom the Commonwealth Fund that the UK is first or secondamong 11 countries on many measures of patient centredness.4The Secretary of State offers reassurance about privatisation ofcommissioning and tells me that I am wrong in believing thatthe consortiums will be required to increase the numbers ofpatients treated in private facilities. I know that commissioningconsortiums will be statutory bodies but read in the current draftguidance on commissioning support, which covers theoperational work that they will do, that “the NHS sector, whichprovides the majority of commissioning support now, needs tomake the transition from statutory function to freestandingenterprise.”5 Furthermore, while I am aware that the bill doesnot explicitly favour any provider, I read in the most recent NHSOperating Framework that one of the measures on which theNational Commissioning Board will be judged is the “trend invalue/volume of patients being treated at non-NHS hospitals.”6Surely, we must expect that commissioners will respond to thisclear incentive?Finally, I remain puzzled about how the legislation is neededto give confidence to the NHS given the results of the recentYouGov poll reporting that 80% of NHS staff expressing anopinion believe that the bill should be withdrawn.7I am sure that, in time, I will manage to understand the reforms.Indeed, it may be that some of the answers are contained in thetorrent of amendments being introduced to clarify the intentionsof the bill, although this begs the question of why, if it was allso clear, they are now deemed necessary. Sadly, I fear that, fornow, my confusion is only deepening.Competing interests: MMcK wrote the article that the Secretary of Stateis responding to.1 Lansley A. Why legislation is necessary for my health reforms. BMJ 2012;344:e789. (1February.)2 House of Lords Constitution Committee. Report on the Health and Social Care Bill. www.publications.parliament.uk/pa/ld201012/ldselect/ldconst/197/19703.htm.3 Watt N. Andrew Lansley accused of presiding over “utter shambles” on NHS reforms.Wintourandwattblog. Guardian 2012 Jan 27. www.guardian.co.uk/politics/wintour-and-watt/2012/jan/27/andrewlansley-nhs.4 Schoen C, Osborn R, Squires D, Doty M, Pierson R, Appelbaum S. New 2011 curvey ofpatients with complex care needs in eleven countries finds that care is often poorlycoordinated. Health Affairs 2011;30:2437-48.5 NHS. Developing commissioning support. Towards service excellence. 2011. www.hsj.co.uk/Journals/2011/11/09/t/q/p/Towards-Service-Excellence_021111-FINAL.pdf.6 Department of Health. The operating framework for the NHS in England 2012/2013. www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_131428.pdf.7 YouGov. YouGov 38 degrees survey results. January 2012. http://cdn.yougov.com/cumulus_uploads/document/7z5fk1xe8g/YG-Archives-38Degrees-NHSWorkers-260112.pdf.Cite this as: BMJ 2012;344:e921© BMJ Publishing Group Ltd 2012martin.mckee@lshtm.ac.ukFor personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribeBMJ 2012;344:e921 doi: 10.1136/bmj.e921 (Published 7 February 2012) Page 1 of 1LettersLETTERS

Martin McKee replies to Andrew Lansley.

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