The Bill to reform the National Health Service has finally received Royal Assent, but the debate about the National Health reforms is a good example of not choosing the right negotiating behaviour for the type of negotiation at hand. Every negotiation calls for different behaviours, depending on the subject matter, the stage the negotiation has reached and the personalities on the other side.

In the case of the National Health reforms, the Government has been negotiating with both health care professionals and with the public at large. The Government has been deploying arguments based on reason – about the need to use resources more efficiently and take medical decisions away from bureaucrats in hospitals and back towards medics. The Reforms have proposed to abolish NHS Primary Care Trusts and Strategic Health Authorities and transfer their £60-£80 billion of commissioning of health care funds to “clinical commissioning groups” principally run by GP’s, as well as the establishment of “Monitor” as an economic/competition regulator. Primary Care trusts would be amalgamated into “foundation trusts” and NHS hospitals would be allowed to earn much more of their income from private patients – up to 49%.

Lack of Emotional Argument

However the NHS is an emotional subject. It is an emotional subject for GP’s and Health care professionals such as Nurses, most of whom enter the profession on a vocational basis. It is also an emotional subject for the public at large, with the NHS forming an iconic part of Britain’s social welfare heritage. The Conservatives are not trusted with this social welfare agenda precisely because (maybe unfairly) they are perceived historically as addressing it in pounds and pence rather than as an emotionally-based priority. The Government also got off to a bad start in dealing with the subject as the Act’s proposals were not contained in the Conservative-Liberal Democrat
coalition agreement nor were they discussed during the election campaign – if you want to address an emotional issue it’s not a good tactic to avoid it. The “Listening” pause which the Government announced in April 2011 came too late and has not been enough to restore this sense of trust.

The upshot is that the Government may have won the battle on NHS reform but it has lost the negotiation. The Government is perceived by many health care professionals and by the public as riding roughshod over their passionately held views, because unfortunately it has failed to convey any emotional arguments to support its point of view. Although the reforms purport to put “patient care at the centre of the NHS”, this kind of rallying cry has been lost in the welter of emotive argument on issues such as whether the focus on competition for funding decisions from private care providers would improve health care or just undermine and fragment the NHS, and whether NHS patients will suffer if hospitals are allowed to make more money from private patients.

Worse still, the Government’s rational arguments have all been largely sidelined and marginalised because the volume of the emotional outcry has been getting louder as more and more groups line up to oppose the reforms. There has been opposition from the British Medical Association, the Royal college of Nursing, the Royal College of Midwives, the Royal College of General Practitioners, Unite, and various pressure groups such as “NHS Direct Action” and “Keep our NHS Public”.

Missing Explanation

This means that the media focus has all been about the fact that there is a major argument going on, rather than the reasons or the emotional motivations behind the Government’s reforms. In all the debate and all the media coverage I have not seen one item which puts forward the Government’s case for reform clearly – even on a purely rational basis. Specifically, I have seen no articles clearly explaining:

* Why GP’s making decisions (based on competitive provision of services) rather than Hospital Trusts taking those decisions, might save money or resources
* How much might be saved
* Why there will ultimately be less aggregate bureaucracy associated with clinical commissioning groups in GP practices than there is at Hospital Trusts
* Or (more emotionally) why treatment will be quicker, safer or more effective for patients
* How clinical commissioning groups will integrate with health care providers in practice (especially for conditions requiring different forms of treatment)
* How results could be measured
* How the new NHS Commissioning Board together with local “health and well-being” boards will provide accountability.

‘Lost’ Negotiation

By failing to address these points, the Government has lost the negotiation and will now find it difficult to make a success of the reforms. This happens in any negotiation where the outcome is imposed on the other side without the argument being won. Those who opposed the reforms will want to ensure that they fail. The opposition may be explicit. Or it may be covert. Or it may not even be consciously done. Goodness knows the reforms are complicated enough for anything other than full scale support to cause major implementation problems.

The Government might have been better off if it soft pedalled on the reforms until it had won the emotional argument – even taking implementation in small, incremental stages until it had achieved this. As it is, by pushing its solutions through the Government makes it likely that the debate on the future of the Health service will re-surface once this wave of reforms has failed to do the job which the Government was originally expecting.