March 20, 2012, by Simon Butt
The Health and Social Care Bill and the ‘Kidderminster effect’: a classic study
As an Emergency Debate on the Health and Social Care Bill begins in the House of Commons, Professor Ian Shaw, Professor of Health Policy at Nottingham’s School of Sociology and Social Policy, gives his professional view of the bill’s bumpy ride this far – a case study of failure that does not bode well for proposed reforms.
At the time of writing the Health and Social Care Bill has not yet been enacted, so it could be said to `beggar belief’ to suggest it could be a failure so soon. However, this is a bill that moves the state more to a position of insurer than supplier of services. It involves a huge top-down reorganisation of the NHS not in the Coalition agreement, the individual parties’ manifestos nor in the Queen’s Speech.
It was unexpected.
As such, the government has had to try hard to secure support for it both from the public and from doctors and other clinicians.
I will use the restructuring of Kidderminster to suggest why failure is likely.
In 1997, Worcester had three District General Hospitals (DGH) for a population of 540,000. Kidderminster had one of smallest DGHs in country, no paediatric department, and a single A&E consultant supported by other staff grades and mixed clinical results. The Royal College of Surgeons was about to remove training recognition and the Health Authority had a £20m deficit.
Its proposal was to amalgamate acute services at Worcester with a new hospital coming on line in 2002, reduce Kidderminster to a 35-bed cottage hospital, and reinforce Redditch to keep 95% of services there. Hey presto: a reconfiguration that improved clinical outcomes and saved money.
However, the Health Authority doesn’t ‘own’ the NHS. The public pay for it; the public use it; the public see Casualty on the TV and understand medical emergencies; and the public see hospitals as more than service centres – they are key status symbols for an area. Just because managers understand why change is needed doesn’t mean that ‘the public’ also does.
The three DGHs were in competition (not cooperating). The winners banked their gains and the losers complained in public. Consultation went badly, headed up by managers not doctors, and the public’s fears were not addressed. Opposition kept growing. A campaign group was formed that challenged for local elections and won, local press and MPs came on-side, afraid to lose public support in the run up to elections. It was a disaster.
There are key lessons from this that ALL health policy analysts are aware of: in a consumer rights-based society you have to take the public with you if you are changing health services. Only medics can explain the need for change to the public and they need to have the Royal Colleges’ support.
The NHS will undergo significant reconfiguration over the next five years not only because of this Bill, but because of the need to close hospitals to move care ‘closer to home’.
This is why the Prime Minister in April last year decided that Secretary of State for Health Andrew Lansley MP needed time to get the professionals and public ‘on board’. Policymaking was effectively ‘outsourced’ to the Future Forum. Lansley was instructed to agree to whatever the Future Forum came up with. This needed a climb-down by the PM and saw him lose face, but he expected that it would be less damaging than a U-turn.
This, in part, explains the PM’s anger this year when he found not only that the pause had not got the professionals ‘on board’ with the reforms, but that there were now significantly more bodies opposed to the reforms than before! It was this that led a Number10 spokesperson to say that the Health Secretary “should be taken out and shot”. It’s also why the PM expects a ‘big hit’ over the reforms. They should have ‘U-turned’ at that time but instead pressed on to retain political face.
Learn lessons from Kidderminster
This suggests a lack of learning from Kidderminster. Every single Royal College of Health is against the bill, as are the three big health unions, with the BMA even passing a vote of no confidence in the Health Secretary. This is mainly because of its privatising elements and the grossly unwieldy structure it promises to impose, which they see being of detriment to patients. What is more, doctors have been actively campaigning against it, with 50 doctors targeting marginal LibDem and Conservative seats in the next election. See also, for example, http://tiny.cc/ah7gbw.
Take away the rights and (considerable) wrongs of the Health and Social Care Bill and anyone can see that it needs the doctors ‘on board’ to make it work. Without this we can expect a Kidderminster magnified 1,000 times across the country. It is hardly surprising that the Prime Minister is looking to a Cabinet re-shuffle before the summer. Considered opinion is that Lansley will go. He would have to, if the government is to try and re-engage with doctors and much-maligned NHS managers to best deliver services to patients. Even then, it’s unlikely to deflect the Kidderminster effect.
Professor of Health Policy