What is the connection between Lord Tebbit and a bin man with a runaway rap hit on Youtube? They are unlikely bedfellows in the growing alliance opposed to Andrew Lansley's health and social care bill. They join the Royal College of Nursing, the Royal College of GPs and the BMA, which has recently called for the bill to be withdrawn. It is difficult to know who supports his proposals apart from the private companies who stand to make billions out of the NHS, and a minority of GPs who haven't been reading the small print.
Concerns expressed by his backbench 1922 Committee combined with a stark warning from Sir David Nicholson about potential chaos have led David Cameron to perform what is being described as a U-turn. But is this a genuine change of heart? Lansley's words to the Commons suggest he has no intention of changing those aspects of the bill that most trouble critics. Rather it seems he believes his challenge is to do a better job of selling his "reforms". His idea of a listening exercise seems to be that we will listen more carefully to him, rather than him paying attention to the hundreds of thousands of healthcare workers and patients who have signed petitions, lobbied their MPs and marched against his proposals.
Campaigners' fears are not about pace and scale but about the underlying intent of the proposed legislation. It is clear now that the endgame is to transform the NHS into a system that finances but does not provide healthcare – a national insurance system which pays the bills while care is provided by competing private, publicly owned and voluntary organisations. There is nothing yet to suggest this has changed.
Lansley's professed aims of a truly integrated service with less political interference are belied by the core elements of the bill, which will lead to a NHS fragmented by competition and private provision while subject to the swingeing powers of the commissioning board.
His intention to divest himself of the traditional responsibility to provide comprehensive, universal, population-based healthcare is deeply worrying, and has been nodded through without remark. These elements all remain, and the gap between the rhetoric and the reality is as wide as ever.
GP commissioning, seen by many as the heart of the reforms, is the bait with which Lansley hoped to reel in the GPs. Most have spotted the hook, and believe the price they are being asked to pay is too high. They recognise that they will be held responsible for cuts and rationing, and that that will do irreparable damage to the patient-doctor relationship. As one doctor noted: "Do I want my GP to look at me as a patient, with a focus on curing my ailments, or as a business person focused on reducing costs and maximising income? For me it's simple, I prefer my GP to remain a GP."
Other dangers are becoming apparent. There are already reports that GPs are forming commissioning groups that do not cover a defined geographic area, excluding lower performing practices and cherry-picking healthier populations. There is thus real concern about some consortiums being the equivalent of "sink estates", where all the most difficult practices and the most deprived populations come together.
And the Kings Fund has recently recommended that entire care pathways be outsourced to external providers, as GPs will not have time to design and commission healthcare. Many believe that once the private sector holds the budget and buys care from the private sector the days of a NHS are numbered.
The fact that so many GPs are setting up consortiums has been brandished as evidence of their enthusiasm for the proposals, but that is disingenuous. Lansley has set the changes in motion before any legislation has been passed, and with PCTs unravelling GPs need to make decisions. Many signing up to commissioning are doing so with the enthusiasm of passengers on a sinking ship climbing into the lifeboat. The new suggestion that not all need to join commissioning consortiums only means those practices that opt out will be run by consortiums elsewhere.
As for the patient choice and voice Lansley claims to be strengthening, the facts once again betray him. Foundation trusts and consortiums have no public accountability. The myth that patients will have more control over their care is just that. Referral management centres are already rejecting one in eight general practitioner referrals, making a nonsense of patient choice. With GPs now responsible for making unprecedented savings the emphasis will increasingly be on cutting the range and quality of treatment available, with the inevitable introduction of top-ups and insurance for those who can afford it.
Lansley says no change is not an option, but it is not clear where the crisis lies. Surveys show that the NHS comes out top for equity of access and value for money. Outcomes are improving rapidly, and the misleading statistics trotted out by the coalition about heart attacks and cancer survivals have been shamelessly cherry-picked. What exactly is the problem to which these "reforms" are the solution? Continues here.