The following article was written by Evan Harris and published today on the Liberal Democrat Voice Website.

On 8th April Norman wrote an interesting article here entitled “The NHS: safe in our hands”. That article is a good basis on which to discuss a few of the problems with the bill and the Government’s approach so far.

We should be clear that Norman Lamb is one of the good guys, who spotted earlier than most the problems with the White Paper and the Bill, and has been very clear that it requires radical surgery. He has also been particularly concerned, and this week expressed this publicly, that the pace of change is financially (and consequently clinically and politically) far too risky.

In his introduction Norman highlighted one key quality of the NHS “Treatment free, when you need it, not when you can afford it. That’s an idea that must never be undermined.”

All good stuff, but a treatment is not free when the NHS does not provide it because it is not deemed cost-effective enough to be made available on the NHS. This is rationing and there is nothing wrong with that as long as it is done rationally and that politicians are honest enough to explain to the public that effective but expensive treatments can only become available on the NHS when there are increases in real terms spending. I hope that the Lib Dems, when economic circumstances allow, will always give the public the option of voting for more NHS spending through fair taxation.

“Under Labour the NHS became bloated and unaccountable, with more managers than nurses.”

The NHS has always been pretty unaccountable and the Health Bill currently plans to make it even less accountable, by reducing scrutiny of local authorities over commissioning and reducing the ultimate duties on the Health Secretary.

By “bloated” does this mean the NHS is over-managed or too big? Are its management costs higher or lower than equivalent health services? All we know is that don’t know as the Health Select Committee concluded last year at paragraphs 33-37 of its report on commissioning. There are suggestions that NHS management costs are increased further by introducing more market transactions.

“More managers than nurses?”

There are 400,000 nurses. There are patently fewer managers than that! About 40,000 in fact. I presume there is some Government propaganda circulating, rather like this nonsense which can still be found on the official Lib Dem website, which has misinterpreted a report that the percentage rate of increase in the number of managers under Labour was higher than that for nurses. Perhaps this misinterpretation is literally or psychologically cut and pasted into articles as was the infamous “UK as twice the rate of heart attack deaths for patients than France” fiction, which I am pleased to see has been put out of statistical misery?

“Bureaucracy must go and patients must get more control. As Nick said in his conference speech in Sheffield, ‘We have campaigned for years for an NHS that gives more power to professionals and to patients.’“

The current plans give more power to a sub-group of sub-group of a sub-group of health care professionals. The entrepreneurial few among the GPs who are a subsection of doctors who in turn are a minority of health care professionals. There is no mechanism by which a patient can influence commissioning decisions unless he happens to bump into to the full-time manager, who used to be her GP, at the supermarket and persuades him to commission service X from Y not Z. Compare that to the ability of locally elected councillors or health board members who can be elected on a platform of service change. Anyway, I venture to suggest that if we want the NHS to be a “wellness” service not a sickness service, with more preventive medicine, then those who wish to stay healthy should have as much influence as those already ill. That means the public as whole having a say not just a selected group of them, called patients.

This whole debate on “power to professionals” is fascinating for me a former Health Spokesman. When I used to oppose the politically-based targets (introduced by Alan Milburn and John Reid) on the basis that they distorted clinical priorities and prevented doctors form providing the most appropriate service for their patents, I was accused by David Laws among others of promoting “producer interests”, (and he is still saying it) perhaps especially because I was a doctor myself. I didn’t think that was true or fair (I was alone in opposing the new GP contract at the time as a bad deal for patients). So it is a curious irony to see the Orange book brigade now defending reforms which actually boast about promoting the interests of the producer professionals.

“And change is needed, too, because we must keep up with an ageing population and rising numbers of people with long term conditions like diabetes and Alzheimer’s, and we need to find the money for new treatments and new technologies so people continue to get the world-class care the NHS is known for.”

Change is needed? No. Positive change is needed. The mantra of reform and its justification is only rational if there is both a logical basis why the reforms would deliver positive change, and some evidence from elsewhere, or from pilots here, to back it up. Neither of those apply to these health reforms. No modern day engineer or mainstream clinician would apply something to their entire practice let alone that of the rest of their colleagues for based on dogma or blind faith.

“Paul Burstow has been working tirelessly to ensure that, for the first time, local government will have a real role in our NHS, holding GP consortia to account”

I am sure that that is what Paul would have wanted but its not there in the bill. There is hardly a role for local authorities to be able to scrutinise, let alone challenge, let alone force change to specific commissioning decisions which – until our intervention – were due to be made in secret. The Health and Well-being boards are currently designed to have a minimum of one (yes one!) councillor on and be responsible for a needs assessment and for strategic oversight of commissioning. If the HWB is important then make it a majority councillor body.

Local authorities “taking on responsibility for public health”

Yes, but if public health is detached from commissioning (and it is currently close bound in PCTs) then the role of public health is seriously diminished. That is just one reason (another being integration of health and social care which as Norman says is essential) why co-terminosity of local authorities with commissioning bodies is essential.

Norman quotes Nick saying at Conference of the NHS “World-class health care for all. Publicly funded. Free. Centred on patients, not profit. So yes to health reforms. But no – always no – to the privatisation of health.”

That sentence could have done with a “comprehensive” at the beginning because the bill in its current form proposes comprehensive cover only to those on GP lists, and that is why our motion called for geographically-based commissioning and geographically-based weighted funding allocations.

It is huge benefit for us to have Norman Lamb in the position he holds because he understands Lib Dem policy and can see the huge risks to us of being lashed to the mast of Tory NHS policy. I also think he can see what lies behind these reforms – that they can be used as a staging post for a new system delivered by a future Tory or New Labour Government where Foundation Trusts (ie all hospitals) are sold off and the Commissioning Consortia become Continental-style social insurers. The Liberal Democrats have called this out and we must stop it.

Evan Harris was Lib Dem Shadow Health Secretary 2001-2003 and is a vice-chair of the Federal Policy Committee.