On Saturday, while the weather was good in these parts, I found myself watching a sort of birth, perhaps more accurately a re-birth or metamorphosis.  A large, ugly and bizarre insect, having crawled from our garden pond, burst open and a beautiful bright green dragonfly slowly emerged and eventually spread its wings (a female Emperor I believe, pictures available here ).  The spectacle was at once captivating, beautiful and horrific – a little like watching scenes from an Alien film.  And once I’d seen one I saw two more transformations taking place elsewhere.

This week also saw the publication of the Future Forum’s recommendations and the very immediate Government response.  What sort of metamorphosis was going on here?

First, some observations.  Those involved seemed to feel they had been listened to (Is it just me or do I hear a weird echo of ‘I agree with Nick’?).  Some but certainly not all of the critics of the original Bill, especially among the clinical groupings, said relatively kind words about both publications.  And there is much that remains unclear – several of the Government responses are of the ‘we’ll tell you (the detail) later’ and ‘this is what we really meant’ variety. 

It also seems that the announcements have, at least in the immediate interim, successfully balanced the competing political interests in the Coalition.  (This has always been more about big P politics than about listening).  True, there are right-wing Tory complaints of watering down of the competition elements of the original Bill, but interestingly that plays into Nick Clegg’s hand in the short-term (‘see, we’ve successfully toned down excessive competition in the NHS and annoyed some Tories too’).  The commitment not to actively seek growth in either the private or public sector seems also to make possible exactly such a change, albeit ‘unintentionally’.

The document describing the changes sets out 19 areas of change in 64 paragraphs.  My own view is that many of these changes are very minor indeed, having the effect of curtailing some of the ‘excesses’ potentially found in the original Bill, safeguarding intent while maintaining overall direction.  I see very little in the way of U-Turns, and much now appears to depend on the wording of the mandate given to the NHS Commissioning Board.

Apart from fixing a political deal the Government felt it had to be seen to fix a deal with the clinicians too (to gain their ‘ownership’ of the planned changes in the jargon).  Yet that is where the recommendations and responses are at their weakest and also least surprising – the latter perhaps because so much had been trailed beforehand.  Why are these the area of weakness?  – because here the greatest opportunity has been missed.  While a cumbersome arrangement of lay inputs with forced chairing arrangements pays lip-service to a very real governance issue, the recommendations repeatedly fail to deal with the other more important deal that was there to be done – the deal with the public at large.  Yes, there is reference to increased involvement of patients and public in planning services, and in a very limited way that is welcome to us. Yes there are limited potentials in different arrangements for Health and Well-Being Boards and for HealthWatch.  However what is not clear is that any of those potentials will stand scrutiny against the criteria established by the Fontis Declaration.  Will those new arrangements be other than marginal?  Will they necessitate genuine involvement not post hoc consultation?  Does the Emperor have new clothes or just a desire to be seen to have new clothes?

The best joke I heard in all this? ‘Andrew Lansley was first to agree when Dave intoned the phrase “nothing about me without me”’!  Whatever individuals’ political futures hold, there too was the very nub of an opportunity missed.

And the dragonfly I watched?  It clung to the side of the pond while it rained all day on Sunday and on Monday morning it was found floating face down in the pond.  The others had gone, who knows where.