Goodbye Lansley - Ministers to retake control of NHS

Last Friday (Feb 5) Health Policy Insight published^[i] the draft of the Government's forthcoming White Paper on Health, which was reviewed extensively in the media over the weekend. The main news in it for dentistry was that the paper included proposals to hand over control of water fluoridation to the health secretary and away from local councils. The move was widely welcomed in the profession especially by the CWF network (@network_cwf), the national organisation of dentists supporting water fluoridation.

Andrew (now Lord) Lansley’s 2012 reforms, when he was health secretary, handed control of the measure to local councils, which led, in October 2014, to a decision by Southampton City Council to scrap plans to fluoridate its water. This followed a vigorous campaign by ‘Hampshire Against Fluoridation’ and tentative plans to introduce the measure in other areas such as the North West of England and Hull were quietly dropped. Speaking in the January 14 Commons debate on dental services during Covid-19, health minister Jo Churchill said she was ‘extremely sympathetic’ towards the measure, so we may expect its revival perhaps.

In his report^[ii], the late Professor Jimmy Steele said the first priority of any NHS system should be ‘a strong, co-ordinated public health system’, something that has not been possible with it being devolved to individual local councils,

The Lansley approach, which was controversial in the Conservative/LibDem coalition, was to take power away from ministers and put it in the hands of administrators. NHS England was given ‘power without responsibility’ to quote Stanley Baldwin’s description of the press in the inter-war years^[iii].  But Ministers were still held accountable to Parliament for the NHS; ‘responsibility without power, the worst of all worlds’ as then Home Secretary David Blunkett, described it in 2002.^[iv]

Without going into any detail, the document says there will be ‘enhanced powers of direction for government’ to ensure that ‘those overseeing the health system’ are held to account. For dentistry this could mean that the focus moves from NHS England’s obsession with delivering UDAs to MPs’ demand that anyone who wants to see an NHS dentist can do so - a shift from activity to access.

Secondly the Lansley approach was to promote competition within the service, hence the over-long process of commissioning new services, typically a year or more and, arguably, the botched orthodontic recommissioning exercise.

The pandemic showed, though the commissioning of urgent dental care practices, that the NHS can move rapidly when circumstances demand and so it should be in the future.

In responding to the January 14 debate, health minister, Jo Churchill said that ‘a transformation in dentistry is necessary.’ She continued: “There is a huge opportunity to deliver a greater range of health advice monitoring and support, using dentists and their teams.”

The demise of the Lansley system could give her the opportunity to achieve this.

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^[i] http://www.healthpolicyinsight.com/?q=node%2F1699

^[ii] NHS dental services in England: An independent review led by Professor Jimmy Steele, June 2009

^[iii] ‘power without responsibility – the prerogative of the harlot throughout the ages’, Stanley Baldwin speech on newspaper proprietors March 17, 1931

^[iv] Speech by home secretary, David Blunkett to Labour local government and women’s conference Cardiff, February 2002

When Andrew Lansley drafted his Health and Social Care Bill, being married to a Doctor obviously drew his focus away from other healthcare providers. The structures were all there for GP commissioning and the formation of Clinical Commissioning Groups, even the removal of PCTs and transfer to NHS England and Area Teams. We can argue if any of this amounted to "no more top down reorganisation of the NHS" as promised in the manifesto, or the most challenging time anyone working within NHS management had ever faced.

It is hard to remember when someone at NHS England twigged or tapped Sir David on the shoulder and said what are we doing with dentists? Are they supposed to be part of this clinically lead new NHS? Someone somewhere found the fag packet, and I think it was John Milne's sister Helen Hirst that wrote the first plan for Local Professional Networks on the back of it. Helen had hardly got the ink dry before she passed the empty fag box to Sam Illingworth; before the final details were released both had jumped ship to the CCGs leaving others at NHS England to finalise.

Of course by this stage pilots had been invited to test the model, this too lacked direction with a "get on and see what you can do" mantra. Even the regular teleconferences to see what was happening and share experiences fell apart amongst the maelstrom of the de structuring of PCTs and the reapplying for posts.

By February and with the impending changes just a few weeks away, the NHS Commissioning Board (remember them?) released Securing Excellence in Commissioning in NHS dentistry was published. Within its pages contained the framework for LDNs and some examples of what the pilots had achieved. Some like in Manchester under the stewardship of Colette Bridgman clearly had an effect, albeit she struggled to fund her projects. Others exampled in the document like the reorganisation of Oral Medicine services in Birmingham perhaps needed placing in the fictional section of any library, but highlighted how little many of the pilots achieved in their lifespan.

Well six months in, we have recruitment processes in all the Area Teams and in others they have appointed a Chair. Many of these posts have been taken by LDC people, some have continued to wear both hats, and for me I am not convinced that's possible. As far as I am aware many of these newly appointed Chairs are yet to be paid for their new job, apparently due to a HR issue at NHS England, it seems like LDNs have taken them by surprise!

Of course the challenges for the LDN Chairs is to assist depleted commissioning teams in delivering national strategy and developing structural changes in service delivery locally, all within perhaps one afternoon a week. Not only is that the challenge but the budget given to them is somewhere in the region of £40,000, a share of a pot of £120,000 secured for Local Professional Networks for dentistry, pharmacy and opticians. The CDO describes this as "seed money" to allow the LDN to grow and show its usefulness, perhaps he is providing the fertiliser?

It really shows the importance of dentistry within the NHS when it's funding is pennies per patient population for an LDN compared to the £25 per patient that CCGs get for management costs. Clearly if members of the dental team are to be involved in LDNs, they are to be expected to do this with benevolence and with no remuneration; it's clinical leadership on the cheap.