It has been a depressing time dealing with the hated Health &Social Care Bill.  We had the better arguments, better advice, and better lawyers and at the end all the support but it was never enough to overcome political expediency.

The LibDem sell out was no surprise but the efforts at collaboration and sharing ideas, amendments and information was still genuine on our part if not on theirs.  The big surprise is that they appear to believe the nonsense they have had to put out about the Bill being a welcome development.

It was a much longer fight than most predicted and the Bill has changed in some important but peripheral ways – like the recognition of the importance of things like Education and Training, Integration and Cooperation which were not in the original Bill.  Progress of a sort has been made on embedding Public and Patient Involvement at least in theory. The enthusiasm for price competition and a strong economic regulator has been damped down at least for now; the issues are now better understood and the forces to oppose privatisation and market forces are now better prepared and better organised.

Clinical Ccommissioning Groups now have more participants than just GPs and some strange sort of governance but the governance is ludicrously weak compared to that previously thought necessary for commissioners in charge of £60bn of public money.  And nobody has a clue about how effective CCGs will be – probably a huge variation.

We now have a National Commissioning Board doing the most local kind of commissioning! It’s a huge unaccountable bureaucracy with outposts and silos that were not even in the Bill led by the Commissar and his gang of four.  This mega quango is both the greatest obstruction to any attempt to drive market reforms through the NHS and the best hope for the NHS to continue to function for patients through the turbulence.

That clash between the ideology of the markets and competition and the steady pragmatism of those who actually have to keep the NHS functioning offers the best hope for implementation of the worst parts of the “reforms” to be slowed and even stopped – by the activism of those on the inside combined with continuing political pressure from the outside.  A long road yet to travel.

We have a pathetically weak role for the patients’ voice neutered at the 11th hour when everyone was too tired to put up more of a fight.

We have Health and Wellbeing Boards with no powers.  We have Senates that exist only out in the mists somewhere.

We have under funded and undervalued Public Health parked on the sidelines.

We have a regulator torn by a massive conflict of interest and with a leadership that is openly ridiculed.  In the power stakes it is now subordinate to the NCB when it was supposed to be the other way round.  Its competition promoting role is hidden but still implicit – with no idea how it can be delivered.

There is nobody outside the Ministerial group who thinks the Bill was either necessary or worth the cost of forcing it through – both political and real money cost. The Bill is a mess of compromises and untested assumptions and few understand it.  It’s an experiment on a huge scale.  We needed brave radical reform of social care and a period of stability for the NHS – we got the opposite.

The Secretary of State for health has given up most of the powers to direct and oversee a Universal Comprehensive National health service – and in time all three of those pillars will be challenged – the N has probably already been sacrificed. The NHS as the provider of the health care we need is gone.  The idea of the NHS having a publicly accountable structure for strategy and planning and the distribution and oversight of our tax paid money has gone.

The values of integration, collaboration and cooperation are acknowledged but competition trumps them all – and the lawyers will make it so.

The NHS will not collapse, the more apocalyptic fears will not be justified but we have seen the end of the NHS as we know it.

Nobody every voted for it.

Irwin Brown

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