The ‘rubbish’ politics of NHS reform

When the leader of a major representative body accuses a Secretary of State of peddling ‘rubbish’ and of being ‘childishly superficial’ it is pretty obvious that something deeper than a simple spat is at play. Dr Laurence Buckman, Chair of the BMA’s GP Committee, took to the airwaves this morning to take on Health Secretary, Jeremy Hunt, in just such a manner. It is precisely what the Health Secretary wanted to hear.

The Government has a political problem: over-crowding and delays in Accident and Emergency Wards up and down the country. As with anything in the NHS, the symptoms hint at deep-seated problems. Demand pressures, the shift to a new localised NHS helpline – 111 – replacing NHS Direct, cuts to community services over a period of time, and the 2004 GP Contract which meant that the vast majority of GPs opted out of providing out-of-hours care have all been cited as root causes.

The King’s Fund points to the difficulty of analysing the causes of the pressures as the data is so slippery across time. What is clear according to the King’s Fund analysis is whatever the cause, capacity limits are increasingly faced and this is why the 4 hour target for 95% of Accident and Emergency visits is being breached on a more frequent basis.

Jeremy Hunt’s problem, therefore, is that supply of accident and emergency is insufficient and almost all the solutions to that take time and are costly. He can look for NHS England to sweat over-stretched A+E departments further but that seems limited. He could bring more capacity on stream but that takes time and money. He could re-establish NHS Direct but that would be a stop-gap, cost money and would be politically embarrassing.

The problem from the GPs’ perspective is this leaves them and their 2004 GP contract which allowed an opt out from out-of-hours services. 2004 was a different funding universe to 2013. If the GPs are sensible they will take their cue from how other public services have been approached by the Conservative Secretaries of State. In both the Department for Education and Home Office there has been a willingness to publicly take on professions and their representative bodies with the objective of reforming public services. For example, through the Winsor Review process Theresa May has shown that Conservative Secretaries of State are more than prepared to drive through change even in potentially politically fraught circumstances.

All the signs are there that Jeremy Hunt has learned from his colleagues. His speech today was trailed a number of days ago. He will introduce a new chief inspector of GPs – a group of professionals he sees as ‘largely reactive’. He wants a new contract based on the quality of around the clock care. The new chief inspector will be critical in assessing that quality. This was not a surprise attack. Jeremy Hunt gave the GPs every opportunity to frame their response. And this morning it came- in exactly the form he was expecting and, indeed, wanted.

It’s quite simply political strategy. The representative body is painted as unreasonable, self-interested, and emotive. Then a communications strategy from the body comes along which appears to be exactly that. Her Majesty’s Opposition then amplifies that. The aim is to deflect attention from the solutions that may cost time and money and towards solutions that are more politically and fiscally manageable. If some emotional distance can be placed between the service and those it serves in the process then that works in favour of the planned reform too.

For the target group playing defence and muscle – the Stoke City strategy – seems to be working until, under relentless pressure the defence is breached. In other public services, in a context of austerity, this is precisely what has occurred. Perhaps the GPs will be the first to resist but it’s unlikely. The dynamic is now in motion and I know who my money’s on. The operational NHS may have been substantially devolved by the Health and Social Care Act 2012 but Secretaries of State are far from powerless. They still have access to institutional reform - a new inspector and contract - and political strategy to pursue their aims.

Somewhere in amongst all this there are patients but this process is now driven by the politics of reform and the fiscal context of a service facing rising demand. Unless the GPs can give Jeremy Hunt a way out that doesn’t involve fundamental reform of the GP contract, they are in a negotiation where they hold the weaker hand. The best chance they have is to appeal to reasonableness and demonstrate an alignment of their own position with the public interest. It’s not at all clear that ‘childish’ and ‘rubbish’ is the best way of going about that.

Anthony Painter is Director, Independent review of the Police Federation. His twitter feed is @anthonypainter.