The health select committee chair – and former health secretary – Stephen Dorrell has been instrumental in delaying the coalition’s NHS reforms. Speaking to Joshua Chambers, he sets out his own plans for healthcare.
When a former secretary of state ends up chairing a select committee overseeing their old department, it’s clearly tempting for them to try to shape policy, rather than just comment on it. “What I’ve tried to do – what we are trying to do – is position the select committee alongside the government in real-time policy debate,” says Stephen Dorrell (pictured above), the health committee chair and a former health secretary in the Major government. “I’ve not really been interested in my select committee sitting back and watching – as you sometimes see them do – before then telling [the department] where it went wrong. We’ve been trying to contribute to the debate as it goes along.”
That debate has been exceptionally heated, with health secretary Andrew Lansley’s Health and Social Care Bill the target of anger, scorn and even a vituperative rap song. In contrast, Dorrell picks apart Lansley’s plans quietly, calmly and politely – sometimes breaking into a genial smile. He thinks Lansley was misguided for putting his reforms into legislation in the first place, he says: “The secretary of state has himself said that [the reforms] could have been done without it, and my instinct has always been to avoid legislation like the plague. For every problem that it solves, history suggests that it creates at least one new one.”
Diagnosis
Dorrell also believes that, as it stands, the bill is too focused on reforming institutions, rather than looking at what is delivered for patients. “The bill is more around management structures, which I regard as a secondary, a very secondary element. The real question is how you change healthcare,” he says. Lansley has said that he wants to “dismantle” large chunks of NHS bureaucracy, but Dorrell believes that “it’s absurd to imagine, and to allow the impression, that the health service doesn’t need management. It needs to be managed… nobody will defend unnecessary bureaucratic process, but it’s often the result of [poor] management rather than excessive management.”
The most controversial part of Lansley’s legislation is the plan to scrap both primary care trusts (PCTs) and strategic health authorities, handing commissioning to GP consortia and a central commissioning board. These consortia would probably need to outsource management and contracting work, and could procure from “any willing provider” – leading to accusations that the coalition wants to privatise much of the NHS.
Esteemed organisations such as the British Medical Association, the Royal College of GPs and the Royal College of Nursing all strongly criticised the reforms. The Liberal Democrats voted for substantial changes at their spring conference, while the Conservatives also became nervous that they would lose the electorate’s trust on the NHS. The prime minister therefore put the Health and Social Care Bill on hold in March, despite it having passed through two readings in the House of Commons and onto the committee stage. Health secretary Andrew Lansley spent seven years in opposition crafting his reforms but the verdict seemed to be that, like the fruit of the medlar tree, his plans had gone rotten before they were ripe.
Too many surgeons?
Last week, Cameron pledged “substantial and significant changes” to the legislation during Prime Minister’s Questions. He has appointed a new special adviser to assist him in reshaping the policy, and – according to the Health Services Journal – set up an advisory group in Number 10 called the NHS Future Forum which will try out alternative ideas to Lansley’s. The health secretary hasn’t been invited to join this panel, while Cameron has parachuted two members of his own team into the Department of Health to take control of a listening exercise which is trying to decide how best to proceed.
Dorrell is glad the prime minister decided to pause and rethink “an enormously complex bill trying to do something that is enormously complicated”, he says. The pause isn’t good politics, he says, because the opposition can now claim that “everything’s gone pear-shaped”. But he does think it’s good government to reflect and rethink the bill, as long as reform is approached in a non-partisan fashion.
Following his party’s collapse in May’s local elections, Nick Clegg has promised to hold up legislation until he is “satisfied that what these changes do is an evolutionary change in the NHS and not a disruptive revolution”. Dorrell says the debate must steer clear of politics, and focus directly on improving the NHS. “What the Lib Dems say doesn’t amount to good government; what is important for good government is that the listening exercise results in a decision-making process that is focused on the requirement to deliver good policy – and doesn’t just reflect a political rebalancing.”
A new prescription
Why change the NHS at all? After all, a professor at the King’s Fund think-tank recently found that satisfaction with the health service is at record levels.
The problem is something Dorrell’s committee has dubbed ‘the Nicholson Challenge’: how the health service handles rising demand, an ageing population, and the ever-increasing cost of medicine and medical equipment. Demand for healthcare is rising by four per cent per annum, so NHS chief executive David Nicholson has called for four per cent efficiency savings for four years running – £20bn of savings. “We are caught between the devil and the deep blue,” Dorrell says. “You have to deliver four per cent efficiency because without it, you won’t meet demand for care.”
Speaking in Parliament the day before our interview, Dorrell noted that no health service anywhere in the world – including the NHS – has ever managed to deliver four per cent efficiency savings for four years running. He therefore wants sweeping reforms which would change the focus of the healthcare system so that it can cope with the needs of our ageing society. “The vast majority of the activity of the health service isn’t around people with a need for an acute episode of care; it’s around people with long-term, complex conditions,” he explains.
Dorrell wants a more integrated system of healthcare – something he believes the bill doesn’t deliver. “I am certain that, as originally drafted, it does not put enough emphasis on the need to achieve a step change in the degree of integration and collaboration in the different elements of health and social care,” he says. It’s an “absurdity of our system” that GP-managed primary care is separate to PCT-led community care, local authority-controlled social care and the hospitals system, he thinks.
The best way to redesign the system will be at a local level, he says, because that will make the change more achievable. “Just doing it from on top doesn’t work; you have to take people with you. That’s true not just of the people working with you in the system; it’s also true of the wider community.”
How to administer the cure
Rather than attempting a huge, top-down reorganisation, Dorrell favours an expansion of the foundation trusts championed by Labour – something which does feature in Lansley’s plans. Allowing hospitals to operate more independently in this way, says Dorrell, will make the health service less centralised. “I’m in favour of the principle that health providers are better locally managed in units rather than seen as a part of a large bureaucracy,” he says.
However, Dorrell wants to clarify the accountability of foundation trusts; they shouldn’t be directly accountable to Parliament – as currently – or to community members on their own boards, he says, but to the commissioning authority. “The commissioner should be defining what’s required in terms of service for patients in return for public money,” he says. “I don’t think it’s the job of Parliament, or indeed of ministers, to intervene in the management of an individual trust. The core accountability of the health service ought to be through the commissioning process.”
As for the identity of those commissioning bodies, Dorrell agrees with Lansley that GPs should be involved in commissioning; indeed, he has pointed out that even Labour tried to increase GPs’ role in commissioning. However, he does want to alter the composition of Lansley’s proposed consortia, improving their accountability. Under Lansley’s plans only GPs would have been able to sit on the boards of consortia, but Dorrell thinks their management boards should have to include nurses, carers, and local authority representatives. “It’s a public authority with a quarter of a billion pounds, on average, of taxpayer’s money,” he says. “It’s reasonable in my view to expect that commissioning authorities should have governance and accountability structures that reflect the fact that they’re spending very large sums of public money.”
What’s more, Dorrell wants to steer clear of the phrase ‘consortia’. “I don’t think it’s a consortium in the proper sense of the word,” he says. “It’s not a private sector institution. The body that’s referred to in the bill as a GP consortium is an NHS commissioning body.”
Taking the pulse of the public
Health care is about more than just the NHS – the Department for Health has a broader role to play in ensuring the wellbeing of the nation. Here, Lansley has set out a radical new approach in his public health white paper, promising that “there will be a profound shift in tone, attitude and outlook. Rather than nannying people, we will ‘nudge’ them by working with industry to make healthier lifestyles easier.”
According to the white paper, in future the government will not legislate to improve the nation’s health; instead it will seek to influence behaviour, inviting big corporations to help out. Here, Dorrell is well aware that there is “clearly a potential problem” with this approach: “there is a potential conflict of interest”, for example, when alcohol companies are asked to help reduce alcohol problems.
Nonetheless, he argues that in order to achieve public health objectives, the coalition must enlist partners wherever it can find them. “The government’s responsibility in the public health debate is to identify realistic objectives and to find ways of securing them, including challenging the drinks and food industries to behave in ways that might not coincide with their short-term commercial interests,” he says. So is it wise for government to align itself with brands that profit from products which harm the nation’s health? Sometimes it’s necessary, he replies: the government could protect its image “by not talking to people who have different interests – but life’s more complicated than that”.
Dorrell does add, though, that influencing behaviour will only get the government so far: “If certain things will only happen as a result of regulation, then the government has to be prepared to regulate.”
The government has set up a ringfenced budget of £4bn to fund public health projects. It is also proposing to establish a new national ‘health inclusion board’ and local ‘health and wellbeing boards’ – the latter run in partnership with local authorities, GPs, and councillors. Creating these boards will lead to more structural upheaval, and it has yet to be determined how they will interact with the proposed GP consortia. Curious about these issues, the health select committee launched a public inquiry into the plans this week.
Career prognosis
Dorrell’s own vision for how to reform healthcare is that of an experienced, pragmatic politician who survived and thrived throughout the internecine conflicts of John Major’s administration. From the outset, he wanted to quietly build on Labour’s reforms, rather than pushing through legislation – a plan which would have created less of a firestorm than Lansley’s proposals. He also believes in devolving power in the NHS down to GPs and patients – in accordance with both coalition partners’ overarching belief in localism.
So, would Dorrell prefer to be implementing his own reforms rather than scrutinising someone else’s? He gives a stock response that seems well worn. “I made a choice in life some time ago to be a businessman as well as a politician, so I have an active life outside Westminster. That’s something that’s important to me and I engage in that actively, which is obviously incompatible with being a minister.”
So, if the call came asking him to be a minister, he’d have to refuse? “That’s not something I’d, er…” Dorrell checks himself and starts again. “It’s not part of the plan; it’s not where I’m going in life,” he replies. “I enjoy doing the job that I’m doing, and I hope I add value in the job I’m doing.”
And the job he’s doing is not just scrutinising the government’s plans, but putting forward his own alternatives. Dorrell isn’t the health secretary, but he’s certainly playing a key role in reshaping health policy.
CV highlights
1973 Graduates with a law degree from Brasenose College, Oxford
1974 Stands for Parliament in Hull East; loses to John Prescott
1979 Elected MP for Loughborough
1990 Promoted to parliamentary under-secretary at the Department of Health
1992 Becomes financial secretary to the Treasury
1994 Gains first cabinet post as the heritage secretary
1995 Appointed as health secretary
1997 Runs to be Conservative Party leader, but is defeated by William Hague
2010 Elected as chair of the health select committee