Memo to Dave

The Health and Social Care Bill is gathering more opponents as people get closer to its full implications, but should you be worried? Is it the case that most of the opposition is selfish, people protecting self and empire? Well, it possibly is, although that is not to disrespect the genuine care that most of them hold for the NHS. The public understand that care for their vocation and that is why you need to look carefully at strategy in the face of this mounting opposition. Whatever its cause the opposition will be spun in the name of protecting the service and you will be cast as the villain.

There are some very good things in the Bill, notwithstanding the disappointment that it is not part of a truly radical and ambitious solution like that suggested in the Unofficial Green Paper (www.bigsocietygreenpaper.org). However, there are also some weak points, and allowing, or forcing, the NHS to break into hundreds of social enterprise providers is one thing that seems to have little opposition and yet I see it as one of the most dangerous. Whereas much of the opposition to the bill is around the introduction of competition, my caution is that the social enterprise providers will not be equipped to deal with that competition, being stuck with tupe obligations and inherited services.

I need to be clear that tupe is not a bad thing and reducing terms and conditions to a lowest common denominator with the private sector should be avoided. These social enterprises however look to me to be risking death by a thousand cuts as they lose profitable services to commercial competition and are stuck with the rest, effectively relying on charity to survive. This is a return to the Victorian era and unlike most of the opposition I see that as the  'system' danger within your reforms.

To avoid this you have a golden opportunity to think big in a low risk way. A complete overhaul of all pensions and healthcare systems, including the way that they are funded, would create greater fairness, reduce the burden on the state of all pensions over the medium term and level the playing field in terms of competition in the short term. There is much more detail on this in the Green Paper but a return to a system where many depend on charitable providers for their care must be avoided at all costs. Equality has underpinned the NHS since inception and must continue. Giving the juiciest parts of it to private providers will simply unpick the rest. As demographic pressures and the necessity of funding from current day tax receipts combine to render it unaffordable, so the social enterprise providers will be the ones without funding to care for their patients in their marginalised and expensive rump of services.

I do accept that competition is needed but you must consider how to balance best value with the long term future of the service and those working in it. Creating a level playing field for competition, and creating a nationally-underwritten framework for health and pensions funding, would do two hugely important things. It would ensure that when competition is introduced, the existing providers have a fair chance; and it would also reassure those nervous about the new commissioning arrangements that sufficient funding will be in place for the foreseeable future. It is therefore possible to save the NHS Bill without touching it at all. It is largely not the Bill that is wrong and if you analyse the opposition you can see that. It is the supporting structure, the methods of encouraging competition and the move away from decent pensions and pay that are causing the obstruction, and these can and should be dealt with outside the Bill.

Gareth