The Health and Social Care Bill is an impressive and visionary document. In its scope and ambition, it rivals any piece of legislation I can remember reading. Andrew Lansley, the Health Secretary, has stressed that these plans for the health service are not something he drew up on the back of an envelope; no, they have been a long time in the making. The bill redraws the operating system for the NHS in England: it
is a 180-degree reversal of Labour's approach, devolving power away from the direct, day-to-day responsibility of the secretary of state.
But that does not mean the plans are in any way democratic. The secretary of state will appoint most members of the NHS board to which his powers of management and oversight will be devolved - and he will be able to sack those whom he appoints. He will also have the power of veto over the appointment of the chief executive. This will be a highly political body. The elected local authorities will have charge only of public health, not medical, dental or ophthalmic care. Most medical care will fall under the control of the new GP consortiums, overseen by the board and the regulator monitor.
Whether the vision of a democratic, locally accountable health service will be realised or will fade and die is in the hands of these GP consortiums. In theory, GPs will respond to informed and empowered patients to broaden the range of services on offer and improve care all round. Yet there are so many conflicting responsibilities and perverse incentives written into the proposed system that, in practice, the relationship between patient and GP - long the great strength of the health service - will come under extraordinary pressure.
Roll up, roll out
GP consortiums are answerable to the secretary of state, the board, the monitor and their patients. The push for greater plurality of providers will not come from patients. Patients are not sufficiently informed about what is in their best interests and survey after survey has shown that they are less interested in being given a choice about where they are treated than about how: in a clean hospital, with good pain control.
In the absence of any likely clamour from patients to open up the market, Lansley is busting it open. GPs will have to put contracts out to competitive tender. The bill even allows the secretary of state to tell consortiums what to put in their contracts (so much for independence) and to require them "to do such other things as the secretary of state considers necessary for the purposes of the health service".
In what looks like a direct contradiction of a promise in the Conservative manifesto to make every alternative provider compete on health service prices, providers will be allowed to tender at below cost price. This will tilt the market unfairly in favour of private-sector operators of "roll up, roll out" treatment centres, where those with less complicated problems can have same-day operations.
When complications do occur, these patients will be whisked off to the local NHS hospital, which will have all of that complex, inefficient, expensive care on standby. This is why an open market is unfair. NHS hospitals will not be competing on a level playing field: they must provide A&E and other high-cost specialisms. By allowing the private sector to undercut them, Lansley is setting up a system that will undermine their profitability. I wonder if patients will see the connection between having their hip operation contracted out to the nice, new private-sector treatment centre and the closure of their local hospital a few years down the line. Whom will they blame if they do?
The second invidious element of this bill is the offering of financial incentives to encourage GPs to play ball. If GPs provide good-quality care, in or under budget, they get paid extra for it. To quote the bill: "The board may, after the end of a financial year, make a payment to a commissioning consortium if, in the light of an assessment carried out under Section 14Z1, it considers that the consortium has performed well during that year . . . A commissioning consortium may distribute any payments received by it under this section among its members in such proportions as it considers appropriate." These payments will be made every year. There's no need to wait and see whether this system will damage care down the line. There is a clear financial incentive to do exactly as Lansley directs.
Power to the patient
So, from now on, patients will have to rely on advice from GPs whose independence is compromised; they will have to be very empowered to be able to challenge that. Yet consultation on the parts of the Lansley plan that are aimed at giving patients control closed weeks ago; the government had not even published its response before the second reading of the bill took place.
The Chartered Institute of Library and Information Professionals, in response to the "information strategy", said: "Our main concern about the proposals in the consultation document is their partial nature. In our view, they do not cover information - most focus on the internal management of NHS data - and neither do they constitute a strategy." So much for the fig leaf of patient empowerment.
But it would be wrong to dismiss this bill as all bad. Stephen Dorrell, a former health secretary who is still highly respected in the NHS, said during the debate at the second reading that the bill only represents "an evolution of policy that has been consistently developed by every secretary of state with a single exception since 1990". He is right. It has the potential to be very creative.
That it also has the potential to be very destructive ought to alarm David Cameron more than it need alarm us. The NHS is a lot stronger than any government.