Health Policy Debate
16 November to 6 December 2005
The BMA will hold a conference in April 2006 entitled, Can we make sense of system reform?
Debate on the different strands of system reform is intensifying because some important parts of policy remain works in progress, it is not clear how they fit together in practice, and because of growing financial pressures. This issue of Health Policy Debate looks at system reform in the round - the politics of reform, financial pressures increasing pressure on providers, recent proposals to change service configurations, commissioning structures, the organisation of general practice and ways in which patients’ relate to the NHS, as consumers and as citizens.
There are signs that system reform is entering a new phase. Paul Corrigan is one of several commentators to entreat the government to become more radical over the last few weeks. At the end of November, Corrigan was appointed as health advisor to the prime minister, replacing Ian Dodge who is returning to the Department of Health. According to the Financial Times the move ‘is a sign that the prime minister is deeply worried that no one in the Department of Health appears to keep a full grasp on the complexity of the government’s health reforms’. A Whitehall insider told the paper that given unrest on Labour’s backbenches over the health reforms, there was also a need for “a political take“ as well as a technical one: something that it was difficult for Mr Dodge, as a civil servant, to provide [Go to note 1].
The politics of reform
Over the last few weeks pension reform became the latest lens through which to view contemporary British politics and the Blair-Brown rift with “sources close to the chancellor” complaining that No.10 were presenting him as an enemy of reform, contrasting with Blair’s preparedness to change [Go to note 2].
Cameron offers to take the baton of reform from Blair
Brown will want to avoid any depiction of him as anti-reform if and when he runs against David Cameron at the next general election to decide who will be Blair’s heir. The ‘Cameroons’ will aim to present their man as someone who will continue reform and a more obvious successor than Brown. Until the election, Cameron will back Blair, making both Labour leaders uncomfortable [Go to note 3].
In an interview with The Times, Gordon Brown rejected the idea he was anti-reform, revealing ‘his growing frustration at being portrayed by the Conservatives – and privately by some Blairites – as an obstacle to radical change [Go to note 4].
Interviewed in The Guardian, David Cameron said, it is “Gordon Brown who is opposing reform of the public services…so I think it much easier to oppose him, as someone who is holding Britain back’ [Go to note 5]. His Lieutenant, shadow chancellor George Osborne, told the FT, “I think we’ve got one great thing on our side: Gordon Brown looks like a figure from the past and we’re going to look like figures from the future [Go to note 6]. In his response to Brown’s pre-Budget report, Osborne called him a “roadblock to reform” [Go to note 7].
The financial drivers of system reform
Gordon Brown is working hard (belatedly, say some) to reign in government finances and present himself as someone in control of public spending. In his pre-Budget report, he announced that he did not expect public spending to grow more than 1.9% per annum between 2008 and 2011. The FT warned of an 18-month inter-departmental fight over how much of that growth each gets [Go to note 8].
Conservatives charge the government with wasting money on administration
With a wish to limit the growth of public spending, the government does not have much room for manoeuvre or money to spend on supporting reforms. This makes the public outcry on NHS deficits difficult to handle and taking reform forward in the face of financial crisis, even more so.
Research by the Conservative Party in November revealed that four strategic health authorities account for 40% of the total shortfall. ‘Worst off is Avon, Gloucestershire and Wiltshire SHA, predicting a year-end shortfall of £115.8m. Surrey and Sussex predicts a year-end shortfall of £104.6m, while Bedfordshire and Hertfordshire reckons on £100m and North West London expects to be £99.4m in the red’ [Go to note 9].
The chief executive of Surrey and Sussex left his job a few days later – seconded to the DH to work on international development [Go to note 10].
The momentum of the Conservative attack was halted by shadow health secretary Andrew Lansley’s assertions that the similarity in the deficit and the increase in the cost of administration since 1997 is “no coincidence”. Temporarily, the focus switched from the management of the deficits to the familiar ground of ‘bureaucracy bashing’ [Go to note 11].
But after ten-days or so the story re-emerged with reports that record numbers of health service trusts were being forced to take measures to cut deficits, including post freezes. The RCN say that newly qualified nurses cannot find jobs in the NHS.
Sir Ian Carruthers, the chief executive of Dorset and Somerset SHA has taken over in Hampshire in light of its financial difficulties. He says trusts are striving to cope with substantial reforms without reducing patient care. “There is extreme pressure on the system” [Go to note 12].
Hewitt comes down hard on poor financial management
In an interview with The Independent, Patricia Hewitt said she will resist demands to bail out NHS hospitals that are heavily in the red to avert a winter crisis.
She said: “A hospital that has a deficit, the first think you want to know is how long are they keeping their patients in for; how much of their surgery is day care; how many outpatient appointments are they shifting to the community? “You don’t say, ‘Let me give you more money to wipe-out your deficit’. You do say, ‘Excuse me, have you done everything you need to do that the good and the best hospitals are doing to use every increased pound of taxpayers money we are giving you to the maximum effect.”
Keen to make this a principle of the left, she added,” I don’t know whether Marx ever said waste is theft from the working classes but he should have done, because it is” [Go to note 13].
A week or so later, the secretary of state announced the forecast end-of-year deficit was ‘around £620m’, somewhat less than Conservative projections, but unprecedented nonetheless.
Hewitt said, “I am also announcing today a further important measure to address the problems in a minority of NHS organisations. Turnaround teams of financial and management experts are being sent to support [those] that have the biggest delivery challenges” [Go to note 14].
People are asking again, where has the money gone?
The Sun asked: ‘What the hell’s going on in the NHS? We’ve all been taxed to the hilt to pay for a world class health service…yet Patricia Hewitt admits hospitals are hundreds of millions in the red. How can this be?’ [Go to note 15].
In contrast to Hewitt, the King’s Fund put out a statement to the effect that ‘deficits are not necessarily the product of poor financial management’. ‘Of the extra cash going into the NHS this year, the King's Fund estimates that around three quarters has been absorbed by cost pressures’ [Go to note 16].
Only 2.4% of the increase has been available for new beds and operations while
‘Ten times as much – 29 per cent – went on NHS pension rebasing. This was a consequence of transferring the cost of inflation-proofing from the Treasury to the Department of Health’. The second largest share, 27 per cent went on pay increases for doctors and nurses and new wages for extra staff. Staffing reforms – Agenda for Change – swallowed another 12 percent, while provision of negligence claims absorbed 5%. Extra spending on drugs took another 5% and the implementation of NICE recommendations, 8 per cent [Go to note 17].
The return of the rationing debate
The Guardian reported that Patricia Hewitt has ‘ordered a winter round of NHS cuts to eliminate the deficit of up to £700m’. A DH spokesperson said Ms Hewitt was introducing the policy ‘in an attempt to break a pervasive attitude among doctors and managers that the government will always bail out trusts if they cannot balance the books. Trusts had to “experience pain locally”.
The paper said that once Sir Nigel Crisp had received the returns reporting the financial outcome for the first six months, ‘he instructed health authority chief executives to scrap the returns and instigate a fresh round of economies to break even at all costs’. Health Authority chiefs ‘are now engaged in fraught meetings to force through the policy of zero tolerance to deficits’ and cuts will be announced locally over the next few weeks [Go to note 18].
A number of stories reported that hospitals are delaying operations and removing patients from waiting lists to save money [Go to note 19]. The director of public health for Ipswich PCT explained that overweight patients were to be denied NHS hip operations and explained, “we cannot pretend that this work wasn’t stimulated by the pressing financial problems of the NHS in East Suffolk” [Go to note 20].
A leader in The Independent said rationing made sense, but the manner in which it is being approached is “cack-handed” [Go to note 21].
On December 1st, Sir Nigel told the Health Select Committee that “improving financial management does not mean compromising services for patients. Any actions that the NHS takes to reduce deficits should not lower the quality of care provided to NHS patients. There is a lot more that some parts of the NHS can do to improve productivity by embracing new ways of working and eliminating inefficiencies [Go to note 22].
Short-term pressures might mean that Sir Nigel’s advice is not strictly followed. A letter ‘seen by The Times’ reveals that a group of London hospitals has been told by NHS managers to postpone surgery for as long as possible in order to cut the trust’s debt [Go to note 23]. Other hospitals are telling patients that they are no longer eligible for operations in order to make savings [Go to note 24]. There were also other reports of enforcing minimum waits for operations [Go to note 25].
PCTs redefining healthcare, putting financial pressure on social services
Public Finance magazine reported that local PCTs are redefining what counts as a ‘health care’ need to make urgent savings. It has heard of six PCTs passing responsibility for paying for the care of people with long-term medical conditions on to the social services department, who services are means tested.
In west-Wiltshire, the director of adult and community services, said, “Community hospitals, wards and beds are being closed, so we find ourselves [in social services] needing to provide more intensive home care services. Because we means-test for people’s ability to pay, if someone is assessed as needing to make a contribution, then we charge them a proportion of the cost [Go to note 26].
Reforming provision
A key aim of system reform is to alter service provision – to expose providers to competition so that the successful may grow and to remove support for unsuccessful and unpopular services.
Payment by results suspended in parts of Hampshire
Although Payment by Results could be advantageous to some trusts, in its early stages it is likely to have a disruptive impact on the local health economy. For this reason, payment by results has been suspended in parts of Hampshire while the SHA ‘battles to control spiralling debt in the health economy’. An SHA spokesperson said, ‘Given the financial challenges facing this health economy, our guidance has allowed primary care trusts and [acute] trusts to modify the risk-sharing arrangements in place to minimise the financial risk on both sides’.
‘In certain circumstances, it has been agreed that income and activity will be fixed, as full blown PbR would only serve to further destabilise the financial position and recovery plans, as would be merely passing the deficit around Hampshire’ [Go to note 27].
University College Hospital plans to move a third of cancer patients to hotels
UCH as a foundation trust is now exposed to full-blown Payment by Results. It faces incentives to lower costs so as not to lose money on tariff payments.
A hospital bed costs around £500 per night and UCH is moving cancer patients to hotel rooms, which are more than £300 cheaper. Patients seem to like it. They ‘receive chemotherapy, stem cell transplants or diagnostic investigations in hospital during the day and retire to their hotel room, often with a family member, in the evening. Hotel rooms are suitable for patients who are well enough not to need 24-hour nursing care yet still require treatment or daily monitoring.’
Robert Naylor, the trust’s chief executive, said: “Once we are satisfied that it is safe and that patients prefer it and can call on a doctor or nurse if they need one, our plan is to do this on a much wider scale. I think this could be achievable for one-third of patients and that is what we are planning to do. “This is not only relevant for cancer care. We are doing something similar with the National Hospital for Neurology and Neurosurgery” [Go to note 28].
Companies short-listed to provide diagnostic scans to the NHS
Nine private sector companies have been shortlisted for contracts to provide almost £1bn-worth of diagnostic scans such as X-rays to the NHS over the next five years. The new contracts are likely to hasten the removal of more work from DGHs, according to the companies bidding.
One of the bidders said, “The Alliance pricing for [the 2004 deal] was very aggressive which means the same will have to be true this time round. That will put a lot of pressure on existing acute NHS hospitals who will have trouble matching the private sector price. PCTs may well therefore choose to place more of their work with the private providers” [Go to note 29].
The end of the District General Hospital?
The Financial Times has had sight of a ‘late draft’ of ‘top level report being prepared in Whitehall’ that could spell the end of the traditional DGH. The report is being prepared for the National Leadership Network, an advisory body set up by Sir Nigel Crisp.
The report says, competition between providers is likely to take much routine surgery out of some hospitals and not all hospitals will be left with the “core” services needed to support trauma and emergency surgery. That is likely to have be managed across networks in fewer hospitals” [Go to note 30].
Reforming the public/private interface
Over the last few weeks, Nicholas Timmins has been writing a series of articles on the coming market for the British Medical Journal.
One of the main benefits of treatment-centres, says Timmins, is their effect on NHS behaviour. ‘Faced by the threat of competition, ophthalmic surgeons and NHS managers have raised their game’. ‘In Exeter, for example, NHS patients who had been told they would have to wait months for a hip replacement suddenly found themselves being offered one at the local NHS hospital within days or weeks of an ISTC opening. Equally, NHS managers have reportedly found it much easier to negotiate cheaper fees with their consultants for extra work, with payments well below the standard BUPA rate’. ‘It is the outcome that competition is intended to produce’.
‘The price for all this may well be disruption of established NHS services locally. How bad that is, and how well it is handled, may well decide whether the outcome of this policy is judged to be a success or a failure’ [Go to note 31].
A greater role for the voluntary sector in delivering healthcare
Over coming weeks more details will be released on the ambitions of the government for the voluntary sector in providing healthcare. Social care minister, Liam Byrne told HSJ that the DH is to draw up standard contracts to make it easier for the voluntary sector to provide primary and community care services. Byrne said, “standard contracts were introduced when the government was anxious to get PFI off the ground. A lot of effort was taken to make sure procurement processes were got right and we’ve got to take the same approach to the third sector’ [Go to note 32].
Oxford treatment centre runs way below capacity
The ISTC that caused so much fuss in Oxfordshire – leading to ‘rows and resignations’ has lost the local health economy over £200k in its first six months because it has only carried out 93 of almost 600 procedures it was contracted to perform.
The head nurse at the ophthalmology unit at Oxford Radcliffe said the treatment centre has so far had very little impact on the trust. ‘In Oxford we only have an average wait of five weeks, so we didn’t need the extra capacity. Fundamentally the damn thing was flawed in the first place’. [Go to note 33].
ISTCs – better data needed
A report on the performance of four of the first-wave ISTCs has called for a marked improvement in data collection in order to compare services with the NHS [Go to note 34].
Reading between the lines of the report the authors acknowledge that ‘generalisation across the programme is not appropriate - the types of services provided and the key performance indicators upon which the audit is based vary considerably. Indeed, there appears to be very little consistency across the four schemes in terms of data collection or analysis. Hence, any audit of the ISTC programme as a whole is virtually impossible based on the approach adopted in this report [Go to note 35].
This conclusion is quite different to the gloss Lord Warner put on the report, which is that is showed there were no quality concerns. [Go to note 36]. The NHS Confederation urged a fresh examination of the effect of the centres, particularly on case mix and doctors’ training [Go to note 37].
Reforming regulation
Private hospitals to face NHS inspection
The Healthcare Commission announced that private hospitals ‘are to face broadly the same system of inspection and regulation as NHS establishments’.
The Commission estimates that by 2008 one-in-seven patients will be treated by the NHS, therefore a “level playing field” of inspection and regulation is needed between NHS-run and independent services.
‘The government will have to legislate before the changes can be made in full’. [Go to note 38].
Tensions over the future regulation of the NHS market
In the current review of regulation, each of the main organisations involved have submitted their views. The review of regulation was announced in March’s budget. It is headed by Chris Outram (former North London SHA chief) and overseen by a review panel; it is expected to report by Christmas.
The Healthcare Commission has called for a single-regulator to cover the financial and economic elements of regulation. They see themselves as taking this role. Monitor would wish the Healthcare Commission to concentrate on being a quality inspectorate while they concentrate on economics, including becoming the price-setter for the tariff.
The NHS Confederation’s response argued that a super-regulator would focus on finance at the expense of quality. Submissions from both the Confederation and its younger cousin, the Foundation Trust Network, argue that separate bodies should be responsible for economic and quality regulation [Go to note 39].
On the 7th December, the King’s Fund will publish a report on regulation and author, Jennifer Dixon says ‘there is more consensus on what the function of economic regulation are than who should do it’. They are of the view that the DH should set the tariff while PbR is phased in.
The Foundation Trust Network has put forward “the Bank of England model” whereby the tariff is set buy an independent panel. Monitor’s Bill Moyes agrees with this approach. “My worry about leaving the tariff in government is that it is always going to be tempting for government to change the tariff mid-tear for a variety of good and bad reasons. We don’t think that is something the system can stand when it gets much bigger.
According to HSJ, sources close to the review suggest that if the DH takes responsibility for setting the tariff then there may no future for Monitor [Go to note 40].
Reforming commissioning
There is increasing recognition that commissioning is crucial to the success of system reform. It is not only about placing contracts, but includes profiling and analysing health needs. The government is keen to roll-out PbC as a brake on acute sector trusts pulling in more work, under Payment by Results.
In her annual lecture to the Faculty of Public Health, Patricia Hewitt talked about the role of public health in commissioning. She said they would monitor and model current and future trends to help manage risk, integrate best practice, and inform future contracts [Go to note 41].
Practice-based commissioning to become an enhanced service
According to HSJ, ‘the government wants to make practice-based commissioning (PbC) a “designated enhanced service” within the GMS contract’. Sources said that, if GMS practices do not take on PbC, PCTs will be encouraged to offer contracts to alternative providers under the “alternative personal medical services contract”.
Michael Dixon, NHS Alliance chair, said he hoped ‘funding would be calculated to cover “clinical headroom” in terms of analysing data and drawing up a strategy to reduce referrals to secondary care, as well as management and staff time involved in implementation and administration”.
Tim Wilson – GP, management consultant and former member of the DH strategy unit – said, “It was always going to be difficult to fund PbC in a cash-constrained environment but there’s no doubt it does need resources put into it to fund the time needed to put into implementing it. “Although people argue the GMS contract has been very expensive, it is nothing compared to the money going into secondary care where there is increasing awareness of overspend, and the only way of getting control of this is by bringing PbC into place” [Go to note 42].
Individual budgets to be extended to elderly and disabled patients, “a way of further opening up services to the private sector
Liam Byrne announced 13 pilot sites across England that will share a £2.6m fund to ‘set up systems to test out individual budgets’. The Minister for Care services said: “Individual budgets will help vulnerable older and disabled people take control of their lives and choose the services that suit them best”. Care managers will help them plan how to use their budget [Go to note 43].
According to the Financial Times, ‘Patients will be able to choose an individual budget rather than receiving it directly from agencies. This could include cash worth up to £80,000 in severe cases. But patients can also choose to receive an indicative budget - a “virtual money box” - enabling them to decide how and where the money was spent without handling it themselves’.
Liam Byrne said, “People will be able to buy in the services they want from a range of different providers. “It is a way of further opening up services to the private sector” [Go to note 44].
Monitor sponsored seminar on the future of commissioning
Monitor are sponsoring a series of IPPR lectures in relation to system reform. On the 5th December, a seminar was held to discuss how commissioning might be strengthened.
Monitor published a booklet entitled, Developing effective commissioning in the NHS. It argues that commissioning encompasses four key functions: strategic planning, contract management, demand management and claims management. It says that the current structure of 300+ PCTs are too small and suggests optimal coverage would be a population of around 1million. The pamphlet argues that commissioning should not be contestable and therefore ‘continue to be performance managed by SHAs and ultimately the Department of Health. Clear objectives are needed to establish the criteria for success and failure [Go to note 45].
In advance of the seminar, IPPR published a paper to set the context for debate. ‘Although commissioning involves purchasing of services, it is much broader in scope. ‘Commissioning incorporates a number of activities, from assessing, planning and anticipating need for services through to contracting for services and managing the subsequent arrangements’.
The paper asks questions about splitting off provision at PCT level when dual commissioning and provision is encouraged at practice-level, which ‘may act as a disincentive to contestability’. It further suggests that because practices will only be set indicative budgets they may not face the consequences of their budgetary choices and this ‘will not encourage GPs to manage demand in the way that the guidance seems to intend’ [Go to note 46].
The King’s Fund publish a report on the future of primary care, including commissioning
For this reason, Richard Lewis and Jennifer Dixon argue that real rather than indicative budgets with real profits rather than savings could be a better option because it will give GPs a stronger incentive to manage demand. While private sector providers might be more comfortable taking more significant budgetary risks, they note ‘GP practices are already beginning to form clusters’ and forming economies of scale.
They note that as ‘practice-based commissioning rolls out, there are new opportunities for independent management groups to develop and offer services to PBCs’. These companies could compete with each other.
They propose a radical development of contestability - ‘to allow patients to choose their commissioner’. Even more radical, ‘patients’ choice of commissioner could be enhanced by the purposeful design of a ‘commissioning market’. This market would extend to a choice of PCT or conglomerate of commissioning practices not defined geographically, but by patient enrolees. ‘By looking to the USA, a number of potential models for achieving this change become apparent’. ‘In an English context, groups of primary care teams and strategic commissioning bodies (currently PCTs) could be formed. These new integrated alliances would compete with each other for patients’.
Clinical integration
Lewis and Dixon argue that a key challenge for primary care is ‘to find a better way of integrating primary and secondary care’ and say there is a need to accelerate ‘the promising developments under ‘PMS Plus’.
The authors talk positively about Kaiser ‘where primary and secondary care clinicians co-exist within a single medical group’, but this would mean significant change in NHS structures and culture. However, such a model could be anglicised and more modest. Effective development could be initiated in the shape of multi-specialty groups (including primary care physicians) or networks’.
‘Practice-based commissioning, in theory at least, offers the right incentives for this to happen. ‘This may well lead to primary care teams expanding to incorporate a range of specialist practitioners (for example, diagnosticians or consultants in major outpatient specialities) allowing more care to be retained within the primary care setting’ [Go to note 47].
Reshaping the organisation of general practice
A paper in the BMJ argues for the development of ‘an integrated system of care with a focus on general practice-based commissioning, drawing on secondary services and preventing too much emphasis on acute care’. It also argues for the abandonment of the tariff to allow groups of practices to ‘negotiate the best possible price and quality within their finite resources’ [Go to note 48].
This is one of a several thoughts recently offered on ways to reorganise general practice.
Competition in general practice
Martin Marshall and Tim Wilson, writing in the BMJ note that ‘general practice is bracing itself’ as ‘the government looks set to introduce some sort of competition into the primary care market’. They suggest that five models might emerge.
- Commercial takeover of practices or the private sector establishing new ones, employing all of the staff
- Mergers of existing practices drawing on a common executive team
- Hospital based services could seek to provide primary care services in outpatient departments or by setting up new primary care clinics linked to hospitals
- Population specific-services would target teenagers, elderly people or commuters and be established by any provider, moving away from the comprehensive family practice
- Condition specific services would target conditions or procedures and could be delivered by independent providers under contract to practices or primary care.
The King’s Fund report also comments on the structure of general practice
Lewis and Dixon note that radical options for increasing competition in primary care have been mooted. One is split registration. Another is to introduce Payment by Results to primary care. Under this system, patient registration would cease and primary care teams would receive specific payments for seeing and treating patients.
But the authors argue that ‘registration has significant benefits’ and warn of ‘serious drawbacks’ if it were to be scrapped. It underpins the continuity of relationships, supports a public health approach and ensures there is clear clinical responsibility for care management. Although the EPR offers some hope, ‘this does not replace the human clinician-patient relationship that can build up over time. ‘Moreover fragmentation of the primary care contract, for example, through a solely fee-for-service system, could increase costs because practices would have clear financial incentives to encourage access’.
An alternative to an open market for primary care ‘is greater power for PCTs to remove the contracts of providers that are not delivering a good enough quality of care’. The authors suggest ‘the periodic market testing of all primary care contractors’ [Go to note 50].
New prime ministerial advisor – Paul Corrigan – publishes a pamphlet saying that the small business model of general practices is not ‘fit for purpose’
Paul Corrigan begins by noting that ‘there are some 9,000 GP practices all trading independently’. ‘This model of primary care has served the country and patients well but it is becoming increasingly clear that it cannot continue to be the only organisational model for the future’. ‘For many decades, the NHS has aimed to move some secondary activity into the primary sector. Not only has this intention failed to become a reality, but the reverse has happened with too many primary care episodes involving hospitals.
One of the problems is ‘the difference in the scale of the organisational structure between primary and secondary care’. ‘A small organisation with few assets is unlikely to put its entire future at risk by investing in, for instance, a new diagnostics capacity. For small businesses, precisely because they are small, the risk entailed…can be too high’.
According to Corrigan, these barriers need to be overcome because if primary care fails to carry out health improvement, establish clear frameworks for the management of long-term conditions, build closer relationships with social care, carry out outpatient and diagnostic services and provide most minor surgery, ‘the NHS itself will fail as hospitals become overwhelmed with demand that should be dealt with in more appropriate primary care settings’.
Corrigan believes that larger organisations are needed and he suggests ‘four examples of larger primary care models’.
- Large GP-led provider organisations. Working with other health professionals and managers, GPs could develop a comprehensive provider organisation. It could be a initiated by a very large practice or by a network of practices ‘developing their scope of provision through a central primary care provision unit which could provide services for a number of practices’. ‘In business terms, GP practices could continue as conventional GMS/PMS practices side-by-side with this extended primary care provider organisation. The latter might be a registered company or possibly a not-for-profit organisation.
- NHS primary care provision through a large private company. Corrigan calls this “the company model”. Larger Health Centres might offer the economies of scale and scope required to ‘organise the critical mass of GPs (at least 10 per centre) that will allow for rotas, which in turn will allow near-24 operation. It could consolidate demand to justify a greater mass of equipment and allow better integration of health and social services.
- Developing mutual providers of NHS primary care. This model would mirror the foundation status enjoyed by acute providers. The mutual would provide a structured approach across practices to chronic disease management, involving both primary and secondary care.
- Building multi-practice partnerships. This model creates a ‘solid managerial ‘platform’ that allows like-minded practices to come together in locally run ‘collaboratives, offering the benefits of a much larger organisation. These Collaborative Platform Organisations (CPOs) allow major economies of scale and give GPs more purchasing clout.
Reforming patients’ relationship with their health and health services
There are two key roles for the patient and the public in system reform. The first is as an individual consumer exercising choice. Policymakers hope to empower patients by giving them a greater say in who treats them. With money following the patient, the theory is that organisations will be responsive to these choices. The second ‘citizen’ role is less well developed as a theory, but the stated intention of policy is to increase public involvement so adding a collective voice which commissioners and providers should respond to.
In her annual lecture to the Faculty of Public Health, Patricia Hewitt said local authority Overview and Scrutiny Committees are ‘one of the main vehicles for tackling the ‘democratic deficits’ in health and healthcare that has existed since the early 1990s’. She said she was ‘reviewing the role of patient and public involvement in the NHS and looking at new ways to bridge the democratic gap – which exists on the commissioning as well as the provision of services’ [Go to note 52].
What do patients and the public want from primary care?
Angela Coulter, writing in BMJ praises the intention behind the Secretary’s of State’s public engagement exercise but counsels her to look at the ‘extensive body of research evidence on what patients and the public want – including conflicting views on priorities. Coulter says it is important to distinguish between what patients want as individual healthcare users and what they hope for as citizens or taxpayers because these are not always the same.
In terms of professionals, ‘a systematic review of the literature on patient’s priorities for general practice care’ showed ‘that the most important factor was “humaneness”, followed by “competence”, “involvement in decisions” and “time for care”.
It is important to distinguish between individuals. Those with chronic disease value continuity over choice ‘while younger patients, commuters and those with urgent needs are more willing to trade continuity for faster access’. And choosing a provider is only one choice. ‘Knowing about the various treatment options and having a say in these is more important to most patients than having a choice of where to be treated’ [Go to note 53].
The wrong kind of choice?
Chair of the Social Market Foundation, David Lipsey, penned an essay for Prospect in which he argued that consumer choice should be limited in public services, but user choice could be extended.
Although critical of individual consumer choice, Lipsey argues there are two elements where choice could help. One is direct payments so people can get what they want rather than what they are provided with and may not want. The second is choice of GP. ‘At the moment, it is hard for a patient to quit one GP and then get accepted on another’s list. Patients however are reasonably well informed as to what constitutes a good GP. The ability to strike up good relationships with patients is probably as important as technical know-how’ [Go to note 54].
Developing patient choice
The IPPR issued two reports in November, each concerned with choice.
One examines the Government’s proposals for individual budgets and is concerned with choice for older people. Although intellectually supportive of the concept, ‘at present there is no robust evidence available that would lead to the conclusion that individual budgets on a large scale will be cheaper, more expensive or cost the same compared to existing provision’. There is simply no evidence. The report argues that ‘the Government should consider introducing a statutory duty on local authorities to provide assistance to use individual budgets [Go to note 55].
A second IPPR report on choice concentrates on how the policy can be made equitable. It starts out by saying that ‘choice should aim do more than create a market’. The primary goal of choice should be to improve outcomes and should be designed with the most disadvantaged in mind. Among its recommendations are:
- That independent sector providers should be subject to the same information requirements as NHS providers
- Disadvantaged groups in particular require support and advocacy
- Patients should be able to choose their source of information and support, and GPs could provide “support prescriptions” for patients who might need targeted advice or advocacy
- The provision of advice should be commissioned and regulated
- Greater choice of GP should be introduced. People with commitments that take them outside their home area should be allowed to register at a secondary practice [Go to note 56].
The Picker Institute published the findings from research with a sample of 3000, asking them about how involved they are in their health. The aim of the research is to assess the capacity for self-management.
- Confidence and willingness to self-manage varies across demographic groups. It is less evident in the elderly, those from ‘lower social grades’ and those ‘who finished education before 16’.
- Those with chronic conditions had not advanced to self-management, particularly those with depression, chronic pain and digestive problems. Perversely, ‘of all the groups within the sample, the capacity to self-manage health was least evident among people with poor health’.
- Over the previous 12-months, survey respondents had made extensive use of healthcare services. Three-quarters made at least one visit to the GP, with 25% seeing their doctor five times or more. 15% had visited A&E.
- A vast majority said they would not hesitate to raise issues with their doctors, but nearly the same proportion said they would not ask for further clarification if they did not understand something their doctor had said [Go to note 57].
There is clearly a lot to be done in advancing the patient and public involvement agenda. The director of operations at the Commission for Patient and Public Involvement (PPI), Leslie Forsyth, urged NHS colleagues not to repeat earlier mistakes by accepting ‘unrealistic deadlines’ as the NHS moves into a new PPI era.
Recalling events, ‘he said, CPPIH has been forced to recruit 5,000 patient forum volunteers in 12 weeks against the commission’s wishes, after government policy was put together ‘on the good’ following the abolition of community health councils’. ‘Inevitably recruiting 5,000 people in 12 weeks made it an exercise in quantity. We tried very hard with quality as well, but all politicians were interested in was: ‘Are you going to hit the target?’ [Go to note 58].
What is the point of system reform?
Professors Corrigan and Maynard clash over the direction of reform
In the Health Service Journal, Professor Paul Corrigan (Prime Minister’s health advisor) and Professor Alan Maynard (health economist at York University) clashed over the future of system reform.
Corrigan emphasised registration as a tool that patients could use to improve health care. Registration ‘is our entry to the NHS. It is ours to place, and not the PCTs to allocate’. He says PCTs need to better understand the health needs of their populations. ‘I need my PCT to fight for my interests in buying my healthcare and not to see itself as part of a cosy historical club of past providers.’
Maynard’s gripe is the lack of evidence employed in policy. ‘To undermine inflexible GPs and facilitate choice, the government has decided that pharmacists and nurses will be able to prescribe drugs and other diagnostic services. The private sector may invest in NHS primary care practices that are largely doctor-free. This is an evidence-free social experiment: it is no known whether such provision is effective, let alone cost-effective’.
Corrigan retorted, ‘to say that the introduction of choice into primary care is a leap in the dark is to demonstrate the traditional mistrust of patients that has characterised the health service of the past. ‘No one is suggesting that there be an unregulated market in primary care, just that within the regulation of entry and exist they are allowed to develop different types of provision’.
With the last word, Maynard accused Corrigan of a ‘religious assertion of the merits of contestability. ‘The NHS needs to incentivise managers to use evidence to reduce providers’ inefficient practices. Current reforms divert attention and energy from such activity’ [Go to note 59].
What is the aim of system reform?
In the last fortnight, two former senior NHS managers have offered their view on system reform and where it is headed. One was Ken Jarrold, former SHA chief executive, during a speech to the Independent Health Management Association. The other was Simon Stevens, writing in the Health Service Journal.
Ken Jarrold’s valedictory speech focused on the NHS before 1997, changes since and its prospects for the 21st Century [Go to note 60].
He describes the years prior to 1997 as a time of ‘relative decline’. He says the years since have seen many successes: increased funding, services increasingly organised around patients, and ‘drastically’ improved waiting times. But since 1997, not everything has gone well.
‘There is a real danger of losing focus on patient and staff experience and the policy on patient and public involvement is in disarray. Too much attention is given to means and too little to ends’. ‘What are we trying to do? How does it all fit together?
Jarrold says the ‘future of the NHS depends on confronting and dealing with [some] negative characteristics of the present. These include:
- Patient and staff experience needs to be restored to centre stage. There is nothing more important. If reform does not secure [this] it should be abolished or changed. He says ‘serious consideration’ should be given to transferring patients’ forums and complaints processes to local authorities.
- A coherent policy framework for the NHS is needed urgently. It is essential to make sense of the big picture – what are we trying to do? Individual initiatives should be assessed in relation to each other and the overall objective as well as assessed in their own right.
- If payment by results works, keep it. If not, abandon or change it. If choice and plurality improves patient experience – fine. If not, think again. All aspects of the reform programme should be subject to rigorous and independent evaluation [Go to note 61].
Simon Stevens notes began a recent HSJ column by noting the difficulties in navigating system reform. ‘Why the turbulence?’ Stevens offers four reasons.
- The possibility that primary care trust and SHA reorganisation becomes drawn out so that attention is diverted from the job in hand. Some PCT chief executives have, for example, been told their jobs will not be decided until next August – virtually guaranteeing nine months of eyes off the ball.
- The deficit-inducing consequences of having struggled to secure productivity gains as against inflation from changes to hospitals doctors’ contracts and Agenda for Change.
- The realisation that the NHS’s financial good times are well and truly over come 2008.
- The fact that some of the key reforms necessary to sustain the NHS need to be implemented faster, whereas the natural temptation is to dilute and defer. As the OECD delicately puts it: ‘Efforts to ensure value for money via reforms to service delivery now need to catch up with the rapid build up of resources’.
- Look at how the wave-two independent treatment centre procurement is handled. Has wishful thinking about existing capacity overtaken more hardnosed insights about the deep-seated challenge of getting to the 18-wek target?
- Look at the vigour with which patient choice is actually implemented from December. Oddly enough, the technology platform may allow open-ended patient choice – will those wider provider options be hidden from patient for three years, and if so, why?
- Look at the extent to which contestablity in primary care is genuinely unleashed.
- Look at the willingness in practice to allow new forms of commissioning organisation, as recommended in a thoughtful King’s Fund paper (see above)
- Look for coherence and clarity in how the system reform agenda overall is understood as a linked and multiplicative set of changes, rather than a series of projects.
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