Could there be any common ground on the Health Bill?

When the eminently reasonable Stephen Dorrell spoke at the #healthdebate at Labours conference I was glad that he was given well deserved applause. He was doing something that far more politicians should do; Venturing into enemy territory, speaking directly to people and searching for common ground. 

He made the point that we often hear from Conservative speakers that the Health Bill continues policies that were already in place. Until last week I might have dismissed this, but as I have listened to the witnesses from the Department of Health at the #midstaffsinquiry  I think he may well have a point.

The Mid Staffs Inquiry has been an astonishing experience; A rare opportunity to see and begin to understand the complexity of the NHS; A chance for all the different organisations that make up this vital part of our countries life to re-evaluate what they are, what they do, and how they relate to the other parts of the system.  It has also laid out for us where things went wrong in what the chairman is now tentatively describing as a whole system failure, and pointed to the changes we may need to make.  

I do not think there will ever be a clear cut agreement about what actually went wrong at Stafford, though the Inquiry will remove many of the false certainties, but Stafford can show us the way forward for the NHS.

The inquiry has been an exercise in trying to find the truth, and that is not at all easy. What we hear as the general public is always filtered. The press and the media give us fragments of stories, and fragments of what politicians say.  The politicians use the media to try to sell the policies that they are attempting to drive through the wheels of government.

The press do what the press do. They present issues in terms of debate and conflict; This side, that side; Dramatic changes in direction.  The battles that turn it all into soap opera; matters of personality, people we love, people we hate. 

Listening to the Ex ministers and to the Department of Health spokesmen I see that this is not the way it is.  Ministers are there to represent us.  In some cases, as with Andrew Lansley, and Michael Gove, they have arrived in position with their own set of passionately held dreams – a vision of the future they wish to create. When they get there, they always find that power is not all it is cracked up to be. Having a vision is one thing, turning it into reality is another.

The DoH as everyone who has listened to the evidence at the Midstaffs Inquiry has heard is packed with people who really do know their subject matter inside out. They understand the sheer difficulty of bringing about change in something as complex and interconnected as the NHS. They will bring to the minister’s sketchy vision the depth of knowledge that can make parts of it work, and they work with tact and diplomacy to modify or remove those parts that are potentially damaging.  It is the Civil Servants job to keep the spirit of their service alive from one minister to another and one government to another. They are there to help us.

It is in this complex dance between elected politicians and appointed civil servants that legislation is brought together, and as the tools for public consultation become stronger the public and potentially the press can play an increasingly strong part in helping legislation take shape. 

As a grass roots Labour party member my dislike of the Lansley plans was strong; Strong enough to get me marching for the first time in 30 years.  But now, having listened to both Andy Burnham and the civil servants I can see that there is much within the Lansley plans which are as he has claimed – a continuation.

·         The quality agenda is being driven in part by the embryonic new information systems which developed under the last government and are now reaching maturity. It is also driven in part by professional concerns about how best to improve standards.  This would have happened anyway.

·         The decentralising of responsibility and the integration of primary and secondary health care with social care is necessary to deal with the challenges of the future and was happening under Labour anyway. 

·         The impetus to help or force hospitals into governing both quality and finance better is necessary and would have happened anyway.

·         The emphasis on the patient voice is in part what Midstaffs has added into the equation. All parties theoretically agree that a stronger patient voice is needed but there is no agreement about how this can be effectively done. I suspect we will spend the next decade trying to work this out.

There is substantial common ground. There is no need for many of the changes to be presented as radical or new. They are simply stages on a journey.  There is no good reason why all parties cannot drop the rhetoric and co-operate on the areas I have outlined.

There is a stumbling block is this – The major structural changes, and increased competition which Andrew Lansley sees as essential , look from the viewpoint of the Midstaffs inquiry room to be both unnecessary and harmful.

There are two main theories on what happened at Midstaffs:

·         The orthodox version, espoused by the press, is that this was a major disaster which nobody saw because of faulty regulatory systems and the failure of communication between a series of organisations that had just undergone major structural re-organisations and were therefore in turmoil.   

·         The alternative version, which I share with many of those closest to the hospital and many of the regulators, is that there has been a significant distortion of the facts.  See http://pressreform.blogspot.com/2011/04/what-forms-our-perception-of-stafford.html , and that the problems at Stafford are both less serious and much more widespread than we have been told. These problems that do exist reflect the key challenges that Andrew Lansley has correctly identified for the NHS; Challenges that are set to increase over the next three decades.  Those people who are close to my way of thinking on Midstaffs  believe the turmoil caused by the series of structural re-organisations left the regulators in a weak position to deal adequately with the major moral panic that arose.  

 The one thing which unites most of the people watching from the public room at the Midstaffs Inquiry is that Stafford cannot and should not be taken as a justification for the changes Andrew Lansley wants to make. The Inquiry will not prove the case for structural change, and it may well prove why structural change is the wrong answer. Whatever it was that happened in Midstaffs is much more likely to happen at times of structural change and financial pressure.  We are creating the perfect breeding ground for future scandals right now.

If I had the opportunity to talk to Stephen Dorrell and Andrew Lansley this is what I would ask them to do. Put the Health bill on hold. Do the bare minimum to stabilise the system and to stop the haemorrhage of talent that has already taken so many people from the system.   Allow people to see the Midstaffs report and learn from it; Consult widely; Trust the Clinicians and the patients and set them free to devise the structures they require to do the job; Seek the common ground that does exist, and continue to build on this.  Then come back with a better and more consensual bill.

Midstaffs inquiry: First impressions of the Department of Health

Early impressions on the Department of Health witnesses.

I wanted to put up a holding blog to let you know there is more to come!  This is a busy time of the year dealing with the harvest, but also the hearings over the last couple of weeks have been so dense and so interesting that it is quite hard to know where to begin.

I feel the need to work on the material slowly and carefully to do it justice.

I will say that hearing from the two ex ministers, Andy Burnham and Ben Bradshaw, and hearing from a number of people from within the Department of health has been a real education.

We are all used to seeing Ministers called to account at the dispatch box whenever there is some scandal within their realm of responsibility. This gives the impression that they are intimately involved with the detail of decisions. I think this is in large measure an illusion.

Listening to the explanations of how a particular decision was signed off has made it very plain to me that things are not remotely the way they are portrayed in the press.  In many cases it is nonsense to think in terms of blaming a minister for following the carefully made recommendations of his advisors.  

A minister sits at the centre of a huge web of information.  They can at the end only know what is fed up the line to them, and information is filtered and refined at many stages before recommendations are passed by the civil service to the minister.  The question that has been asked all the way up the line on the Midstaffs question, is if things were going so badly wrong at the hospital how is it that no one knew.  It is pretty clear that the minister could not have known. No one close to the hospital saw a problem, so there was nothing to ring any alarm bells at any level.

In the Midstaffs case, most of the dealings with the hospital were not a matter for the department of health. The Health care commission, the Care Quality commission, and also Monitor are all set up with the explicit intention that they should act as independent regulators. The minister cannot, should not, and does not involve himself in their operations. In the case of Midstaffs the ministers were concerned and they or their advisors asked questions and offered support, but they also respected the independence of the regulators.

One thing that should be clear is that a minister is not there as an expert. That is not their function. They are there essentially as an ordinary people, elected by us in order to represent us and to ask questions on our behalf.

It is clear that the Department of health contains many incredibly skilful civil servants with a deep knowledge of both their specialist fields of knowledge and of the constraints on action.

In the event of some public crisis is the minister that is sent in to bat. In the matter of carrying out policy the civil service will do what they can to carry out the ministers bidding, but they also have a role to advice ministers against ill-considered actions. It is good for us that this is the case. People often comment on the way that big scandals or tragedies tend to bring about illconsidered and ineffective legislative responses. That is often what happens when public and press pressure override the natural caution of the civil service.

There is a tension. Many of the things that we need government to set in motion, improvements that will give us better services, forward thinking proposals, are ideas that are worked through and tested for years. Ministers often think in a much more short term manner. They need to be able to stand up at the ballot box and answer hostile questions today.  They need to be able to fight for scarce resources. They need to be able to persuade the press and the electorate that they are doing a good job, with eye catching initiatives.

If we think of “Yes minister” there is the sense that the civil service can at times prevent things from being done, I am not sure that that is how it is.

At the inquiry We have been looking at four themes, Foundation trusts, Quality, The Patient voice and Commissioning.  What is striking with all of these is the degree of continuity that exists. 

Foundation trusts began under the last Conservative government,  continued and developed under Labour, and have now been given additional impetus by the coalition. They have been seen as desirable by all parties because they all recognise that there is a genuine need for organisations to manage their affairs more closely themselves, in accordance with local need.  (Ministers all probably also want to ensure that when a hospital scandal blows up, as they do all the time, that a Foundation trust is a sufficiently independent entity for the minister to be able to say "This is not my responsibility").  Ministers all recognise that there is an element of unreality in the claim that your hospital can be “run” from Whitehall.  Midstaffs has revealed some serious problems with the Foundation trust model, but these will need to be resolved, because this is the direction of travel.  

Quality, if you listened to the press in the run up to the election,  and to the current government was the discovery of Andrew Lansley, but we discover that Sir Liam Donaldson has been working on the agenda of quality continuously since 1998, and that there are many very well developed tools for developing and driving up quality, some of which are now going to be dropped, or placed within new organisations. Much progress has been made, but like many of the big challenges faced by successive governments it is very difficult to do. There are real breakthroughs now. The idea of measuring quality has been made possible by the development of impressive new statistical and information tools, and made essential because of the political imperative of listening to the patient voice.  

The Patient voice, is also claimed by Lansley as his creation, but again it has been a growing pre-occupation of the last decade.  The success of the midstaffs  pressure group in attracting the political patronage of the conservative party has now meant that ways have to be found to pick up complaints more effectively. This is another area where everyone agrees that it must be done, but no one has yet found an effective way. The methods are still evolving, but the information technology to help do this job is very likely to be in place within the next few years.

These are good developments, It should make government much more responsive. No doubt if it all works out much credit will be taken for it, but it owes much more to developments in the wind and the skill of the civil servants than it does to any genius on the part of ministers!

GP Commissioning is the big new idea of the Lansley Health reforms, but it has been emerging since 2002 as practice based commissioning, These have acted as trial runs for the reforms that will happen in some form.

The civil servants are showing us how much can be done by evolution.

I am left after hearing from the civil servants with a strong wish that we could calm down the noise around politics, the need for big initiatives, big changes, eye catching stories for the press. We can do all of the things that need to be done without the big structural changes.

So far, the ministers in this government have been in a mad tearing hurry. If they could slow down do less and listen more maybe we would all be better served.