Simon Stevens, new head of NHS England, is in for a rude awakening

http://www.theguardian.com/commentisfree/2013/oct/25/simon-stevens-nhs-england-rude-awakening

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As he sowed, so shall he reap. Simon Stevens will get his just deserts as he takes up the reins of NHS England, only to find this horse has no bridle or bit, galloping out of anyone's control. That was, of course, precisely the explosive "creative destruction" Andrew Lansley intended. Stevens returns from the biggest US health company to an NHS whose current path he designed as Tony Blair's adviser. Now he must piece together some coherence from the fragments of what Sarah Wollaston, MP and GP, called "a grenade" tossed into the NHS.

As Lansley outlined his scheme in 2010, Stevens wrote a paean of praise in the Financial Times. It reads as a touchingly optimistic vision, where choice and competition in a perfect market deliver everything a patient or GP could desire. When he sees what he's inherited, he may get a rude awakening. But he shares the blame, claiming authorship: "What makes the coalition's proposals so radical is not that they tear up (our) earlier plan," but "move decisively towards fulfilling it – in a way that Mr Blair was blocked from doing by internal opposition".

He lists the plan's glories: in "the new model NHS, patients are rightly being promised that 'no decision will be made about me, without me'". No sign yet of that. He praises "the severing of day-to-day political control of the NHS", but now he'll find his own control severed. How will he marry his vouchers for pregnant women with wildly unpopular maternity closures? His hope that "patient power will become real, GP commissioners will fire on all cylinders and hospitals will be liberated to innovate" is a world away from today's NHS.

But his greatest regret may be his praise for "the decision to extend competition law across the health sector and treat the NHS as a regulated utility, with an economic regulator – Monitor". Faith in competition fills his writings – but reality is biting back. Monitor, engine of NHS competition, has only just understood its destructive force: its chief executive, David Bennett, recently recoiled, saying Monitor would be "mad" to enforce the Lansley competition rules leaving commissioners to "spend all their time running competitive processes because they're terrified they're going to get in trouble if they don't". Too late now.

So far, 63% of contracts have been put out to tender by clinical commissioning groups (CCGs), now run by just a few GPs. The 211 CCGs are widely regarded as no match for the private sector in writing complex contracts. Section 75 of the Health and Social Care Act forces them to put all but a few services out or risk any putative bidder challenging them in court. Bringing competition law into the NHS means no one can control these unleashed forces.

Stevens is a strong advocate, as are most NHS managers, of the need to reconfigure hospitals to merge or close the unviable. But competition law will prevent him. Last week the Competition Commission forbade Bournemouth and Poole hospitals from merging as it reduced patient choice. That really is mad – and the entire NHS gasped in shock. That's a recipe for everything left in aspic, whatever the cost. Only now is the full effect of the NHS act dawning on its strongest advocates.

I had a glimpse this week, sitting on The People's Inquiry for London's NHS looking at the capital's rudderless attempt to rationalise services. Here's an example of the madness in south-west London, where there's a long-standing scheme to close some hospital units and send patients to fewer specialist centres. Whether or not it's a good idea to close Epsom and St Helier, the act risks making it impossible. All power is devolved to local CCGs – and one refuses to co-operate. The others are not allowed by competition law to meet and agree: they have to meet in separate huddles in the same room and "spontaneously" reach the same decision. How crazy is it to treat NHS organisations as if they were wicked cartels when they try to collaborate?

Local campaigners may use competition law to claim closing hospitals is anti-competitive: they certainly see no "patient choice". But if patients and GPs are in control, there will be few closures and Stevens at NHS England can do little about it. One sign of the chaos: an emergency extra law was rushed through the Lords this week to give NHS bankruptcy administrators power over surrounding viable hospitals, to leapfrog the judicial review won by Lewisham hospital campaigners.(Yes, it's incomprehensible.)

Watch Stevens demand more changes to the law if he's to control the unfolding chaos. Half of NHS trusts have announced a deficit for this year – that's unprecedented – yet by 2017 the NHS must "save" £30bn. The Care Quality Commission says one in four hospitals are a safety risk, but their inspections aren't allowed to count numbers of staff: the NHS has haemorrhaged 6,000 nurses since 2010. Many CCGs that control NHS funds are chaotic, with services falling between gaps, no one paying for them. Privatisation rushes on, at least £11bn so far, but private providers escape the NHS duty of openness or freedom for whistleblowers. Waiting times are rising, ambulance and A&E times growing, as the social care crisis blocks NHS beds with winter approaching.

Stevens will find many perversities in the competition culturre. He said top-down control was a disaster – but he may find fragmentation and lack of strategic control far worse. Can he make his perfect market work – or admit he might have been wrong?

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