Heath policy debate
14 to 27 March 2004
HPERU undertakes research, and economic and policy analysis in five broad areas: (1) the workforce, (2) patient choice, (3) plurality of provision,
(4) incentives, (5) organisational and service development. Health Policy Debate summarises debate in these areas from newspapers and journals, think tank reports, meetings, press releases, and newly published research.
Workforce
New DH workforce figures revealed that the NHS now employs a record 1,282,900 people [1].
London is the toughest place to work
The NHS staff survey (undertaken by CHI and detailed in the last summary) revealed ‘shocking rates of violence and aggression against NHS staff’ – one in six (200,000 according to above figures) said they had been physically assaulted in the past year, while 37% had experienced ‘harassment, bullying or abuse at work’.
‘London acute hospitals topped the league of tough placed to work with more than half of Chelsea and Westminster Healthcare trust staff experiencing some form of violence or aggression in the previous 12 months’.
The CHI survey found ‘many incidents went unreported because a majority of staff were unconvinced that management would take effective action’ [2].
Black and Asian managers to be fast-tracked
‘The NHS is quietly assembling a cadre of ambitious black and Asian managers for fast-tracking into senior positions to counter a white bias in the top echelons of the service’. Sir Nigel Crisp has ‘led the way’ by appointing a black nurse as his private secretary to develop her managerial career and ‘is asking 500 chief executives of hospitals and primary trusts to follow his example by mentoring minority ethnic staff in every NHS organisation in England’ [3].
The GMC : handling complaints and appraisal
Sir Graeme Catto gave an interview to the Health Service Journal saying he is adamant the Shipman Inquiry ‘should not lead to the GMC’ role being usurped’. He is, for example, “totally, absolutely and vehemently opposed to another national body that would collect all complaints relating to patients’ and relatives’ concerns – it seems to me to be an anathema”.
The GMC has seconded one of its directors to the Healthcare Commission (as CHAI is to re-brand itself) to explore the idea of a single complaints gateway’.
Moving on to revalidation, he says the appraisal system will be robust enough for this purpose. He admits the process is likelier to be patchier in primary than secondary care because ‘relationships between GPs and PCTs are less clear and because the system started a year later than in hospitals’. He questions fears that sufficient information is not available for revalidation saying that “the information base has been increased inexorably”. He anticipates the new GMS contract will help because it requires better collection of confirmation information, such as cervical screening and immunisation rates. In secondary care, he says, revalidation information “might be prescribing data, outcomes, readmission rates or surgeon infection rates” [4].
Patient choice
At a ‘big conversation’ event, Tony Blair promised “to put the patient in charge” after listening to ideas for his party’s next election manifesto. At the event, ‘debate highlighted concerns that it might disadvantage those without access to meaningful information’.
‘But the group found it difficult to conclude precisely what information patients would need. Barnet and Chase Farms hospital trust director of communication cautioned against the ‘risks of creating a marketing culture where the GP surgery becomes a battle of the brochures’ [5].
‘The chief executive of Enfield PCT said, “We need to make sure that it doesn’t end up reinforcing the gulf between the middle classes and those who struggle to access services in the first place”. A carer at the conference agreed, saying, “where there is choice those who shout the loudest always get the most”.
One idea to emerge from the event is that patients should have regular check-ups to improve the health of the population.
Pilots for chronic disease management
Elsewhere, John Reid announced ‘plans to fund 28 demonstrator sites to help keep patients with complex chronic disease out of hospital [6]. Deputy chief executive of North Bradford PCT, Lesley Hill, explained how her organisation is looking to move to a model of management based on ‘principles of US healthcare provider Kaiser Permanente’.
One of the differences is that ‘clinical leadership starts at the top. ‘We have a chief executive who is a practising GP’ and ’20 other clinical leads who look after specific clinical areas’, ‘each supported by a manager’.
She says the PCT aims to work in a collaborative way with GPs and, in this vein, is critical of the new GP contract. ‘General medical services want to incentivise everything primary care does. We do not believe that is required, and will only lead to a culture of gaming to ensure that chronic disease and access targets are met, rather than quality improvements made’ [7].
Pilots to extend choice
The Sunday Times reported that steps are being taken toward ‘full patient choice’. A plan to offer a choice of date and doctor will be offered to patients at a group of London hospitals and those in the Yorkshire towns of Harrogate and Barnsley. The article noted the initiative ‘could also lead to surgeons publishing their patient death rates’. ‘Access to information about surgeons’ track records is already available in America, but so far senior British doctors have resisted attempts to make them follow suit, arguing that it will lead to surgeons rejecting difficult cases that might affect their position in the “death league” [8].
Three further reforms needed to increase capacity, says Labour MP
Labour MP, Frank Field, praises the choice initiative, but says it must go further. He suggests three reforms.
First, ‘the Government should establish a website, let’s call it www.easy.op.com, detailing information on the length of each waiting list. Patients would be able to access it themselves and choose to join the shortest queue’. ‘Secondly, some of the new funds being pumped into the NHS should be earmarked to bring more foreign teams into this county’. ‘The third reform centres on opening up fully the European health market for NHS patients. At present any of us can complete an E112 form and have our NHS operation over the Channel. But the Government does its best not to publicise this health passport. Instead of hiding the fact that NHS patients can go to Europe for treatment. The Government should positively encourage it. It should spearhead a campaign advertising how NHS patients can access treatments in Europe’.
‘The reforms I advocate here could be put into operation immediately. They would also put patients in the driving seat. That is where they have to be if the Government is to reform successfully what is Britain’s only loved nationalised industry’ [9].
Plurality of provision
The Conservatives continue to develop their critique of the Governments’ handling of NHS reform. Former ministers Peter Lilley (social security) and Stephen Dorrell (health) performed a double act during the budget debate. ‘Quoting heavily from the recent OECD report, they insisted that the rate of improvement in the NHS has slowed since 1999 when Mr Brown started chucking money at it. Such as? A 2.9 per cent rise in operations performed a year, against a 1.9% rise now. Spending grew under the Tories, but, Mr Lilley said, “it was moderate and within the capacity of the economy to provide it and for services to absorb it”. The Tories argued the failure of public sector reform will pull down the wider economy.
Michael White, political editor of the Guardian, says this will become ‘a vital election battleground’, even ‘more important than Baghdad’ [10].
Arguments continue over the efficacy of the patient’s passport
A report from the Social Market Foundation (SMF) think-tank argued that the use of privately funded healthcare was a good thing and would enhance choice, innovation and ease pressure on the NHS. But it also said that a tax-funded system should stay and the government should not seek to subsidise private insurance’. Conservative proposals for a passport policy would effectively involve “deadweight” costs because the subsidies would be taken up by those who already shun the NHS’ and the Tory dream would reduce the NHS to a safety net, left only to deal with “bad risk” patients’ [11].
Two days after the report, John Reid went on the offensive, attacking the passport policy at Labour’s spring conference in Manchester. “As always, the Tory policy is providing assistance for the few. What is different this time is that it is the rest of us who are expected to pay for those few to get ahead of us”. Reid went on, “the only way you get to have a Tory choice is to have enough money to pay nearly half of your operation”. For those who cannot, “their so called choice is really a sham” [12].
Think-tanks nowadays are also taking sides on the ideological debate within choice. Ruth Lea, director of the Centre for Policy Studies, wrote to the Financial Times to ‘take issue with the notion that the rich (and in many cases the not-so-rich) who currently is the private sector are being “subsidised” by the taxpayer-funded NHS. These people are merely being allowed an entitlement to care that their taxes have paid for’.
She said she was ‘also baffled by the notion that the NHS would be left with the “bad risk” patients. This does not apply to the NHS as either funder or provider (and it is helpful to make this distinction). Under the universal passport scheme, the NHS as funder will clearly be dealing with everyone whether “good”, “bad” or “average” risk. And as provider, people, whatever their risk, can use their passports to choose whether they use private or NHS provision. Why then should NHS provision end u merely as safety net’. In her view, ‘the passport ameliorates, rather than compounds, the two-tier service’ [13].
On the 22nd March, the same day as the Social Market Foundation report was issued, Tim Yeo, shadow secretary for health and education, told the Commons, “I can announce that it will not be the policy of the next Conservative Government to offer tax relief to people who take out private insurance”. Instead, “the patients passport will enable NHS patients access to the private sector, to all those independent providers to whom they have previously been denied access…and the precise basis on which that access will be granted is an issue on which we are now consulting” [14].
The move was reported as a ‘significant policy U-turn’ by the Times [15]. But Mr Yeo said that the patients passport was enough to stimulate the private sector and insurance does not need to be subsidised as well.
PFI debts hurting hospitals
‘At least 10 NHS hospitals built with private-sector funds, are facing deficits amounting to more than £40m’. ‘One hospital has had to close a ward, another has raised its car-parking charges for visitors, and several others are cutting back on agency staff to sae money. The large monthly sums they have to pay to their private consortium partners, along with the rising number of emergency admissions, has put them under financial pressure’.
The report was compiled by London Health Emergency and a representive, John Lister, said the hospitals built in the first wave face a unique handicap in the new competitive environment – under payment-by-results. If the trust runs into financial difficulties – if some of its services are above tariff costs - it has less flexibility to cut costs. ‘The only part of the budget the trust itself controls are clinical services: doctors, nurses and patient care’ [16].
Incentives
Payment by results is now formally with us, even if it will be slow to develop in practice. One small part, not well understood, is a detail that could become critical to the financial solvency of commissioners – the Market Forces Factor (MFF).
The King’s Fund’s chief economist, Jon Appleby presented analysis at a seminar on PBR organised by the Office of Health Economics and wrote an article for the Health Service Journal on the same subject.
The MFF was ‘initially recommended by the resource allocation working party (RAWP) in 1976…as a way of adjusting allocations for unavoidable variations in healthcare costs around the country. It is a mechanism to even out the purchasing power between commissioning bodies.
It is needed because, for example, pay for inner London is a third higher than in the rest of England (although Appleby said at the PBR seminar that there were also significant variations even within London). ‘The latest trust-specific MFFs show a variation of around 40 per cent for acute trusts and a slightly smaller variations for PCTs’.
‘Faced with such variation, what might purchasers be tempted to do, move contracts in order to get more bangs for their buck? There is an obvious limit to this approach, however. Lower price hospitals will not be able to increase activity by much in the short term. And, of course, the residents of Paddington and its environs may not think much of travelling to Walthamstow for their inpatient care ‘[17].
One senior PCT manager in conversation this week (they were talking to Tom Smith at a conference on payment by results) said the MFF was already causing problems in payment by results. If the PCT wants to move patients to be treated elsewhere, do they pay the local MFF (from where care is commissioned) or the MFF calculated in the area where care is received? This is one of many small detail issues (with big consequences) that is still to be clarified, even though the system is about to roll out.
The cost of meeting end of year targets
John Reid was pleased to announce the NHS has met targets for quicker treatment – no one waiting for longer than nine months at the end of March. But as the Health Service Journal reported, this achievement required a ‘last minute sprint’. ‘In some areas, this has meant pouring substantial amounts of money into the independent sector.
Peter Jeffreys, managing director of Medinet, which arranges private sector operations says his business arranged about 1000 extra operations and was still receiving calls in the last two weeks of March from trusts that had left it late. These trusts were not able to negotiate good rates and Jeffreys says the independent sector exploit this position. “In March, they know that people will buy at any price”.
Winchester and Eastleigh Healthcare trust realised it faced a significant capacity gap to meet the end-of-March targets. ‘In order to address this, it has spent £2m on buying capacity in the private sector in the private sector. “We are having to find most of that from our bottom line. We are going for foundation status and we are told we must break even” [18].
A Health Service Journal editorial (18 March) says ‘if this year is anything to go by, there is a covert belief among many trust chief executives that busting the budget to hit waiting list targets is acceptable, even necessary, given the pressures on the service. Next year is likely to be very different, with the final 12 months of the 2002 three-year finance settlement producing the tightest squeeze between extra cash and the improved performance it is meant to fund. The annual game of chicken between trusts and the Department of Health will be played for very high stakes’ [19].
The difficulty of the task ahead and the need for greater capacity was reinforced by a report that ‘the NHS needs to increase the number of operations by 30 per cent to seven million a year by 2007 to meet government pledges on waiting lists’ [20].
PCTs feel the pinch of payment by results
Hugh Taylor, DH director of strategy and business development has written to StHAs, which are overseeing negotiations between foundation trusts and PCTs, to say he ‘cannot stress enough the urgency of the timely signing of contracts. The letter continues, “the key step change needed over the next couple of weeks is to enable PCTs to sign off contracts even without agreement about some elements at the margin’.
The letter led the Health Service Journal to report that PCTs are being pressured into signing legally binding contracts with foundation trust applications that could leave them in financial difficulties [21]. Senior managers told the Journal they were ‘furious they have had as little as two weeks to draw up the complex legal document that will bind them into deals with foundation providers for three years’.
A senior source at Cambridge City PCT – which contracts for around £45m with Addenbrooke’s – said it was under considerable pressure to agree to the contracts so that Addenbrooke’s financial position looked strong when its application is put in front of the regulator. “Had we known what the financial implications would have been during the consultation, I don’t think we would have supported Addenbrooke’s application”.
Another PCT chief executive said that PCTs had been “kept out of the loop” on the likely financial impact of foundation trusts. ‘And he said the hurry to introduce foundation trusts had meant the consequent introduction of payment by results had been rushed’.
Nigel Edwards, director of policy at the NHS Confederation, told the Guardian, “it is not acceptable to compel PCT chief executives to sign contracts they do not agree with. That is in nobody’s interests [and] will poison the well of relationships between NHS organizations’ [22].
Service and organisational development
CHI no more
Dame Diedrie Hine (chair) and Jocelyn Cornwall (acting chief executive) talked to the Health Service Journal about CHI’s three-and-a-half year lifespan. ‘What really gets them fired up is sheer envy at the better hand their successor body has been dealt’. They are envious at the large staff, the 17-month lead in time, and greater powers to correct problems, such as placing trusts on special measures. Jocelyn Cornwell says, “We never had that weapon in our armoury”. Dame Diedre says, “We could make a diagnosis, but we couldn’t prescribe the treatment” [23].
They are glad that almost 100% of the staff will move from CHI to CHAI, but Dame Diedre ‘regrets that it could not make use of some of CHI’s directors’. None will transfer to the new organisation.
A CHI report based on four years of reviews [24] ‘completes CHI’s national commentary on NHS services’ [25]. It ‘warns that relations between some clinicians and managers are so bad they put patient safety at risk’ [26].
The report stated that trusts were improving in some areas but not in others and warned that variations across England and Wales were still too great [27].
Jocelyn Cornwall, launching the report said, “The lack of clinical leadership within acute trusts and continued problems with the accuracy and quality of trust data are areas that urgently need to be addressed. Performance targets have driven improvements to care but should not replace local response to patients’ needs. It is important that the service now concentrates on redesigning services with quality in mind” [28].
Dame Diedre, in the interview cited above, says although the new body is working on ways it will gather information, “some of the most difficult problems for NHS management – dysfunctional clinical teams, indications of bullying and harassment – these are the sort of things you only really uncover by visiting”. Cultural insights of this kind will be more difficult to elicit by the new body [23].
The Healthcare Commission is born
‘The Act’ made provision for the creation of The Commission for Healthcare Audit and Inspection to replace CHI and while the new organisation will be legally known as CHAI, on its launch it has rebranded itself, the Healthcare Commission.
The new body is coming out with a lot of new ideas. Chief executive, Anna Walker, ‘confirmed the commission was considering a charge for trusts which refer too many of their complaints upwards to its independent complaints service’ [29], but they will not be penalised for receiving high numbers of complaints. The idea is to provide an incentive to ensure that local trusts resolve complaints locally.
The NHS takes action to resolve problems with problems in IT implementation
Richard Grainger, director of the IT programme, says foundation trusts that opt out of the national programme ‘will be buying inefficiently and risking data incompatibility. Although foundation trusts will be required to ‘cooperate with the national IT procurement programme, and to ensure their systems are fully compatible with it, they will not be obliged to be part of the programme itself’ [30].
‘Trusts that have already spent heavily on their own IT systems are particularly likely to be tempted away from the national programme and associated costs’. UCH is one trust that has spent heavily on an electronic patient record system.
It has been decided that clinical and managerial engagement with the national programme is not what it might be. The programme will hold nine conferences – four nationally and five locally – in the next 12 months and a shake-up of the leadership in the IT programme has been announced.
Aidan Halligan is to be appointed co-director of the IT programme and will lead on engagement with clinicians or get “buy in” as the Guardian put it [31]. In typical fashion, Halligan said that enthusiasm is growing and that “the only risk [for clinicians] is not to take the risk”.
‘He told a conference in Harrogate that, with all the NHS contracts in place, “the shopping trip is now over” and now was the time to fully engage staff in its implementation’ [32]. John Bacon, currently director of delivery at the DH has also been drafted in to chair the programme and will be looking to secure management “buy in”.
Richard Grainger will retain responsibility for leading on commercial and technical components. But changes to the leadership of the IT initiative has fuelled speculation that Grainger ‘is being lined up to take charge of IT projects across government’ [33] leaving the NHS IT project to Halligan and Bacon.
References
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