Conservative reform and the baying mob

In Pakistan, Aasia Bibi, a mother of five, has been sentenced to hang under Pakistan's blasphemy laws.  Meanwhile, in the UK, the Tories are keen to push through a series of reforms that promote decentralisation, devolution and empowerment, to create what David Cameron calls an, “empowering state” rather than an “overpowering state.” Rather than debating the horror of double glazing in a grade two listed house, Bibi's story confronts some of the big questions about how a society should be run. Religion, class, and human rights. Bibi's life. Yet, Bibi's plight could hold a warning to Cameron and his allies.

The 'localism' proposals cut across a range of policy areas: in crime they propose to make police locally accountable to a directly elected individual and will oblige the police to publish detailed local crime data statistics every month hold the police to account for their performance. In health reform Primary Care Trusts are being dissolved and responsibility for commissioning services will be given to local GPs. With the reform of the National Institute for Heath and Clinical Excellence (NICE), the decision about what drugs a patient can access will be left to the doctor. In planning, local communities will be able to propose development which, if it meets certain safeguards and gets 50% of support in a local referendum, will be  built without planning permission.

In principle, this all sounds perfectly legitimate. However, as the BBC's Nick Robinson said in his blog recently, "Governments with money centralise and claim the credit. Governments without cash decentralise and spread the blame." In practice, the Tories are passing over a lot of responsibility and tough choices without providing the money to carry out the new duties properly. The medical reforms are a good example. Health Secretary Andrew Lansley has confirmed that Primary Care Trusts are to be abolished by 2013, from when GPs will plan hospital care and manage budgets. The PCTs will be replaced with 500 GP consortia.

The exact proposals have yet to be published but the overall effect will be to leave far fewer people  without the appropriate training or experience, with a smaller budget, making some very tough decisions about local priorities. Not only will the GPs on the consortium have to work alongside colleagues struggling with their own set of priorities, they will also come face to face with patients each day. The nature of the job also means that GPs tend to be prominent people within the community. GPs and the consortium members, in particular, will no doubt be subject extreme personal pressure from individual patients and organised groups.

On the back of these reforms, the Conservatives intend to strip NICE of the power to turn down new medicines. NICE ensures that the drug budgets within the NHS are used in the most cost-effective way. The power to turn down medicines was a response to the postcode lottery when some patients could get treatment and others couldn't. The pharmaceutical industry has always been critical of NICE and must be rubbing their hands with glee at the thought of influencing local GP consortia to provide more expensive treatments.

Dr Clare Gerada, chair of the Royal College of GPs, attacked the propsals:


"GPs will bare the brunt of the proposed £20 billion savings. I'm concerned that my profession, GPs, will be exposed to lobbying by patients, patient groups and the pharma industry to fund or commission their bit of the service. There could be letters from MPs and patient groups, and begging letters from patients. At worst, the negative impact for GPs could be patients lobbying outside their front door, saying, 'You've got a nice BMW car but you will not allow me to have this cytotoxic drug that will give me three more months of life.' Patients might think that the decision made about their healthcare will be based on self-interest – GPs saving money for themselves rather than spending it on patients. Certain treatment decisions, and a GP consortium's need to balance its books could be misconstrued...Making GPs "the new rationers" of NHS care could ruin the long-established bonds of trust between them and their patients." 

The fact is that whether we like it or not, the NHS has a limited budget and there is an opportunity cost for every decision made. That is, for every new cancer drug that provides perhaps a year of life, a seemingly more banal but long term and life enhancing treatment may be denied. There is a choice. Do you want to make the decision between extending a life temporarily or providing a number of hip operations? Such decisions require objectivity, careful un-emotive planning away from frontline pressures.

Meanwhile, in Pakistan, Bibi's case is the first time a woman has been sentenced to death for blasphemy. It has provoked a cleric in Peshawar to offer a reward of 500,000 rupees (£3800) for her death and has led to the murder of Punjab governor Salmaan Taseer by one of his own guards. The liberal governor had dared to take up Bibi's cause with the president and condemn the blasphemy laws. His death prompted a 'rally against fear' but as Declan Walsh noted in the Observer yesterday, politicians in Pakistan are 'terrified of being on the wrong side of the blasphemy debate.' The government has subsequently confirmed that they will not repeal the laws.

In her home town of Itanwali, Walsh reported that the local people are growing impatient for the sentence to be carried out. However, it appears unlikely that Aasia Bibi will be hanged. Despite this atmosphere of fear no blasphemy convict has ever been hanged in Pakistan. In 2001, Dr Younus was accused of defaming Muhammad. His conviction was finally overturned by the Supreme Court. In fact, according to The Observer,  most blasphemy prosecutions are overturned by the appeal courts, which are to some degree immune to the pressures of the mob that afflict local benches. Usually the judges simply find that there's no evidence to support the case.' In other cases the defendants have received a presidential pardon.

There are enormous differences between Pakistan and the UK but I think the case flags up some important issues for policy-makers. The rush for local decision-making needs to be considered very carefully.  Do we want our health priorities decided by the marketing department of the drug companies or by the local organisations who shout the loudest? As the Tories rush through their 'localism' reforms, I think the lesson of the Bibi case is that only authority, size and space can create the robust decision-making that is 'immune to the pressures of the mob'.

It's a matter of life and death.