David Cameron will announce this week another humiliating climbdown, putting the brakes on the Government's health reforms in a desperate attempt to rescue his reputation as a defender of the NHS.
In the latest embarrassing example of the Prime Minister being forced to intervene in the policy of one of his ministers, Mr Cameron will publicly admit to mistakes in the plan by the Secretary of State, Andrew Lansley, to hand £80bn of health spending to family doctors, characterised by critics as privatisation by the back door.
Mr Cameron will announce a "pause" of up to three months in the progress of the Health and Social Care Bill through Parliament, to allow for more time to reassure clinicians, patients and coalition MPs. One option being considered is a series of public meetings at which Mr Lansley would be forced to restate the case for reform in a less confrontational manner.
Mr Cameron is expected to share a platform this week with Nick Clegg, the Deputy Prime Minister, in an attempt to stave off a Liberal Democrat revolt. They will seek to reassure patients who fear the break-up of the NHS and the loss of free care at the point of use. The plan to replace primary care trusts and strategic health authorities in England with hundreds of GP-led consortia by 2013 has been almost universally criticised by doctors, nurses, unions, patient groups and senior Tories and Lib Dems, from Norman Tebbit to Shirley Williams.
Key areas of concern include a lack of accountability and transparency of GP consortia spending public money – dubbed "secret clubs" by critics – and the priority given to competition over the interests of patient care. Health contracts would be open to challenge under EU law. There are also fears about the loss of regional clinical networks, which have driven improvements in cancer and heart disease, and about the speed of the changes at a time when the NHS is also having to find £20bn in efficiency savings.
Lord Owen, the former Labour health minister and foreign secretary, accuses ministers of not knowing what they are doing. In an exclusive article for The Independent on Sunday, he warns: "Without... a deliberate slowing down of the procedures, the NHS is heading for a train crash and David Cameron as the train driver, and Nick Clegg as his guard will forever be held responsible."
A petition demanding the reforms be reconsidered, posted on the 38 Degrees website, has already attracted 250,000 signatures. The Royal College of Nursing said the level of opposition meant "this is the time to pause and fundamentally review the legislation", while the British Medical Association demanded a "complete rethink" of the plans.
Politically, the policy is fraught with danger for the Conservatives and Lib Dems. No 10 has ordered "radio silence" on behind-the-scenes talks aimed at ensuring both coalition parties can emerge from the crisis with some credit for improving the policy.
Since becoming Tory leader in 2005, Mr Cameron has repeatedly insisted the NHS would be "safe in my hands" and frequently promised there would be "no more pointless and disruptive reorganisations". Mr Clegg is under pressure to secure significant concessions after his party members rejected the Bill in its current form at the Lib Dem conference last month.
Downing Street is anxious that poor communication means even the Bill's commendable key aims – improving quality and making services more patient centred – are close to being hijacked by the talk of "privatisation".
Several meetings have already been held between Mr Cameron, Mr Clegg and Mr Lansley. Andrew Cooper, the new head of strategy, and Craig Oliver, the communications director, are also thought to be taking a close interest in the formation and presentation of the new policy as a first major test of their appointment to beef up the Downing Street operation.
One Tory minister joked that Mr Lansley will have to be "Spelmaned" – a reference to the humiliating policy reversal imposed on Caroline Spelman, the Environment Secretary, over the forests sale.
The Department of Health insists the policy remains unchanged, but conceded that, like most Bills, "some amendments" would be made. A spokesman said: "The principles remain the same, as does the clear direction set out by the reforms".
This weekend the Lib Dems sought to steal a march on their coalition partners by setting out in detail the "radical surgery" they believe is needed to the legislation before they will support it. Andrew George, the Lib Dem member of the Commons health committee, warned: "If we get this wrong it would have a more significant impact on the party and the country than the difficulties we had over university tuition fees."
John Pugh, chairman of the Lib Dem health policy committee, added: "There is widespread agreement that the legislation is in trouble. We do not want a fudge on this; we want substantial changes to the legislation before it is passed."
Extra pressure will be put on the Government on Tuesday when the Commons health select committee publishes a highly critical report on the role of GPs in contracting treatment for patients. Stephen Dorrell, committee chairman and a former Tory health minister, said: "This is taxpayers' money. The Secretary of State is accountable for the quality of care."
Concern is also spreading in Conservative ranks. Sarah Wollaston, a Tory MP and former GP, cast doubt on the scale of the reorganisation, warning that there didn't seem to be a body outside the Department of Health to monitor rogue failing GPs. "Some doctors are not as good as others. How do you pick them up? Dispensing practices that spend hugely more than any other GP on prescribing – how do you contain those costs?"
Overruled by No 10
William Hague, Foreign Secretary Struggled for several days with complaints over the evacuation effort from Libya, before the Prime Minister moved in to take charge. Mr Cameron said he was "extremely sorry" about the problems, and added: "Of course, there will be lessons to learn from this."
Caroline Spelman, Environment Secretary Defended plans to sell off the nation's woodlands ("It's time for the Government to step back"), until the PM twitched in the face of fierce opposition. Another review was heralded at PMQ, when Mr Cameron was asked if he was happy with the policy. He said: "No."
Michael Gove, Education Secretary Obdurately resisted claims that cutting a £162m fund for competitive sports effectively meant the coalition was abandoning school sports, until Mr Cameron decided to reveal plans for a rethink, in the public arena of Prime Minister's Questions. "It does seem to me that we all have a shared interest here," he told Labour's former sports minister Gerry Sutcliffe.
Anne Milton, Public Health Minister Accepted that stopping free milk for under-fives was "likely to be highly controversial", but insisted the "outdated" freebie should be reconsidered. Mr Cameron had personally binned it. "You have to look at the impact on poorer, more vulnerable members of society," his spokeswoman said. "The Prime Minister felt that keeping milk for the under-5s was part of that."
Liam Fox, Defence Secretary Forced to apologise to MPs after 38 British soldiers received emails telling them that they were being sacked. Mr Cameron's official spokesman said: "The Prime Minister is very, very clear that the way this has been handled is completely unacceptable."
Critical list: Competition and accountability give cause for concern
The progress of the Health and Social Care Bill will be halted before it reaches the House of Lords, allowing time for significant amendments to be made addressing concerns raised by MPs, NHS staff and patients groups. Issues include:
MPs want changes to the commissioning groups, or consortia, so they include other health professionals, including doctors, nurses, psychologists and lay people. The boundaries of each consortium should match those of local councils to ensure effective co-ordination of social care, public health and chronic conditions – which account for about 70 per cent of NHS resources. There are also concerns about picking up rogue doctors and dealing with potential conflicts of interest between GPs who provide health services and also sit on the commissioning boards.
Competition could threaten the survival of NHS hospitals undercut by large private companies that "cherry pick" the easy, most profitable treatments. Critics want to limit the "any willing provider" policy to areas such as elective surgery and non-urgent treatments, where they are known to drive improvements, because patients are able to exercise choice. It is also unclear to what extent the NHS in England will be opened up to EU competition laws. Multinational firms could repeatedly challenge contract tendering in the courts, costing the health service millions. At present, the only duty of the super-regulator, Monitor, is to enforce competition, but campaigners want an additional requirement to ensure collaboration between healthcare providers.
It is unclear how GP consortia will be held accountable by a new National Commissioning Board, how failure will be measured and dealt with, and how consortia will manage poor performance among their own GPs. MPs want GPs' meetings, decisions, accounts and outcomes to be at least as open to public scrutiny as primary care trusts (PCTs) and strategic health authorities are now. Lib Dems pledged to introduce local democratic accountability to the NHS by transferring commissioning responsibility to local government. This hasn't happened, and the new, council-run Health and Wellbeing Boards have no real power in the current Bill. The Lib Dems want boards to be able to "sign off" all decisions.
The staunchest critics want ministers to abandon the plan to force GPs to take over all commissioning by April 2013, because some will simply not be ready. Some want PCTs to continue in some form to minimise disruption to services or loss of skilled staff. Details are also unclear about how training and planning the NHS workforce will be managed after the 10 regional Strategic Health Authorities are abolished in 2013. And there are concerns about how the National Commissioning Board will preserve specialist clinical networks in cancer, heart disease, trauma care, stroke and diabetes, which often stretch across large regions.
Matt Chorley and Nina Lakhani
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