“Policymaking is not about dealing in black and white; it is about deciding between shades of grey”

Lawyers – as I know only too well from my personal life (I spent two decades married to a barrister) as well as my professional (I was chief legal ombudsman) – see things in terms of legality and illegality, guilt and innocence. Political thinking (at least in England) is shaped by the binary nature of the (historical) two-party system: you are either in Government or in opposition, on one side of the House or the other. And for professions whose origin is in objective, provable fact, the temptation to approach things in a binary way, with propositions either being true or false, is overwhelming.

Yet social and healthcare policy is not a binary business. There is no such thing as the perfect policy – the one which will achieve all your aims quickly and at low cost. Nor are there (many) policies which are so dreadful that they are inexorably doomed to failure. Policymaking is not about dealing in black and white; it is about deciding between shades of grey. It is about balancing different sorts of cost with different sorts of impact, and about deciding what negative consequence you can live with and what you cannot. And unlike laws – judicial or scientific – policies are not intended to be absolute. They do not bind expressions of the truth, but instead generalities which admit to exceptions.

That is the context in which one should approach the Government’s new medium term healthcare plan.

Leaving aside the – admittedly disappointing – fact that there is no mention of optometrists, the plan signals the continuation of the long-standing healthcare policy of devolving decision-making, not merely at Integrated Care Board (ICB) level, but beyond. It is a neighbourhood level that is described in the 10-Year Health Plan.

For those unfamiliar with the reality of government policymaking, the message is clear: national is dead; it is local that matters.

Up to a point, Lord Copper. For all that Ministers articulate a policy of devolution of decision-making in public, behind the scenes things are a little more nuanced. Yes, there are strong advocates of devolution: Streeting’s de facto number two, Karin Smyth, being the most prominent. But the return of Alan Milburn as a key adviser has strengthened the centralising tendency in government. Plus, with healthcare being a key electoral issue, and Labour so far behind in the polls, Ministers know that time is running out to impress voters and demonstrate that they have begun fixing the NHS in a way that people can see and feel. Waiting for the newly reformed ICBs to deliver is not a politically attractive plan.

Healthcare policy is not a binary game. We need to be ready to fight at a local level. But we should learn from what our primary care colleagues are doing and fight nationally too

The national and local push

All very interesting, you might say, but what has any of that got to do with optometry? Well, the answer is simple. If, as our members tell us, one of our aims should be to drive up the amount of clinical work going into High Street clinics, we need to capitalise on the positive signals contained in the 10-Year Health Plan.

If we want services like Minor Eye Conditions Services and CUES, cataract pre- and post-op support, and glaucoma repeat readings available to everyone in England (and surely that is what we want), we need to know who to pitch to. If we take the localism agenda as a binding statement of the Government’s intentions, we have to aim to fight it out ICB by ICB to get what we want. And given the financial pressure ICBs are under, not to say the cultural influence over their decision-making exerted by the hospital sector, that strategy will not be a quick and easy process.

All this only applies if, as I say, we accept that a preference for local decision-making excludes the possibility of such services being mandated from the centre. What is interesting is that, for all the emphasis on the local in the public policy statements, our colleagues elsewhere in primary care are busy directing their pressure on the centre, targeting Ministers and Department of Health and Social Care officials rather than ICB commissioners. The dentists and the doctors are focusing not on extending their existing portfolio of services, but renegotiating their contracts. The pharmacists, on the other hand, having in recent years secured the Pharmacy First contract (commissioned nationally), are seeking – with some success – to add additional clinical work to their national portfolio. As they know, an expressed preference for localism does not rule out ministers imposing national solutions if they believe that it is the best way to get things done.

That is the context in which we need to frame our lobbying activity. With the Government desperate to improve the patient experience, to reduce pressure on GPs and A&E, and to unlock waiting lists, and the clock rapidly ticking down on this political cycle, optometry has an offer that should be compelling to ministers.

Yes, policy says that commissioning is for local decision makers to determine, yet healthcare policy is not a binary game. We need to be ready to fight at a local level, but we should learn from what our primary care colleagues are doing and fight nationally too.