The real impact of the Health Care reforms depends not on their design but on their implementation. Anna Dixon argues that the government has largely failed to win the support of the medical profession for the Act – as it now is – and yet without their support it is difficult to see how they can make this work

Dixon, Anna

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blogs.lse.ac.uk http://blogs.lse.ac.uk/politicsandpolicy/2012/03/29/hsc-fraught-implementation-dixon/The Health and Social Care Bill is now law, but itsimplementation will be fraught with challengesMar 29 2012The real impact of the Health Care reforms depends not on their design but ontheir implementation. Anna Dixon argues that the government has largely failedto win the support of the medical profession for the Act – as it now is – and yetwithout their support it is difficult to see how they can make this work. After many long nights spent debating the hundreds of amendments laid beforethem, members of the House of Lords will have breathed a huge sigh of relief thatthe Health and Social Care Bill has finally been granted Royal Assent. Secretary ofState for Health Andrew Lansley will be equally relieved but for other reasons. His grand plans toredesign the NHS, developed during six years in opposition, have had a very difficult passage and,after much amendment, the final results are very different from the original.Lansley’s original aims were to liberate the NHS by giving patients more choice, clinicians morecontrol and organisations greater freedom from central control and political interference. To realisethis, the Bill was originally designed to do several things: establish a powerful regulator to promotechoice and competition (the new Monitor), hand over commissioning budgets to groups of GPs,abolish layers of regional and local NHS ‘bureaucracy,’ and  hand over responsibility to morepowerful independent bodies including the NHS Commissioning Board and Public Health England.The reality is quite different. Monitor will tackle anti-competitive behaviour where this is not in theinterests of patients and the public, but its more interventionist powers have been removed.Commissioning groups have more governance requirements and population responsibilities, needto be subject to more scrutiny by local authorities through health and wellbeing boards and havemore stringent requirements on the handling of conflicts of interest. The Department of Health is inthe process of downsizing and handing over responsibilities to various arm’s length bodies, and theabolition of primary care trusts and strategic health authorities is well under way. However, the newstructure of the NHS Commissioning Board suggests it will try to fill the gaps left behind withregional and local offices.We know from our analysis of previous reforms that the real impact depends not on their design buton implementation. The task of implementation lies in the hands of others beyond government whomay not share in the vision, may have their own priorities and interests, and may be influenced byother more powerful pressures. Whether these reforms deliver on the government’s vision and havethe desired impact of improving outcomes will depend on the actions of the newly created nationaland local organisations. Here I set out briefly the three priorities that face the implementers.A new approach to commissioning: at national level the NHS Commissioning Board needs toset out a clear vision for commissioning that focuses on securing improvements in health andproviding the best health care for local populations with the resources available. It needs to providethe tools for local commissioners to contract for services (not with organisations), to specify thestandards and outcomes (not the means of delivering them) and currencies which transfer risk toproviders with incentives to innovate and change to more effective models of care (not rewardingactivity). At local level, clinical commissioning groups need to work closely with local authorities toensure their focus is on outcomes for their local population. This sounds very complex – what itreally means is they need to focus on transforming services locally, not on transactions andperformance management of providers.Establishing clinical and financially sustainable providers: at national level the NHS TrustDevelopment Authority, which has been set up to oversee the transition of all NHS trusts to becomefoundation trusts, needs to be given the freedom to restructure trusts that are not sustainable (ratherthan having to force mergers, which evidence has shown often result in poorer performance).Monitor will also need to act early to find solutions for foundation trusts that are no longer clinicallyand financially sustainable rather than waiting until providers are failing. Locally, the leaders ofprovider organisations need to recognise and make difficult strategic choices about their futuresustainability. They need to be allowed to stop providing some services themselves and to developinnovative partnerships with other public, private and third sector organisations.Balancing the benefits of choice and integrated care for patients: at national level Monitor willneed to carefully balance the benefits of integrated care for patients with complex needs and thepotential benefits of greater choice and competition. It needs to send a strong signal to localcommissioners and providers about the importance of integrating care and explain how they can dothis without breaching competition rules. Locally, commissioners will need to think carefully aboutthe feasibility and desirability of applying competition to different types of services. They will need tooffer a degree of choice and contestability but recognise that the majority of users have complexneeds that span health and social care and physical and mental health.In the face of these challenges, the real risk is inertia – that leaders in the system resist the reformsbut in so doing resist change. The government has largely failed to win the support of the medicalprofession for the Act – as it now is – and yet without their support it is difficult to see how they canmake this work. The political debate about the Act may be over but the political repercussions if thehealth and social care system does not change to meet the unprecedented challenges it faces willbe great. Any failure to do so will firmly land at the government’s door.Please read our comments policy before posting.Note:  This article gives the views of the author, and not the position of the British Politics andPolicy blog, nor of the London School of Economics. About the authorDr Anna Dixon is Director of Policy at The King’s Fund. She has conducted research andpublished widely on health care funding and policy. She was previously a lecturer in EuropeanHealth Policy at the London School of Economics and was awarded the Commonwealth FundHarkness Fellowship in Health Care Policy in 2005–6.You may also be interested in the following posts (automatically generated):1. With a likely cost of £4 billion, the Health and Social Care Bill has all the hallmarks of anavoidable policy fiasco.2. Bad science concerning NHS competition is being used to support the controversial Healthand Social Care Bill3. ‘Social kettling’ and the closure of domestic violence shelters are amongst the new challengesfor feminists in 2011: they are responding with a new activism, using social media andcollective action4. Meeting the demand for care will mean ensuring the private sector health market is fit forcompetition

The Health and Social Care Bill is now law, but its implementation will be fraught with challenges

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