Contagion threatened from NHS in England

Early on what was to be the hottest October day on record, I boarded a train for York, to take part in the annual conference of the National Health Service Consultants’ Association. Now, York is a very long way, but the discussions turned out to make every sweat soaked mile worthwhile.

The Association includes some of the most senior clinicians in the NHS. Drawn together from right across the range of different specialisms, they were united in a deep fear of what is about to happen to the English NHS. Next week, the Lansley Bill goes to the House of Lords, and a great deal of hope is being pinned on its revising capacity.

In the chaotic aftermath of the summer’s ‘listening exercise’, over 1000 government amendments were laid to the original Bill. Labour argued that consideration should begin again, with a clean slate, a fresh text and a full parliamentary process. Instead, the government ploughed ahead with a scrutiny process so flawed that it might yet embolden some members of the House of Lords to press their powers further than their usual ‘gentlemanly’ conduct of business allows.

In the slightly incongruous setting of Bedern Hall, the 14^th Century headquarters of the College of Vicars Choral, and under the shield of the medieval York Guild of Builders, the members of the NHS Consultants Association identified their targets in the Bill, and their tactics for defeating what was commonly called the ‘Blue Murder’ of the health service in England. The afternoon’s discussions were expertly led through the maze of parliamentary drafting and process by Dr Evan Harris, until the 2010 General Election the Liberal Democrat MP for  Oxford West and Abingdon. Below are just half a dozen of a much longer list of changes which the Bill’s opponents most hope to see brought about in the Lords:

• A reversal of the current so-called ‘hands-off’ clause in the Bill, which lawyers say will absolve the Secretary of State of an obligation to provide a National Health Service.

• Removal of all references (direct and indirect) to the promotion of competition by Monitor, the regulator of Foundation Trusts in England.

• Removal of the ability, currently built into the Bill, to transfer public assets (such as land, buildings and equipment) to bodies outside the NHS.

• Retention of a cap on the level of private income which Foundation Trusts can generate, and which the Bill seeks to abolish.

• Explicit prohibition of the wholesale outsourcing of commissioning to private companies (to avoid the danger of commissioning GPs simply handing over their responsibilities to predatory companies, outside the NHS).

• Creation of a new duty to ensure that allocation of funding to different parts of the NHS in England is needs-based.

Now, why should any of this be of interest to readers of ClickonWales? Doesn’t devolution mean that the Lansley Bill stops at Offa’s Dyke? Shouldn’t we and best keep out of a private, English, quarrel? Well, only up to a point, Lord Copper.

Cross border flows between the Welsh and English National Health Services are substantial and, in the past, have been controversial. More than 15,000 Welsh patients are registered with English GPs, and more than 20,000 English patients  are registered with GPs in Wales. The porous nature of the border makes our position very different to that which exists between Scotland and England.

The complexity and intensity of the Wales:England interface meant that detailed work was always needed to keep the two systems working effectively alongside one another. But that was when the basic, underpinning principles of the two systems were closely aligned. Now, with the English system veering sharply in the direction of marketisation and privatisation, that relationship is about to come under real, renewed strain.

Our ability to fashion the Welsh NHS in the way that we would like will inevitably be influenced Lansley’s English NHS Bill. Here are five examples:

1. The Bill abolishes, or reforms, a series of bodies which had previously operated on an ‘England and Wales’ basis. Gone, for example, will be the Health Protection Agency and the Alcohol Education and Research Council, both of which had a remit which included Wales. Gone, too, will be the National Patient Safety Agency, which has hitherto operated under a service level agreement with the Welsh Government. Even more worrying are the changes planned for the National Institute for Health and Clinical Excellence (NICE), which may change the basic principles on which it has operated to date, and much reduce the relevance which its work has had, up until now, in Wales.
2. It leaves a huge hole in the training arrangements which have existed for new doctors in the NHS. Medical students trained in all four nations of the United Kingdom are equipped to work in every part of the country. The fragmentation of the English NHS means that future training arrangements are bound to be affected – and, in the view of those who met at York, diluted. If the English system is broken up in this way major questions lie ahead for crucial medical education arrangements in Wales.
3. It drives a coach and horses through the system of England and Wales contracts which have been a pillar of the post 1945 public services. The argument about why Wales loses out in any system of ‘regional’ pay bargaining have been rehearsed too extensively to need repeating here. Yet, that is clearly the ambition of those who have framed the coalition Bill. In an organisation where staff costs make up such a dominant line in its budget, in-coming private providers will, inevitably, look at driving down pay and conditions, in order to make profits. It is ostrich-like to act as if such developments in England would have no impact in Wales.
4. It introduces a new, inherent instability into the system, where inter-dependencies are so intricate. Ministers in England have made it clear that no Foundation Trust which goes bust will be rescued. What if one of those happens to be on the English side of the Wales:England border?
5. It opens up the whole European issue. To quote senior Lib Dem peer Shirley Williams, lifting the cap on private beds in Foundation hospitals means that they will ‘inevitably’ be subject to European and British competition law. At that point, it would be very brave to assume that competition law would stop at the border. Welsh Ministers already receive some of the most zealot-like advice about the legal requirements of European and local legislation. Previous Health Minister, Edwina Hart, made it clear that she did not intend the Welsh NHS to be made part of a market in goods and services. However, decisions being made in England may yet overwhelm the most determined Welsh policy-positioning. Writing for the IWA’s journal Agenda, Marcus Longley recently summed all this up when he said that the challenge posed to Wales, by the Lansley Bill, is one of the ‘contagion of ideas’. We may not want to catch what is going on in England, but some diseases, once the virus is out of the bottle, may just be too contagious to resist.

All this means that Welsh politicians and policy makers have a direct interest in playing our part in defeating the worst aspects of the Bill. We have a vigorous and effective cadre of Welsh peers in all parties who have demonstrated their willingness to take an independent line on previous issues where there have been clear Welsh interests at stake. On the cross-benches, too, we have individuals, such as Lord Elystan Morgan and Baroness Finlay of Llandaff who speak with real authority on these matters. They may well be vitally important in securing the majority needed to defeat the Government in the Lords. There’s a game of blue murder afoot, and we need Welsh players out there on the field, and playing it to the finish.