So what does the crystal ball tell us about the NHS in 2012?
As with most crystal balls it mainly gives us a refraction of what was happening at the very end of the year before. The future really is a continuation of the past. And December 14th and 15th 2010 set the seal on 2012.
On December 14th we heard Stephen Dorrell and the Health Select Committee raise the issue about the resources for the NHS over the next few years. For some weeks he had been saying that the money will be more important than anything else and all he did on the 14th was to say this louder. He is right to say that this is very hard. The NHS has never managed to do this before for one year and now it needs to do it for 4 years running. This looks unlikely.
The Lib Dem’s human shield in the DH stepped forward to provide an explanation to the Today programme, and his main defence seemed to be that the previous Government also recognised the need for these reforms but had failed to achieve them. He then mentioned the importance in terms of saving money of the drop in the length of stay in hospital. He is right this is vital, but it is not new and has been dropping for some time. It will be interesting, in 2014, to see if the length of stay has gone down faster in the four years from 2010 – or whether by contrast it dropped faster from 2006-10. But without wishing to be unkind about the human shield, he really does not have an explanation of how this money is going to be saved.
If you are in commissioning in the NHS it is clear how this is going to be done. Beds and wards will be closed. If they are closed quickly the NHS will manage to find its £20 billion. If they are closed slowly it won’t. What that means in practice is that for the £20 billion to be found there will have to be more wards and beds closed than ever before. It is the extent to which the coalition Government will be up for that in 2011 which will determine how much money will be saved.
Of course there are other efficiencies that the NHS can make but to find this large a sum of money in this short a time will need significant changes in hospital configuration. The task for 2011 will not have been made easy by the reopening of beds and wards by the current Secretary of State in May 2010. 2011 will see, in line with clinical advice, most of these closing again.
2011 will start will the Bill and will just about end with the Act. Most of Parliamentary politics will be taken up with this. It will be an enormous Bill and the DH are trying to slim it down by moving some of what were originally 800 clauses into schedules and secondary legislation that can be dealt with later. The opposition will probably question the extent of this use of secondary legislation.
We will have to wait and see what is in the Bill, but I suspect that what the Government starts out with will be different from what it ends up with. This will not be caused by Government defeats – although if the Government sticks to its current line I can see two defeats looming. But it will be raised by the Government developing a better understanding of the Bill as it goes through Parliament. If you were allowed to bet on such things I would say that the Bill will be 700 plus clauses and the Government will introduce 250 new clauses as it goes through Parliament.
Where will it be defeated? If it sticks to the line on ringfencing public health money to local government it will be defeated in the Lords because local government (including the Secretary of State for local government) does not want more ringfenced grants.
If it sticks to its line of not designating membership of the Boards of GP Commissioning Consortia it will be beaten by a campaign to put a nurse on every one; and if the nurses win others may well follow.
As this goes through Parliament the DH will be setting up the architecture for the new organisations. The appointment of David Nicholson to set up the NCB and be its CEO was the obvious Quid Pro Quo of the Treasury to allow the current Secretary of State to go ahead with his reforms. In every other way it is an odd appointment. One might think – and old fashioned fool that I am, I do – that you would want a CEO who is to be in charge of something called “Commissioning”, to have had some experience of actually commissioning NHS health care. But no.
I would think that, over the year, as executive board members of the NCB are appointed some of them surprise, surprise, will also nothave commissioning experience but will have worked with their CEO in SHAs and in the DH.
This will cause the reforms some very real problems. Since the people in charge of allowing the GP Commissioning Consortia to develop and work will have little experience of commissioning – or of being a GP – we can expect some real problems here.
But Stephen Dorrell is right. Whilst this will be the biggest Bill to go through this Parliament, it will pale into insignificance against the money issues. The Government believe that for 2011 and 2012 money will be saved through the ‘increased focus’ of the old regime. SHAs will build up, from April 2011, inefficient hospital funds of about 2% of their budgets and over the year this money will be dolled out in bungs to get hospitals through the year.
This will work in most places.
It will not work everywhere.
There is insufficient money in the NHS uplift this year to reward inefficiency everywhere that it occurs. It is also the case that from April 2011 some GP Commissioning Organisations will be driving to efficiency in the NHS – and this will increase the amount of funding necessary to keep inefficient institutions going.
Nick Bosanquet has said that at the end of October 2011 the NHS will go through its fifth financial crisis since inception. He may be right, but I don’t think this will be universal. It is much more likely that most of the NHS will slide by on a slick of bungs, but there will be some who will not make it.
It is the size of this group will set the seal on whether the current Secretary of State is still there at the end of 2011.