Health policy in the media
January 2005
January 2005 has seen a huge amount of health policy debate. One reasons is that policy is generally shaped post-announcement, generating a whole load of reports and media stories. Another is that some of the big issues in health are key social issues - the appropriate balance between public and private provision in public services, for example.
It is important to keep abreast of policy debate and to help with this Health Policy Debate will appear regularly and concentrate on the following areas: (a) professionalism;
(b) standards and assessment; (c) incentives; (d) plurality; (e) debate around models of clinical and organisational management.
Simon Stevens speculates on the key policy debates to come in 2005
At the start of any year, it is useful to think about what will be the big debates ahead. According to Simon Stevens, former health advisor to the prime minister, 2005 will see a 'major growing pains as the NHS becomes more incentive driven'.
'The tariff system for paying hospitals will magnify purchaser (in)effectiveness. Strong purchasers will be able to use it to move money around between providers and categories of care ... but weak purchasers will find themselves taken for a ride, paying for extra activity at full cost.'
'At the moment only 20 per cent of heart attacks are coded as 'complicated'. Were providers to decide that should be 50 per cent, purchasers would see their bill for heart attach care rise by 17 per cent. How many primary care trusts or strategic health authorities are tooled up to scrutinise this kind coding drift?'
'PCTs will only realise the benefits of managing long-term conditions if they can accurately predict who will be their highest-risk patients. But how many PCTs are using sophisticated tools as against crude rules-of-thumb?'
'So expect four solutions to be offered during 2005':
- PCT mergers
- Breakaway groups of GPs will aggregate their new practice based budgets
- Once limitations in current arrangements are realised, 'expect new bolder initiatives'
- A proposal that patients should be able to choose their own purchasers
One key debate that Stevens doesn’t mention is professionalism. This will become a key debate in during 2005.
The final report from the Shipman Inquiry
Dame Janet Smith chair of the Shipman Inquiry published her sixth and final report. She drew the Inquiry to a close by saying that Shipman’s profession allowed him to kill. While she thinks it very unlikely that another mass-murdering doctor will emerge this is because few share his extraordinary personality not because the professional system was capable of rooting out a criminal doctor whose unprofessional behaviour had been drawn to its attention. That same system is still in place and should not be.
She ended by noting the government is considering her recommendations and said she very much hoped they would be taken on board.
The Donaldson review is highly relevant to the future of professionalism
Almost as soon as she finished speaking the government announced a review to 'help protect patients from poor medical practice and misconduct'.
John Reid said,
"We take what Dame Janet Smith has said very seriously. We will not settle for a quick and weak response to her inquiry. It is clear that a review into patient protection is needed, immediately followed by strong patient protection measures informed by the review's findings. We want to put an end to the idea that the General Medical Council is a representative body for doctors. It is not. Its primary role must be to protect patients."
"In order to ensure we do this effectively, I have asked the Chief Medical Officer for England, Sir Liam Donaldson, to undertake a review and report his advice. Only by having a robust system for testing doctors’ fitness to practise can we increase patient confidence and promote good medical practice."
The review will cover three areas: the role of the GMC, the revalidation process and standards of patient safety and Liam Donaldson will have a group to advise him
Response from the GMC
The GMC indicated it may give up some of its powers if that helped to protect patients.
Sir Graeme Catto said the GMC's website would soon carry more information about doctors' disciplinary records, including past convictions at GMC hearings. He told The Times that he agreed the GMC's role was to protect patients, adding: "Medical regulation needs to adapt to changing circumstances. We would like to see what the adjudication tribunal looked like - we are not antithetical to the concept".[Go to reference 2]
Don't get carried away with individual blame, it's all about systems
The health editor of The Independent, Jeremy Laurance, 'wrote an article which asked why Sir Graeme Catto had not fallen on his sword following the drubbing the GMC got in Dame Janet Smith's fifth report from the Shipman inquiry'.
Two weeks later, at a dinner hosted by the Royal College of Paediatricians, Laurance found himself seated next to Catto.
'Sir Graeme was his usual charming self and gave me a full and frank account of his views on revalidation - the "MOT for doctors" that Dame Janet wants to see toughened - and explained under what circumstances he would resign (if it ends in a fudge).'
'There are some tricky negotiations ahead and no one is predicting what form the new check on doctors' competence will take, how the profession will react or even if self-regulation will survive. But whatever the outcome, it will not eliminate risk.'
'Safe doctors are essential, but they are only part of a wider picture. Safe systems are what count, for identifying patients, administering drugs, matching blood and ensuring surgeons don't lop off the wrong limb.'
'If only the Department of Health understood.'
'Another guest at the dinner told me how an inquiry he chaired into the introduction of a new treatment that was linked with a series of patient deaths was held up for almost a year because ministers insisted that someone be blamed.'
'One method of assessing competence, for surgeons, is to check their individual death rates. But this may be bad news for sicker patients. In New York, a survey of 120 cardiologists found 80 per cent admitted they had avoided performing an angioplasty - threading a wire up to the heart and inflating a balloon to widen a blocked artery - on a patient they considered too risky. They were worried how it might affect their ranking in the league table.'
'As the authors from the University of Rochester commented, an attempt to provide the public with information has ended by creating a conflict for the doctor which may actually worsen patient care'[3]
Standards
Non-execs removed from the board of Royal Wolverhampton Hospitals trust
An entire non-executive team were ordered to stand down by the NHS Appointments Commission over its part in allowing the trust to amass a £10m deficit.
A review chaired by Professor Robert Tinston found 'that financial stewardship at the trust had failed, and that the situation had been compounded by a board which did not challenge the position robustly'.
It is not an easy job being a non-executive director in current times, said Nicholas Timmins in the FT. The whole of the Bradford team were asked to stand down last month.
Too many non-execs, according to former NHS chief executive Sir Alan Langlands, who is currently chairing an independent commission on a code of governance for public services, "are not sure what they are doing, why they are there and what is expected of them".
This is not their own fault: 'they receive too little training; they have to balance the public interest with their accountability to government for taxpayers' money; they often operate in special areas that are becoming more businesslike as markets are introduced into public services; and, as the regulatory environment, with new forms of inspection and regulation, becomes more complex, they are judged against government-set standards, regulators' demands and local people's views of the purpose of them.[Go to reference 4]
Non-execs to be trained to interrogate trust declarations of standards
Non-executive board members will be trained to interrogate their executive colleagues on whether that are meeting the standards set out in the new Healthcare Commission rating system.
The new system will require trusts to self-assess where they stand in relation to the core standard domains. Trust boards will have to sign these off, as well as the patients forum and strategic health authority.
Sir Ian Kennedy says, "Trust boards have a legal responsibility to be meeting standards of quality". "We are working on training for members of boards as to what it is you should be looking for and what those standards are about so they can be properly equipped to interrogate - in the nicest way - other members of the board"[5]
Incentives
John Hutton gives evidence to a House of Commons select committee on choice and voice in public services
The session took place at the height of the recent Brown-Blair hoo-ha and so it is perhaps not surprising that the opening question asked for a coherent explanation of the approach to choice within the government. The committee’s search for an intellectual justification of choice within public services is interesting.
The committee chairman explained he was asking for clarity in the government's approach to choice,
"because when I look at, for example, what the Prime Minister says about choice - quoting his speech in January 2003, he says: "Choice mechanisms enhance equities by exerting pressure on low quality or incompetent providers. Competitive pressures and incentives drive up quality, efficiency and responsiveness in the public sector". Then, if I look again in 2003 at the Treasury's paper on meeting the productivity challenge it says: "It is important to ensure that choice is not promoted at the expense of equity or efficiency, particularly where there are market failures and capacity constraints." I am not wanting to make a trivial point about are there differences here between Number 10 and the Treasury but the substantive point is, is it not the case that although the Prime Minister seems to suggest it is an easy relationship between choice and equity and efficiency, in fact what the Treasury says is "hang on a minute, there can be real problems here in trade-offs with equity and efficiency"? I would not mind hearing you say something about that to start with.
Hutton admitted it was "the $64,000 question…which goes right to the heart of this whole debate about to what extent choice can level up quality and efficiency and equity at the same time".[Go to reference 6]
Hutton was asked about the possible closure of hospital departments under Payment by Results. He said that PCTs could commission new providers in rural areas where there is little choice and if a department anywhere would close, it would be because of patient choice. The sum of patient choices would say whether a department should remain. He said the "most powerful voice is choice"[Go to reference 7]
Another question from the chairman of the select committee was whether there would be a trade-off "between having a service driven by the notion of choice and having a service driven by the notion of cost-effectiveness?"
Hutton said, "No, I do not think so. I think if you look at - which I know you want to look at later - the payment by results mechanism which we are proposing to use as, if you like, the policy instrument to facilitate patient choice, what payment by results and all prospective payment systems do in health care systems is reward efficient providers, not reward inefficient providers. I think choice and payment by results together, and they are two parts of this very important reform, can help promote efficiency in the use of capacity in a health care system".
There are signs that the government is not as confident as it sounds about the Payment by Results regime, especially as the perversities within the incentives regime come to light.
Foundation trusts find new games to play
An "exclusive" in the Health Service Journal reported an 11% increase in A&E admissions and very strong indications that foundation trusts are gaming the Payment by Results system to increase revenues.
Foundation trust |
Increase in A&E admissions |
Increase in A&E attendances |
Bradford |
21% |
0% |
Birmingham |
18% |
4% |
Derby |
18% |
3% |
Stockport |
17% |
-1% |
Cambridge |
16% |
9% |
Peterborough |
11% |
3% |
Devon and Exeter |
7% |
1% |
Gloucestershire |
5% |
-1% |
Sheffield |
5% |
2% |
Docaster |
5% |
1% |
Sunderland |
4% |
2% |
Guys |
6% |
7% |
UCH |
3% |
9% |
Chester |
-2% |
-1% |
England |
11% |
4% |
'There is concern that the combination of the payment by results tariff and the A&E target have created a 'double perverse incentive' for acute trusts to admit patients via A&E for non-clinical reasons'.
'Under the current payment by results tariff, most patients admitted via A&E whose stay lasts less that 48 hours automatically trigger a £1200 invoice to be paid by PCTs, even if the patient is discharged in less that 12 hours'. While this payment has been cut for next year it is still 'far in excess of the £200 charged for an outpatient appointment'.
From next year the tariff will be £600 - still £400 more than the outpatient appointment.
The foundation trust in Bradford has worse than usual financial problems and so perhaps it is no surprise that it topped the table of increased admissions (21%) even though there was no increase in attendance.
HSJ understands 'the PCTs contested this bill and this was one of the fundamental issues that led to the current crisis’. Apparently someone in the PCT noticed that over half of the admissions via A&E involved length of stays which were under 12 hours.
The chief executive of North Bradford PCT says ‘this has to be dealt with by the financial review team’, that are reviewing incentives in the PbR system.
If such trends continue, foundation trusts will bankrupt PCTs very quickly and HSJ estimates this behaviour will lead to an 'extra £4.3bn bill for commissioners'.
It is not just Bradford. Stockport foundation trust admitted 17 percent more with only a 1% increase in attendances. Birmingham University Hospitals Foundation Trust and Derby Hospitals financial trust both admitted 18 per cent more patients via A&E compared to a 3 and 4% increase in activity respectively.[Go to reference 8]
An editorial says: 'There is no evidence that any trust is gaming the system, but rumours abound'[Go to reference 9]
At the time, the DH would 'make no apology for this'. A spokeswoman said, "it is good patient care. We no longer allow patients to spend many hours in A&E". She added that changes made to the tariff would mean acute trusts would no be overcompensated and "far from driving up admissions, PbR can be used by PCTs to ensure care takes place in appropriate surroundings"[Go to reference 10]
The government choose to delay the roll-out of PbR
Though initially defiant, the government quickly moved 'to dramatically downscale this years roll out of payment by results amid panic that original plans could trigger a catastrophic '£1.5bn imbalance' across the NHS'.
'The last minute move is being seen as an emergency measure to halt a process that could have triggered a financial crisis ... acute trusts would have gained a total of £1.5bn more than the DH had forecast.'[Go to reference 11]
One senior official said that there were "too many risks involved", adding that the large shift in the movement of funds around the NHS "would be very destabalising".
Instead of payment by results covering 70% of activity this will be scaled back to 30%.[Go to reference 12] Both the Health Service Journal and the NHS Confederation welcomed the decision as 'sensible'. [Go to reference 13]
One could get the impression that the government has not fully thought through the consequences of their policies. It talks tough about trusts that "fail" in the payment by results regime. But what will it do when it comes to the crunch?
The real answers appears to be that they still don't know. According to the Financial Times, 'the DH is seeking urgent outside help to create a system to deal with financial and clinical failures in the new, more competitive, NHS market that the government has created'. 'A tender to create "a failure regime" has been issued with the task seen as so urgent That potential bidders were initially given little more that 10 days to respond. The DH says it needs a system in place for the start of the financial year in April.[Go to reference 14]
DH says next wave of foundation trusts have the option to employ PbR in full
The government were keen to insist that they were not backsliding on PbR and in a sign that seems to indicate faith with PbR, it emerged that the next wave of foundation trusts will have the option to work fully with PbR. It suggests the government are looking for trusts to be fully confident about PbR and how they plan to work with it.
The news came from a meeting between finance directors from current and applicant foundation trusts and the DH. 'Emerging from the meeting, NHS Confederation Foundation Trust Network director Sue Slipman said it had been decided that all these trusts would be given the option to go to full tariff, based on 2005-6 prices, or a 'minimum income guarantee' based on 2003-4 figures.
Ms Slipman said, "It is likely in the next wave of applicants there will be more trusts that are going to be able to operate effectively at full tariff so they will be given the choice to do so. They will be looked upon as a test bed for full payment by results implementation".[Go to reference 15]
NHS Trusts almost £500m in the red
Acute trusts in particular need to raise as much revenue as they can given their dire financial position.
Another HSJ survey estimates the total deficit at nearly £500m. The most optimistic accounts put the figure at £200m.
SHA |
Deficit now (£m) |
Projected |
South West London |
69.2 |
0 |
West Yorkshire |
40 |
0 |
Thames Valley |
34 |
19 |
Norfolk, Suffolk and Cambs |
30 |
38 |
Hampshire and Isle of Wight |
29.8 |
18.9 |
Avon, Glos and Wilts |
25.5 |
17.1 |
Leicestershire, Northants |
22.8 |
7.4 |
Surrey and Sussex |
22.6 |
15.7 |
South West Peninsula |
21.6 |
18.1 |
North and East Yorkshire, |
19.1 |
0 |
Northumberland, Tyne |
18 |
0 |
Birmingham and Black Country |
17.4 |
0 |
Beds and Herts |
17.3 |
19.4 |
Nort West London |
16 |
34.8 |
Greater Manchester |
16 |
0 |
County Durham and |
13.5 |
19.5 |
Shorpshire and Staffs |
12.2 |
0 |
North East London |
12.1 |
1.5 |
Trent |
11.7 |
12.7 |
North Central London |
11 |
0 |
Kent and Medway |
9.5 |
0 |
Essex |
9 |
0 |
Cumbria and Lacashire |
8 |
12.5 |
Cheshire and Merseyside |
6.5 |
0 |
Dorset and Somerset |
2.8 |
0 |
South Yorkshire |
2 |
0 |
West Midlands South |
0.6(+) |
2.2(+) |
South East London |
no figs |
no figs |
Total |
497 |
224.3 |
According to the HSJ leader, the usual excuse that it will sort itself out by year-end is wrong for two reasons. First, 'the problem is much greater than the normal shortfall at this time of year'. 'Second, trusts are much less free than in previous years to juggle numbers on the balance sheet, sacrificing long-term planning for hitting short-term targets. In other words, the fudge factor has diminished'.
In a similar survey last year, chief executives reported smaller deficits and the vast majority predicted they would reach balance, which they did. This year 'almost half do not expect to break even by the end of March 2005'.[Go to reference 16]
The HSJ says, 'the effects are predictable: many trusts have reduced or closed services'. 'Recruitment, in particular, is being squeezed, and it is not surprising that a BMA survey found that a quarter of trusts have frozen some vacant consultant posts'[Go to reference 17]
"Some of the projections offered by finance directors look a little optimistic. A former finance director pondered the reasons why. 'Are there some big reserves at the centre that people are relying on? They can't use capital, which is the tradition route; partly because the rules have changes, but also because the national programme for IT has spent much of the capital money already".
"Either some of these SHAs are going to do something heroic in the next four months, or they have a huge amount of money in their back pocket. And perhaps a further possibility is that some are just saying they are going to break even for forms' sake"[Go to reference 18]
Blaming new contracts for the financial position
A number of managers are now saying publicly that the financial problems they are facing have been compounded by the new contracts and are blaming 'serious pay inflation right across the scene'.
According to the HSJ, 'the biggest obstacles to achieving balance appear to be the costs of new contracts for consultants and GPs along with the associated costs of out-of-hours services, plus the roll out of Agenda for Change'.
Mike Farrar told the HSJ, 'the problems are to do with a number of national pay deals ... 'One would hope for something from the government in return but that may not come immediately. So we will have to absorb it for the time being'[Go to reference 4].
Monitor reports on what went wrong at Bradford
Monitor commissioned a report into what went wrong at Bradford Teaching Hospitals NHS Trust. The FT obtained it 'under the freedom of information act'.
It says the trust was hit by a financial crisis due to a range of changes occurring at the same time. These included the introduction of "payment by results" (local PCTs queried one in five bills); the new consultant contract, which cost far more than expected; the introduction of the working time directive, which limits the hours junior doctors can work, and higher pensions. The report argues that there are important lessons to be learnt for the rest of the NHS. Foundation trusts cannot simply expand their work and expect to be paid for it as Primary Care Trusts have to take account of competing demands from community, family doctor and mental health services.
Bradford was a victim of "a barrage of changes" that are hitting all parts of the National Health Service, according to an analysis of the crisis. The report says there was a failure to understand how foundation status and payment by results "profoundly changes the way in which the system operates", with "traditional NHS funding solutions" no longer
available.[Go to reference 19]
Plurality
BMI Healthcare will bid for 2nd wave ITCs
BMI, Britain’s biggest private medical group has decided to bid for the second wave of ITCs.
Chief executive, Ian Smith said "We'd like to be a very significant player in this market. We're the biggest in the private sector, and we want to be a very significant factor in the public sector too".
BMI didn’t bid for the first wave because "they weren't competitive. They were still thinking of the old private hospital model. We have to engineer something much more streamlined that that."
Smith plans to split the management team of BMI because the treatment centres will be need a different model of management to deliver "a tailored service based on a low-cost operating model that will be run almost entirely separately in terms of sites and facilities, staff and branding"[Go to reference 20]
NHS chief executives attack DH's handling of ITC programme
'Chief executives of acute and primary care trusts have launched a fierce attack on the DH for its handling of the independent treatment centre procurement programme.'
'In an HSJ survey of over 100 chief executives, 61 per cent described the DH’s approach as 'prescriptive', 56 percent said it was 'political' while 27 per cent said the programme was being enforced via 'bullying.'
'A staggering 73 per cent said they did not feel the scheme represented good value for money for the NHS. And 79 per cent of acute trusts said they had been required to reduce or forgo activities to support the central programme.'
The NHS Confed's Nigel Edwards said the centralised approach to procurement left the service in danger of ‘hitting the target but missing the point.[Go to reference 21]
'Chief executives say the pressure o contribute to central targets to increase independent sector capacity is putting NHS service in jeopardy.'
'One described a "ludicrous situation" he was facing in which elective work was set to be carried out in existing NHS premises sold or leased to the private sectors, simply to meet the 15 per cent commitment. Several feared hospitals with new private finance initiatives or foundation applications could become financially unviable as the activity assumptions on which they were planned were radically reworked.'
'Southampton City primary care trust director of commissioning and service improve, Dave Meehan said his PCT would be taking away £2m of activity from Southampton University Hospitals trust from April because of its contract to provide orthopaedic services at Capio’s New Hall Hospital in Salisbury.'
'He said it made the trust, which is predicting an end-of-year deficit of £12-£14m, would have to downsize its orthopaedics department. The contract would take around 50 per cent of elective work from Southampton General Hospital over the next five years'.
'Mr Meehan said patient choice meant this could also have serious financial implications for the PCT. 'When we have got a contract which in this case has a fixed number of slots, of course we wish to ensure choice, but if the population does not wish to to Capio then there would be some expensive haps if weren’t able to fill them.'
He said PCTs needed to work together so they were able to share slots allocated to the independent sector, given that filling ITC appointments currently ' 'take precedence' because of their fixed contracts.'
"The contract with the private sector is take or pay - if we don't take the slot we have to pay for the operation anyway. That's such a challenge to us'.[Go to reference 22]
The effects of ITCs on London
According to the Evening Standard 'the South West London Strategic Health Authority has analysed the effect across London of the impact of increasing independent sector provision on the NHS'.[23]
The paper says:
- From 2008 onwards the NHS within south-west London has sufficient capacity to meet targets without requiring additional independent sector activity.
- Work should be shifted from existing NHS hospitals to the independent sector "even though this is not required".
- In north-east London “achieving the 10 per cent target will be challenging. Insiders say although a private treatment centre is already planned it will be difficult to send through NHS operations there for it to equal 10 per cent of total workload.
- In south-east London, additional planning will be needed. Currently only three per cent of the workload is done in the private sector and this will need to be increased substantially.
- In north-west London "there is plenty of spare NHS capacity and achieving the 10 per cent target will be problematic". The NHS has enough beds to do all the work in their sector and more so sending 10 per cent of their operations to the private sector will be expensive and unnecessary.
- In north-central London, there are already new hospitals planned and if they go ahead as planned the "additional capacity via the independent sector will be unaffordable". The paper says: "It is difficult to envisage how South-West London would be able to benefit significantly. Once the NHS has met its 18-week target there will be no need to send any work to the private sector as there will be enough capacity within the NHS".
Lord Browne, the chief executive of BP - and a former donor to the party - spoke out against the Blair wing of the party over what he described as the spread of "pseudo-markets" within the public sector.
Speaking to the World Economic Forum in Davos, he said attempts to create internal markets in the public sector were "damaging professional people who probably should not be subject to these pseudo-markets". He said he was talking about "academic institutions, hospitals, jails, and all sorts of things". His speech was entitled "does business have a noble purpose".
In Scotland, at the same time, in a speech entitled "social democratic politics in an age of consumerism", John Reid was arguing that consumer values were relevant to the public service and had once motivated the once-mighty Co-operative movement.
He argued that Labour had lost its way politically when it neglected such forces after 1950.
He argued there was a "false dichotomy" between citizen and consumer put Mr Reid at odds with many of the chancellor's declared positions at a time when Mr Brown is seen as preparing to succeed Mr Blair.
Meanwhile, Lord Browne argued that the application of a market mentality would damage public perceptions of business. He said that "pseudo-markets" would not deliver the benefits of real markets and that business shared the misgivings of unions and Labour activists about markets encroaching on all walks of life. He said, pushing markets into the public sector threatened to turn people against business.
Financial Times defends 'pseudo markets'
An editorial in the FT noted that 'the use of market-like mechanisms to improve public services has been the big idea in public sector reform' for over nearly 20 years and 'has seemed to some to offer a sort of a holy grail: it allows services that society believes should be free at the point of use or that should be subsidised - in the UK's case the NHS and state schooling in the former category, or universities and social care in the latter - to remain so, while still subjecting them to some of the benefits of the market.
In this context, the attack from Lord Browne is 'all the more remarkable'.
'Such a top businessman, one might imagine, would be more in favour of such an approach than against it'.
'The alternatives, after all, are to leave the expenditure of public money largely in the hands of professionals such as doctors or teachers who have a direct interest in high standards but little intrinsic interest in value for money; to subject them to endless centrally determined targets and performance management; or to come round every few years with the crude bludgeon of an efficiency drive aimed at cutting "waste and bureaucracy".'
'The first of these approaches may create happy professionals. But experience shows that it does not necessarily lead to happy consumers or to good budgetary control over taxpayers' money. Services can too often be organised to suit the convenience of the supplier rather than the consumer.'
'The other two approaches can be every bit as dispiriting for professionals - distorting priorities, consuming time and effort in form filling, and producing changes to services locally that make no sense - as the pressures on professionals that Lord Browne noted that market-like mechanisms can bring.'
Pseudo markets do indeed come at a price. For a start, in some sectors there are clear limits. Closing and substituting a failing school is much easier than doing the same to a big hospital - hence the health department's current search for a "failure regime" aimed at preventing the very failures that a market would normally be allowed to generate.
They also 'produce transaction costs' and 'continuing analysis is needed on a case-by-case basis to ensure that measurable benefits outweigh them'. 'And precisely because the financial incentives of markets are so powerful, their design (and in the public sector they have to be designed) needs to be right or deeply unintended consequences can flow'.
However, in the absence of a better alternative, the FT is still in favour. 'Well designed - so that they introduce the needle of competition into the public sector rather than a disruptive war - there is good evidence that they have their uses. At least until someone comes up with something better. Perhaps Lord Browne can do so'.[Go to reference 24]
John Reid publishes his views on the positive role markets can play in healthcare
John Reid has set our his ideas on markets through the Social Market Foundation in a new book making the intellectual care for extending market disciplines into healthcare.
On the last day of January, John Reid spoke at the Social Market Foundation at the launch of the book.
Reid argued that with greater patient choice and new financial incentives, the NHS can learn from the market "without importing the market’s ethos or the market itself."
In an interview with the Observer the day before the speech, Reid set out his case in more simple terms: "If people haven't been getting [a good local service] for 60 years and still aren't, should they be entitled to go elsewhere in the health service and get it? And if you are given that entitlement, is it more likely that the local provider will be prompted to give them a better, quicker, more personal service? I think the answer to both is yes".
At the launch, one audience member raised the question of doctors not being fully behind plans.
"To those who have misgivings about it, I say two things: firstly, I will protect the founding principle of the NHS of equal access to healthcare provided free at the point of need. The second is I will never apologise for the extending to the mass of working people the privileges that have been monopolised only by the well-heeled and well-connected since time immemorial. Why on earth would we not be proud of extending that degree of information and power?".[Go to reference 25]
Scottish move closer towards plurality of provision
The Scottish are not employing markets and forcing trusts to compete for patients, but according to The Courier, there are now practical plans being set in place for a greater plurality of provision.
'A private hospital in Dundee is to treat 1000 patients from Tayside and north-east Fife in a £500,000 deal to cut lengthy queues'.
'No currently-employed NHS staff will be employed. The contract between the NHS and the private sector is believed to have specifically ruled out the use of NHS staff "moonlighting".'[Go to reference 26]
The European dimension of plurality
An angry opinion piece in The Guardian took the time to explain the implications of the EU directive on professional services for the NHS.
'Although it has received scant media in the UK, the "Bolkestein directive" has provoked mass protests and debate in France, Belgium, Sweden and Denmark.'
'The directive, which Britain will seek to push through when it takes up the presidency of the European Union later this year, has two main aims: to erase any national laws and standards that make it difficult for European companies to enter the markets of other member states, and to allow European companies to run businesses anywhere in the EU according to the rules of their "country of origin".'
'Healthcare services are thought to amount to about 10% of the EU's GDP, so the potential for private companies to make profits from healthcare is vast. But publicly funded healthcare systems have until now been protected by national laws. Under "control of entry" regulations in the UK, pharmacies are granted licences to dispense NHS prescriptions only in areas accessible to those most in need. Supermarket giants such as Asda Walmart tried to persuade the government to get rid of this rule but, after a public outcry, the Department of Health refused, knowing that deregulation would destroy many community chemists.'
'The Bolkestein directive would require the UK to remove these rules because it regards them as an illegal barrier to market entry.'
'The government has bowed to pressure from the British Medical Association and others and promised to try to exclude "publicly funded healthcare" from the scope of the directive. But this does not offer as secure a protection as it appears. The Department of Trade and Industry has stated that it does not want to deny market opportunities to private healthcare providers and says there is no clear definition of "publicly funded healthcare" in EU law. '
'The fact that the DTI rather than the Department of Health is negotiating the UK position in Brussels is a further cause for concern.'
'The trade union movement is worried that construction companies will no longer have to abide by UK health and safety laws on building sites, and environmental campaigners fear that local planning rules, which govern where supermarkets can open, will be judged to be an illegal barrier to market entry. Attempts to stem the growth in the number of bars and nightclubs in city centres will also be thwarted by a number of clauses'. [Go to reference 27]
Clinical management
Choose and book
Every paper reported that only 63 people had booked a secondary care appointment electronically during a GP consultation. The government had said the figure would be more than 200,000 by now.
Of 1500 GPs surveyed, only 3% felt 'very positive' about the scheme whereas '61% felt either 'very negative' or 'a little negative'. More broadly, almost half felt its introduction would widen health inequalities.[Go to reference 28]
The report questioned the readiness and capacity of PCTs to introduce choice and notes that only 12% of them have a 'change management plan in place'. While 'question marks ... over PCTs capacity to commission in a dynamic environment' do not effect the roll-out of choice for December 2005, 'it will rapidly become more important after that point' because PCTs will have to respond to patients' choices with a changing set of contracts'.
Doctors are blamed by some papers for blocking reform
Jeremy Laurance suggested, in The Independent, that 'choice is in disarray because of opposition from family doctors'.[Go to reference 29] An editorial in the Daily Mirror, entitled 'Docs can do better', blamed doctors for blocking improvement. Doctors 'operate the worst closed shops in the country. They refuse to change so they can protect the way they work'.
While doctors are 'highly respected for their dedication and skill. They should match those qualities with flexibility in how they work'.[Go to reference 30]
Not all papers took this line. The Times, for example, said the problems were 'partly technical and partly psychological. First, the system itself is not yet complete. Many GP's computers are not compatible and many hospital specialities are not yet configured to receive e-bookings. Moreover, an intermittent fault with authentication has prevented some GPs gaining access to the system'. The Psychological issues, it said, could have been avoided had 'the government communicated more coherently with GPs'.[Go to reference 31]
The Government respond to choose and book
In an announcement, the day after the NAO report was issued, John Reid spoke to the New Local Government Network in London and announced that he will act to speed up the scheme and make £95m available to reward PCTs that can deliver the scheme.
Some will worry that in the context of mounting financial pressures and the need to keep a reign on referrals - even with the policy of choice - that PCTs seek to use this money to offer a centralised service that works differently to the way Choose and Book was initially envisaged. Plan B would see a local centre handling calls placing referrals for patients from a phone-line.
However, payments will be made in three stages. The first will be available as practices install computer systems, the second when 50% of referrals are made this way, and the third after 90% are electronically referred. The government seem pretty wedded to this system.
As Richard Vautrey pointed out, financial incentives alone will not resolve problems - there are issues around consultation time, the adoption of all-new computer systems, and confidentiality issues.[Go to reference 32]
Only practices that adopt Choose and Book systems will be able to engage in Practice Based Commissioning
'The government is to attempt to boost its flagging IT strategy by insisting that GPs install the electronic 'choose and book' system if they want to take advantage of practice based commissioning.[Go to reference 33]
HSJ editor finds the link "a curious one". He empathised with a GP who told Pulse magazine, "I don’t want to be a glorified travel agent" and also noted that "practices that have the capacity and skills to take on commissioning will also be those who will have the least problem with choose and book. Practices least keen on choose and book are also those likely to be least attracted by commissioning. Adoption of both policies will be much faster in health economies with a smaller number of larger, well-resourced practices".[Go to reference 34]
Plan to offer GPs extra cash to encourage patients to choose treatment centre or, as the Guardian put it, 'no choice about choice'
According to the Observer on Jan 30th, 'health officials are planning to offer GPs extra cash to encourage patients waiting for an operation to choose a private treatment centre, with the bill paid by the NHS, rather than the local hospital.'
The move to 'incentivise' doctors is in order to make the patient choice initiative work.
The DH denied it was behind the move in Nottingham to send more patients to private centres in order to cut waiting lists.
But in the interview with the Observer (noted above), the health secretary was keen to say there would be "no turning back" on the extension of patient choice.
He signalled a fresh shake-up which could go much further, with private firms taking over some GP services, not just offering routine surgery, and the involvement of chemists in routine care.
The newspaper reports they have had sight of a confidential document sent to 28 primary care trusts (PCTs) in Trent and South Yorkshire proposes measures to encourage GPs to make more use of the local private treatment centre for orthopaedic surgery. One suggestion is 'cold-calling' patients on the waiting lists.
'Health officials are desperate to send more patients to the centre, run by the South African firm Care UK Afrox Healthcare, because they have agreed a £98 million five-year contract for more than 5,000 operations.'
One of the reasons for pushing GPs is that the take up of ITC places have proved slower than expected. 'Most patients have opted to go to the big NHS hospitals in Nottingham, partly because their GPs know the consultants there, and partly because they are easier to reach by public transport'.
'The lack of take-up cost the local PCTs £2.3 million last year, the equivalent of 400 hip and knee-replacement operations and it has emerged that up to a half of all those who need hip and knee replacements could not go there anyway because it does not have the medical back-up to deal with complications'.
Reid says there is no alternative but to raise awareness of alternatives. 'Once you get patients quicker access, more power, greater information, greater choice, they will not give it back'.[Go to reference 35]
The King’s Fund commission Derek Wanless to review the care of the elderly
Sir Derek Wanless will look over a 20-year time-span at care of the elderly; it will be published in spring 2006[Go to reference 36]. The King’s Fund is investing £250,000 in the exercise.
He will look at the long-term needs of ageing population as he baby boomer generation passes retirement age over the next 20 years.
He will pursue questions such as, how many will need home care or care homes? Will medical science provide new treatments for disabling conditions, such as Alzheimer’s? Will older people demand higher standards of service?
Once he has established the likely supply and demand for social care he will consider how much it will cost, who should pay and who should do the work.
Niall Dickson, King’s Fund chief executive says, "I think there may be some nervousness about the government tackling this themselves, but I don't think there is a lack of understanding in government that this is an unresolved issue. What they provided over the last few years is a sticking plaster".
For Wanless, the key questions are "what do people want from social care and do they look to the state to provide it? We start without making any assumptions that any one model is right".[Go to reference 37]
All change in Wales?
A whole debate erupted around the timing of Rhodri Morgan's decision to replace Jane Hutt as health minister with former GPC committee member, Brian G two days before the resumption of business. Had the Prime Minister forced the move?
Following the appointment, a range of stories appeared on the issues the new minister must face. According to the Western Mail, 'two out of three NHS Wales leaders would not rely on the health service in their own country to care for a loved one'[Go to reference 38].
The NHS Wales Barometer 2004, compiled and published by researchers at the University of Glamorgan found ‘political, managerial and professional leaders believe that by May 2007:
- Recruitment and retention problems will still cause service failures;
- Orthopaedic waiting times will not be brought into line with those in England;
- Welsh patients will still be waiting more than six months for an operation;
- Social service departments' performance will not be judged as either satisfactory or higher;
- NHS Trusts will still be in financial recovery;
- Local Health Boards will not be regarded as effective;
- Public and patient involvement in service planning and monitoring will not have major impact.
References
1 Simon Stevens. Battles for 2005. Health Service Journal : January 13, 2005; 17.
2 David Charter. Patients come first for GMC. The Times : January 28, 2005; Read more about this here: www.timesonline.co.uk/article/0,,8122-1460059,00.html.
3 Jeremy Laurance. Having safe doctors is part of a wider picture. Safe systems are what really counts. The Independent Review: January 25, 2005; 7.
4 Nicholas Timmins. A hand for public service non-executive. Financial Times : January 31,2005; Read more about this here: www.ft.com
5 Ian Lloyd. Directors to face boardroom grilling, Health Service Journal: January 27, 2005; 7.
6 The United Kingdom Parliament. Transcript of John Hutton’s oral evidence to the Public Administration Select Committee; read more about this here:
http://www.parliament.the-stationery-office.co.uk/pa/cm200405/cmselect/cmpubadm/uc49-iv/uc4902.htm.
7 John Hutton speaking to the Public Administration Select Committee Inquiry into Choice and voice in Public Services. House of Commons; January 20, 2005.
8 Mary-Louise Harding. A&E target and PbR hit trusts with finance double whammy. HSJ: 6 January 2005; 5.
9 Comment. Why are A&E admissions rising so steeply? HSJ: 6 January 2005; 3.
10 Mary-Louise Harding. DoH under pressure to tackle perverse finance incentives. HSJ: 6 January 2005; 6.
11 Mary-Louise Harding. Payment by results delayed to avert £1.5bn finance crisis. Health Service Journal: January 13, 2005; 5.
12 Helene Mulholland. NHS hospital funding reform scaled back. The Guardian: January 11, 2005; read more about this here: society.guardian.co.uk
13 Alastair McLellan. Unfinished business will keep politicians and managers busy. Health Service Journal: January 13, 2005; 3.
14 Nicholas Timmins. Health department rushed to create system to deal with failures in the NHS. Financial Times: January 24, 2005; read more about this here: www.ft.com
15 Helen Mooney. Next foundations will get full PbR option. Health Service Journal: January 27, 2005; 6.
16 Daniel Martin. Why the NHS is facing its bleakest outlook in years. HSJ: 6 January 2005; 14-15.
17 Comment. Financial black hole poses tough questions for boards. HSJ: 6 January 2005; 3.
18 Noel Plumridge. Blind optimism or blinkers. HSJ: 6 January 2005; 15.
19 Nicholas Timmins. Flagship hospital hit by barrage of changes. Financial Times; January 31, 2005; read more about this here: www.ft.com
20 Nigel Hawkes. The giant of private care will bid for NHS work. The Times: January 10, 2005; 4.
21 HSJ reporters. Chief executives attack DoH’s handling of ITC programme. Health Service Journal, January 20, 2005; 5.
22 HSJ reporters. Target pressure threatens services. Health Service Journal: January 20, 2005; 6.
23 Rebecca Smith and Paul Waugh. NHS at war. Evening Standard: January 18, 2005; read more about this here: www.thisislondon.co.uk .
24 Editorial comment. Pseudo markets rule OK. The Financial Times: January 31, 2005; read more about this here: www.ft.com.
25 Gaby Hinsliff. The man who wouldn’t be king. The Observer: January 30, 2005; read more about this here:
http://observer.guardian.co.uk/politics/story/0,6903,1401687,00.html
26 Marjory Inglis. Patients to go private to cut NHS queues’. The Courier: January 27, 2005; read more about this here: www.thecourier.co.uk
27 David Rowland. In the health trade. The Guardian: January 20, 2005; read more about this here: http://www.guardian.co.uk/analysis/story/0,,1394117,00.html
28 Controller and Auditor General. Patient Choice at the Point of GP Referral. National Audit Office: January 19, 2005.
29 Jeremy Laurance. New NHS referral system cost £3m for 63 bookings. The Independent: January 19, 2005; 14.
30 Voice of the Daily Mirror. Docs can do better. Daily Mirror: January 19, 2005; 6.
31 Leader. Choice for the few. The Times: January 19, 2005; 17.
32 Press office. BMA responds to new Government money for choose and book: January 19, 2005.
33 Daniel Martin. Practice-based commissioning will boost ‘choose and book’. Health Service Journal: January 27, 2005; 5.
34 Alastair McLellan. Link with choose and book will not encourage take-up. Health Service Journal: 27 January 2005; 3.
35 Jo Revill and Gavy Hinsliff. No choice about choice. The Observer: January 30, 2005; read more about this here:
http://observer.guardian.co.uk/uk_news/story/0,6903,1401817,00.html
36 BBC News. Wanless to launch care of the elderly. BBC news online: January 31, 2005; read more about this here: http://news.bbc.co.uk/1/hi/health/4222253.stm
37 John Carvel. Age shall not weary him. The Guardian: February 2, 2005; Society 10
38 Madeline Brindley. Most Welsh NHS leaders would seek care in England. January 19, 2005; 6.