Health policy debate - 24 March to 15 April 2005
The general election campaign finally kicked-off. The King’s Fund hosted a breakfast election debate between the three main parties. Most of the debate centred on MRSA and public health. Interestingly, Conservative Andrew Lansley omitted the “patient passport” scheme from his parties list of key
priorities. [Go to note 1]
Lansley states his commitment to the NHS
In an interview with the Health Service Journal Lansley gave the strong impression he is a defender of the NHS.
I have a whole flank of people that I am guarding against, who want to move to co-payments systems, social insurance systems and so on, on the basis that the NHS cant work. I don't believe that. I want a system of delivery which protects the values of equity of access for the population while at the same time introducing genuine competition and choice to energise and incentivise the NHS as a whole.
"All I can see in the social insurance model is that it is going to segment the population. Some people will get better services than others and some would end up with some people having to pay more".
Lansley says 'he is pleased that health secretary John Reid has returned to what he believes are, at heart, Conservative policies following Labour's first term and slash and burn on Tory health reforms. He claims credit on behalf of the party for the introduction of competition, plurality of provision - including the greater use of the independent sector - and the decentralisation of budgets to GPs.'
He thinks 'the electorate and the people working in the NHS would probably think it was sensible to have Conservatives delivering Conservative policies.'
In response to accusations - from the Health Service Journal - that he less than keen on managers he says he will not set a rarget for how many there should be. Lansley says as budgets are devolved in primary care it will be the choice of GPs how many administrators they employ.
He apologises for raising statistics – "but I'm afraid it raises the point very clearly" - to him it doesn't sound right that there are 33,000 administrators in PCTs compared with 30,000 GPs. [Go to note 2]
The Economist says Labour has to demonstrate a return on its health investment in a third term
Focusing on the record of the government The Economist examined the challenges in the next political term. They say that 'in the 2001 election, Labour could travel a long way on hope for the NHS [and while] in the 2005 election Labour will extend that offer, this time it will be held to account for its record. The government will also be judged on the ambitious reforms it has introduced in its second term of office.'
Labour has poured money into the NHS on an unprecedented scale. In the six years to 2004-5, spending has grown at nearly 10% a year in nominal terms - around 7% a year after adjusting for economy-wide inflation. The government is now under pressure to show results in return for its increased spending. A big reason for the gap between cash and output is higher pay and while the government has portrayed this as investment, 'the health-care unions appear to have held the government over a barrel of its own making.'
'Altogether, the NHS has been securing a lot more real resources with its extra cash. Unfortunately, it has been using them less efficiently than before: output has grown more slowly than real inputs. NHS productively has declined at an annual rate of around 1% in the five years to 2003.'
It is not all bleak. The belated return to an internal market - more ambitious in scale than the Conservatives - is a good thing as are the incentives given to the British private sector to lower their costs and provide more care. The article warns: ‘There is a financial crunch looming as the Labour money dries
up.’ [Go to note 3]
Christoph Lees calls for a debate on more fundamental reform
Writing in Hospital Doctor, Lees says the fundamental question now is not about levels of funding in the NHS. The question now is different. Has this money transformed the NHS? While there might have been improvements, they are the margins. Waiting lists have been reduced since the explosion in spending, but the average waiting time has remained stagnant and, under some measures, increased.
‘Many argue that the beauty of the NHS is that is provides access to care to all, no matter their status or wealth. This is nonsense. Quality is all too often dependent on being articulate having an intimate knowledge of the NHS or where you happen to live. This inequity discriminates against the elderly, the less well educated and the less well-off.’
‘Before suggesting the answer is to continue to pump money into the system, we should consider the Scottish example. NHS Scotland spends over £200 more per head than England, but greater resources have not improved outcomes; waiting lists and waiting times have both risen.’
‘We should fund patients either through the tax system or by way of universal insurance, to purchase healthcare from the provider of their choice. The poor and unemployed would have their contributions supplemented or paid for by the state. Patient power would allow resources to be directed to those units providing quality and capacity. Competition would drive up standards.’
‘We should debate these alternatives maturely. It will need a lead from those of us in the NHS who believe that real change is in the interests of professionals and patients alike.’ [Go to note 4]
Labour launches its manifesto
Reading Labour’s manifesto, the similarities between its health policies and the “radical” changes Lees is calling for are striking.
In an interview with the Financial Times Mr Milburn says one of the central aims for his manifesto is that Labour will make the recent improvements to public services "irreversible" - as irreversible as Margaret Thatcher's massive privatisation reforms in the 1980s. He is also keen to stress the manifesto will state that there will be no ideological limits on private involvement in public services.
Mr Milburn said Labour had learnt an "important lesson" during a second term that had been peppered with internal battles over public service reform. The changes to the National Health Service, allowing more patients to be treated more quickly, had shown that reform worked. "There can be no going back to monolithic services," he said.
"There is no doubt, and you see it most graphically in the NHS, that where there has been greater diversity of provisions, there has been more choice for users, that has produced better services . . . so there can't be any going back." [Go to note 5]
Hospital doctor says doctors are going off Labour
A Hospital Doctor ‘General Election Survey shows the number of doctors backing the Labour government has plummeted by more than half in the past four years, to just 13 per cent. In this year's general election, 27 per cent of hospital doctors claim they will vote Conservative, a significant rise on the 20 per cent who backed the Tories in 2001. Three-quarters of the 707 hospital doctors surveyed say health policies are an important influence on their decision-making.’
Despite the Government's investment in the NHS, many criticise its track record on clinical targets, NHS bureaucracy and use of the private sector. One respondent said: 'Labour has generously funded the NHS. Unfortunately, they also seem to have made its doctors feel undervalued and isolated. This attitude towards doctors must change if health care in the UK is to grow and flourish.'
‘Eight out of ten doctors believe the Government's health policies have failed to bring about an improvement in life as a doctor in the NHS. The profession is split over whether patients have benefited overall, with marginally more saying they haven't.’ [Go to note 6]
The Times surveys doctors on their views of New Labour health policy
An exclusive survey by The Times of the consultants, GPs and academics who campaigned for Labour on the eve of the general election eight years ago reveals widespread disillusionment over the Government's reforms.
They felt 'badly let down'. 'Just 17 said that they would give the pary similar backing now. Twenty two would not sign the letter again’.
Many of the Doctors feel that Labour has pursued the right-wing policies that they had feared from a Tory administration. Only a third of the doctors said that the current Government had met their basic expectations for the NHS. 'Others spoke of feeling deceived by political promises that had come to nothing.’
'Many said that they were now left wondering how to vote to limit the damage to the health service'. [Go to note 7]
In her analysis, Alice Miles, said much of the tension was that politicians had fought hard to wrest control of the NHS back from health professionals. She notes that ‘John Reid, recently bemoaned the fact that the media reported a complaint from the BMA about the use of foreign radiographers in the NHS, without mentioning that the BMA is, in fact, merely the doctors' trade union. So of course it complains when foreign doctors challenge their hegemony.’
‘Much of Labour's reform agenda has been aimed at wresting power from the hands of doctors. Successive governments have since fought to regain some of the control given to them in 1948’. [Go to note 8]
Not all doctors were so negative about Labour. Medical advisor to the Shipman Inquiry, member of the BMA equal opportunities committee and chair at Manchester University, Aneez Esmail told The Times that "critics should not forget" the parlous state of the NHS in 1997. "I think many of those who are critical have very short memories about what the situation was like under the previous government". [Go to note 9]
What is the public’s view of health in this election?
The prominence of the NHS in this election is reinforced by a Sunday Telegraph poll. In response to the question has the NHS got better under Labour 29% said better, 29% said worse; 40% said it was about the same and 3% didn’t know.
They were asked whether they thought Labour had kept its promises on the NHS. 29% said Yes, 55%, No and 7% didn’t know. ‘Health services’ is the most important issue to 19% of people, tax and public services to 15%, law and order, 15%, Education 14%, the economy generally, 14%, and immigration as low as 8%. [Go to note 10]
Performance
Which? to rate hospitals on whether they are meeting consumer expectations
Which? is to turn its attention to the country's hospitals and schools, at a time when the Government wants to give parents more choice over their child's school and patients a choice about hospitals.
Which? research shows the public is more concerned about the services that they pay for with taxes than those that they shop for on the high street.
Nick Stace, the director of campaigns at Which? said that they will work out how to audit public services to see if taxpayer’s expectations were being met. "We are going to see where we could add value and bringing about improvement. This might in the form of league tables or ratings". [Go to note 11]
Government claim waiting list success
New waiting list figures showed ‘that the number of patients waiting to be admitted to hospitals decreased by 16,700 from January to February 2005, a 10.2% drop from the same period a year ago. The number of people waiting more than nine months for admission to hospital fell by 19,400 since the same period last year’. There was particular success on orthopaedic waiting times. [Go to note 12]
The Conservative shadow health secretary, Andrew Lansley, said the latest statistics were deceptive. He said: "Today's statistics only give half the picture. There are still over a million people in the UK waiting for NHS treatment. Average waiting times have increased since 1999, and many patients suffer on hidden waiting lists, not included in Mr Blair's targets." [Go to note 13]
The cost of meeting waiting list targets
Dr Rod Storring, a consultant physician based at King George Hospital in Goodmayes in Essex, part of the Barking, Havering and Redbridge Hospital NHS Trust, wrote to Mark Rees, the chief executive, about a meeting held on January 10 this year.
"Dear Mark
Re - Meeting trolley Wait Targets.
We were told at the Senior Medical Staff Meeting on January 10 that you had had six separate phone calls from the DH congratulating you on having done better than any other trust in the North Thames.
Did you feed back to the ministry the cost of this? Do you know what the cost is? Here is some of it.
At the end of that weekend our team had more than 100 patients. This is more than twice as many patients that we can safely look after. Patients were therefore at risk and indeed there are many example of this.
Patients are removed hither and thither around the hospital, one patient visiting seven wards in six days! A consequence of this is that the whereabouts of patients were not infrequently unknown to the doctors who were supposed to be looking after them!
The Juniors were totally exhausted and a number of them were in tears. The sickness rate amongst juniors is unprecedented - the morale of the juniors is lower than I have ever see it.
The organisation that you use for us to look after our patients is at best of times inadequate and now is, of course, hopelessly stretched. I came across two x-rays without the patients' names on them - I cannot remember when I last saw that. With all this extra work, of course, the efficiency with which we can manage patients is obviously reduced and the turnover of patients slower.
I appreciate that the NHS is a hierarchical organisation, but in my view there is a duty in a democracy to feed back the consequences of following the orders of our political masters. The medical director's contribution to this discussion was that we would have to continue what we are doing until the lection regardless. This coming from a fellow director, I find disgraceful". [Go to note 14]
Professionalism
Numbers of trust-grade doctors in paediatrics rockets by 156%
Numbers of trust-grade doctors in paediatrics have rocketed by 156% per cent, a survey by the Royal College of Paediatrics and Child Health shows. The report suggests hospitals are using trust posts to side step national employment standards, leaving post holders open to exploitation. It also suggests further 'substantial increased' have occurred since the census was carried out in 2004.
Numbers of SAS paediatricians fell by 4.4% nationally between 2001 and 2003 and so 'it may be that now the status and conditions of SAS doctors are becoming more regulated and recognised, trusts are turning to trust posts as a more malleable source of doctors'
There has also been a 13% fall in number of academic paediatricians since 1999. [Go to note 15]
President of Royal College of Ophthalmologists says more NHS doctors should work in ITCs
According to Hospital Doctor, pressure on government is mounting to allow more NHS doctors to work in ITCs as new figures suggest ophthalmologists are struggling to find consultant jobs.
‘The number of consultant ophthalmology posts plummeted by 40% in 2004 according to figures from the Royal College of Ophthalmologists., leaving SpRs in the specialty without a job to move on to.’
President of the RCOphth said "It would make sense for these doctors to have the option of working in an ISTC”. [Go to note 16]
Royal College of Radiologists recommends all Alliance Medical scans are checked by NHS doctors
The Royal College of Radiologists (RCR) has told its members that radiology departments should continue to check scans carried out by Alliance Medical.
In a memo, seen by Hospital Doctor, the college said that although there were signs of improvement, radiology departments still had major concerns. College president Prof Janet Husband and Prof Adrian Dixon, RCR warden and clinical guardian of the scheme, said in the memo that it would be 'prudent' for radiology departments to check reports.
[This is] partly for quality control purposes, but mainly to identify urgent and other cases which would warrant discussion with your clinical colleagues, they said, urging members to seek extra funding for their departments to carry out the work.
A Department of Health spokesperson said: "With the appointment of Prof Adrian Dixon as clinical guardian of the contract we see no reason why there should be such "alleged" concerns of quality. As Alliance is already double reporting there should no reason for radiologists to be re-reviewing these
scans." [Go to note 17]Plurality
Reid says there is a limit to private sector involvement, Blair says there isn’t
At the launch of the manifest to Health Secretary John Reid suggested there would be a limit on private operations. "We don't need any more than seven or eight per cent". But he was corrected by Mr Blair, who insisted there would be no fixed cap. He said, “We want to expand NHS capacity. We are not going to set an arbitrary limit on whether you need to go outside the NHS”. [Go to note 18]
An interim-evaluation of Evercare is published
According to HSJ ‘a major report into progress at nine Evercare pilot sites in the NHS has found widespread satisfaction with the model but does not produce evidence either of reduced admissions or cost-effectiveness’.
The report involved surveys of patients, nurses and GPs by Picker Institute Europe as well as interviews with PCT managers conducted by Evercare staff. Of 1,128 patients and carers surveyed, nearly two-thirds said overall care was better, while two-fifths said care was a lot better. Patients who were referred because of previous unplanned admissions consulted their doctor and less often and required fewer hone visits and outpatient appointments.
However, key data on reducing unplanned admissions and cost effectiveness was not included. ‘The report says that, although it was possible to track a reduction in the number of unplanned admissions for patients, it was impossible to extract how much of this was due to Evercare’s intervention’.
The report also calls for better community infrastructure, such as intermediate care facilities and community-based diagnosis, to provide alternatives to admission. [Go to note 19]
Rod Sheaff who is leading the evaluation was more blunt in Frontline – the newsletter of the National Centre for Research and Development in Primary Care.
‘Even making favourable assumptions about the impact of Evercare the overall effects on admission is likely to be small, and the same probably applies to the community matron scheme. Our evaluation of Evercare is continuing, but at this stage, we think that the NHS should test different models of case management for vulnerable older people. In one scheme in Runcorn, for example, it seemed to be the early involvement of social services when old people were admitted that reduced the use of hospital beds by getting people home earlier’. [Go to note 20]
Monitor announce that Foundation Trusts will be able to borrow up to 40% of their income
Monitor has reached an agreement with the Treasury that means foundation trusts can borrow up to 40 per cent of their income.
Trusts will be able to borrow on a sliding scale determined by Montor depending on their financial risk rating, and only those with the best score will be allowed to borrow the full 40 per cent of their income. [Go to note 21]
Complaint lodged against cosmetic surgery cartel
A super complaint into the health provision market is to be lodged with the Office of Fair Trading, according to The Times.
Analysts and health industry experts said that Britain's £375 million a year cosmetic surgery market was the probably target. There have been concerns that patients are asked to sign up for surgical procedures after consultations with unqualified advisers. There are also criticisms that the risk in what can be unnecessary operations are not always adequately explained.
Paul Saper, a management consultant, told The Times that "in parts of the cosmetic sector, there are no rules at all". [Go to note 22]
NHS Counter Fraud Squad build case against price-fixing of generic cillins
The NHS Counter Fraud Service has made a breakthrough in the NHS's longest running and largest fraud case. The civil claim for damages centres on an alleged price-fixing cartel that cost the health service more than £58m.
The investigation concerns alleged anti-competitive cartels that restricted the supply and fixed the price of three commonly prescribed generic drugs: antibiotics based on penicilin (cillins), the anticoagualant warfarin and the ulcer drug rantidine.
In early April, the DH settled with Ranbaxy (UK), which had allegedly been involved in fixing prices for warfarin and rantidine. The company agreed to pay £4.5m compensation and provide full cooperation with the ongoing proceedings. It did not admit liability. [Go to note 23]
Patient and Public involvement
There are some interesting debates emerging on the role of the public in service redesign and particularly how they can have a say in what happens.
In England, one of the consequences of choice will be the closure of departments, something which the government says is an inevitable consequence of its policies and a sign of success, that consumer choices are working. But it is naïve to think that there will not be huge discontent and campaigns launched to defend particular services.
To some extent the UK government must recognise this as they have put a number of tricky debates on hold until after the election.
The implications of current policy are that Charing Cross hospital in west London would shut down and its services move to its sister hospital, the Hammersmith. Senior health officials will not discuss these proposals publicly until after the election. Consultants at both hospitals were told of the plans last week, but were warned by their chief executive that it would be officially denied if the plans emerged in the run-up to polling day.
Shadow health secretary Andrew Lansley said it was essential that local people were consulted fully on the plans. 'If there are plans being worked on, then it is not the job of the NHS to suppress information, even if we are coming up to a general election. It isn't necessarily the case that creating one super-hospital on one site is the best way forward. The NHS has to be responsive to the needs of patients and GPs and to have a proper conversation with them about what they want to see.'
The Charing Cross hospital, a 19-storey block in Fulham, was opened 32 years ago, but faces looming financial difficulties. It is part of the Hammersmith Hospitals NHS Trust, which has run into debt as a result of attempts to attract many more surgical patients. Three years ago it bought a private hospital, Ravenscourt Park, to carry out thousands more hip and knee operations. However, it was left with hundreds of empty beds - and projected debts of up to
£37 million - because many patients were sent instead to private treatment centres by their GPs. [Go to note 24]
A debate in the Scottish Parliament on the future form of health services
After having agreed to form clinical networks with the medical profession, Health Boards have been reviewing service provision and making proposals for the movement of services as well as inevitable closures. Some of the plans have led to a public revolt. A doctor won a seat in Glasgow on a defend-a-hospital ticket.
The Scottish Executive have responded to this discontent in two ways: appointing Sir David Kerr to review the form of future services and orchestrating a visible public debate.
On the 12th April, the debate moved back to the Scottish Parliament which hosted a special session to discuss the situation. Experts were invited – David Love representing the BMA – and 20 members of the public won a seat through a ballot. Also represented, were union leaders, academics and campaign groups.
In advance of the debate, Roseanna Cunningham, the convener of the health committee, said ‘the unique event was planned by members to bring together all interested parties in planning a viable future for the health service’.
Richard Norris, director of the new Scottish Health Council set up to bring the public closer to the running of health services, also will take part. He said: "A fault line has developed between the public on one hand and health boards and professionals on the other over issues like the centralisation of services, and that is why it is really important this debate is happening." He added, "I very much doubt we will have a consensus at the end of the day, but until we start debating the issues you do not know what to build for the future." [Go to note 25]
During the debate Mr Norris hammered home the importance of public relations. "It is important that the NHS gets better at true public involvement and starts to give everyone the opportunity to have their voice heard and listened to by health boards. When health services appear to be pushing through change against the views of the communities they serve, however, there is a cost - and the cost is a loss of trust and goodwill."
Part of the aim of the debate, of course, was to improve the public image of the Parliament and the debate appeared to do the trick. The Scotsman opined that ‘Six months after opening, Holyrood finally laid claim to the title of people’s parliament, as more than 100 individuals with a particular interest in health responded to an invitation to join a discussion on the way forward for the NHS’. [Go to note 26]
Scottish councils say they want control of health
Some would argue that one way to make health services more democratic would be to tie their management to local authorities where those who make bad decisions can be voted out of office and are more accountable to local populations.
In Scotland, the Convention of Scottish Local Authories told the Executive that they should “lead the public sector”. President Pat Watters cited Health Boards as “unaccountable bodies which do not have the same levels of scrutiny as councils” and that have lost control of their budgets. He said: "If you had people on health boards up for election, they would not get elected because of their performance. We do not have budgets running away with themselves. We keep them under control." [Go to note 27] Incentives
Director of public health in Norwich says Payment by Results is a misnomer
In contrast to Scotland, England is seeking to reconfigure its services not through collective debate but via the individual referral choices of hundreds of thousands of patients. As the new system draws near, doctors are becoming increasingly concerned.
In a letter to the Health Service Journal, Norwich DPH Peter Brambleby described payment by results as a ‘misnomer’.
‘It is payment for activity irrespective of the result. Financial flow is triggered whether the patient leaves hospital better, worse or even dead. Increased throughput should not be seen as a result in its own right. Some wholesale policy changes cannot be introduced piece-meal. For payment by results to work it would have to be applied simultaneously across emergency and elective cases, outpatient, inpatient and community activity. And only after the necessary IT was in place. Anything less is bound to lead to gaming and instability, especially when primary care trusts and hospitals and individually accountable.’
Without 'unbundling' the payment by results tariffs innovation and sensible local flexibility are stifled. In the present mixed economy, payment by results is little more than a price-fixing cartel of dubious legality.
‘PCTs need a thriving secondary and tertiary infrastructure and should budget to ensure these are sustainable. Neither PCTS not hospitals benefit from a mechanism that incentivises activity per se. Finance should flow according to health programme objectives. The primary focus of the NHS should be a health of the population, not a competitive scramble between organisations. Payment by results paradoxically is a threat to the stability of hospitals and PCTs. We need a better model, and in programme budgeting we have it.’
‘Payment by results has stimulated an interesting debate. But it won't work, ditch it.’ [Go to note 28]
Mark Britnell describes Sir Nigel Crisp’s vision for the NHS as revolutionary
Writing about Sir Nigel Crisp's recent paper: A Patient led NHS, Mark Britnell says he 'initially found the document an easy and gentle read’.
‘On the surface it ambles along covering ground that we have all become familiar with - long term conditions, plurality, choice, practice-based commissioning, the value of staff and the NHS 'kite mark' symbolising our everlasting values and quality'.
But then, consider the following passages:
"Risk management in future will also involve a clearer approach to dealing with failure. High-performing systems accept that failures will occur, and handle them decisively ... this means recognising that some services are indispensable while others can be replaced"
Britnell says, as you read the document again you find yourself becoming uncomfortable in places ("the time is right for the NHS to take a fresh look at how emergency and urgent care should be organised") as uneasy passages pop up with increasing frequency.
'Just weeks before a general election, I cannot remember a time when a permanent secretary has been allowed, or been bold enough to make such broad-ranging comments on future policy and direction it joins together previously aired directives in a much more commanding way. Britnell found chapter 5 - ‘Making the Changes' - a particularly powerful and disturbing read as it promised fewer primary care trusts and strategic health authorities, more foundation trusts and much more competition from the private sector'.
He sees some flaws in the plan too. 'I think the stated desire to move all NHS trusts on to a similar financial regime to foundation trusts' demonstrates that the thinking is not yet fully developed when it comes to managing markers and promoting patient choice'. ‘While it is the case that elective care can undoubtedly be carried out away from traditional acute settings it is not clear to me how many NHS trusts will be able to operate as 'going concerns' with the 3-10 per cent income destabilisation created by patient choice and payment by results.’
‘There are also the issues of market creation and management. Even merged PCTs and SHAs may not have the right skills to fulfil these tasks. We need to be very clear on the focus of any new organisations and the timing behind any organic restructuring. Created and managing markets takes time, skill and effort'.
At this point, Britnell gives us a glimpse of what he would like to see develop in the new system: integration. From his position, in a teaching trust, he wants to drive this top down.
Britinell knows that choice will lead to changes in service provision. This will inevitably lead to debates about the closure of departments. ‘What is needed’, he says, ‘is the political will to face the difficult questions involved in service redesign’.
'Professional staff, royal colleges, workforce specialists and managers all need to think very carefully about public and patient engagement if we are to make the necessary but dramatic changes to our outdated system of primary, secondary and tertiary care that has prevailed since the late 1960s.'
'While it may not quite be a contradiction to let a state monopoly create a managed market' - and allow choices to direct service redesign - 'it certainly is not a task for the faint-hearted.' [Go to note 29]
Complaints that teaching hospitals are having too much influence on the structure of PbR
According to Bob Dredge, until recently in charge of the PbR policy at the DH has warned that ‘political manoeuvring could wreck the government's flagship NHS finance reform’.
Political pressure from powerful teaching hospitals was behind the government's decision in June to halt plans for fairer re-distribution of training and research and development monies worth £5m.
Mr Dredge went on to describe the DH's decision in December to allow health economies to unbundle the tariff to reflect local patient flows and to make adjustments to the short stay tariff as a political fudge to show the NHS was being listened to. And he said that continued unbundling of the tariff undermined the reform and ran the risk of leaving finance systems back to where we stated.
Dredge implied that the financial system should not be changed to make life more comfortable. "PbR was designed to be a destabiliser – a policy that would rock the system, which it is starting to do. The question is: can we overcome the influence of certain powerbases and hierarchies to gain the real evidence-based cash benefits?" [Go to note 30]
Writing in the Health Service Journal Noel Plumridge also argued against unbundling, something the BMA has called on the government to do. ‘Whenever large acute focused initiatives are extended into the 'murkier, complex areas outside the hospital gates' it is an exploratory expedition.’ ‘One of the central issues is that the core concept of a hospital spell - a finite process of admission, treatment and discharge- does not translate easily into non-acute
care.’ [Go to note 31]
Noel Plumridge accepts that PbR rewards acute episodes and when you are paid by the episode there is an incentive to admit patient and ten discharge them quickly. there is no financial incentive to care for people outside of hospital.
The question is, ‘what would a healthcare resource group for depression look like?’ The DH approach is to unbundle the treatment and create more detailed HRGs for each part of the clinical pathway. But this has yet to be attempted, and requires better cost information than most mental health trusts currently have - not to mention a consistent approach on recording treatment and care. [Go to note 32]
Government look to expand APMS
The DH is looking to pull in new providers 'through a new standardised private sector procurement programme. Companies so far have resisted proposals to ‘provide in-hours primary care, such as direct access to medical tests and services for long-term conditions like diabetes, through the alternative provider medical services contract introduced last year’.
To encourage take up, a DH central team will be established with a £4m budget to 'pump prime' APMS procurement. The purpose is to give commissioning advice to PCTs, according to Dr Colin-Thome. "We want to engage with GPs in working out specifications to fit local need in order to formulate services".
He suggested that the procurement programme could help GP practice that wanted to expand to get a foothold in a neighbourhood SHA, for example. [Go to note 33]
The Health Service Journal finds doctors and managers are positive about Practice Based Commissioning
‘Supporters of practice-based commissioning will be relatively cheered by the results of our survey on the subject. The proportion of commissioning budgets is not likely to be huge but almost every GP and practice manager we asked saw themselves becoming involved by 2008. Perhaps the most interesting finding is why those practices which are not among the earlier adopters are choosing to wait.’
‘The number one reason is a lack of clarity provided by the Department of Health guidance. The guidance is not very detailed. Some practices also believe there is too little incentive to take up practice-based commissioning.’
‘If the system is to work practices will need greater management resource and the confidence that investing in new staff will be worth their while.’ [Go to note 34]Innovation
A debate is launched on the 24-hour childcare needs of health professionals
Writing in The Times Camilla Cavendish says, ‘the future of the NHS is female: it employs about 250,000 men and 950,000 women, some of whom are moving fast up the ranks. So we’d better wise up to the fact that to keep the NHS working around the clock we need to start providing childcare around the clock. Otherwise we’re going to see a post-natal brain drain of talented women who can’t keep patching together a nursery here, a grandmother there, a friend in need, to match their ever-changing shifts’. [Go to note 35]
NICE is becoming the agency for political fudge
An editorial in Healthmatters, a left leaning quarterly journal, focused on the decision of NICE to limit the availability of an Alzheimers drug.
‘The proposal has been met with outrage by old age psychiatrists across the country, and by the Alzheimers Society. The image that NICE now risks acquiring is that of a tight-fisted and cold-hearted rationing agency that writes off the old and infirm.’
‘The government has brought the problem on itself. The belief that political decisions about what is provided by the NHS can be transferred from the government to quangos of apolitical technicians, making decisions by applying scientific formulae, is nonsense.’ It means that ‘the problem is simply 'returned to sender', as the technicians blunder into political controversy’.
As a political arena, NICE ‘represents the meeting point of three powerful forces: the alliance between the pharms industry and the medical profession, the power of consumer lobbies emboldened by the government's commitment to public involvement, and the need of the system to get maximum benefit from every pound spent. This must be uncomfortable for the technicians, who are rattled by the current problem and already looking for a way out.’ [Go to note 36]
The Health Service Journal thought it outrageous when Reid intervened to say NICE should re-examine its decision. Unlike Healthmatters, they want an agency that is independent of the political process.
‘John Reid has taken the opportunity as a 'stakeholder' to question NICE's draft recomendations to restrict access to a group of Alzheimers drugs’.
‘There is rarely such a direct challenge from government. it is hard to separate the health secretary’s intervention from the politically charged atmosphere. the cynical may wonder if Mr Reid would have spoken up so loudly if the Daily Mail had not made the issue a cause celebe and if, as they grey-friendly budget demonstrated, the government was not making such a strong to older voters’.
‘NICE has until October to make a final decision. A change of the staff seems likely. That does not necessarily muddy NICE's independence but it is vital that it shows it has taken proper account of all 'stakeholder' including Mr Reid, rather than merely having bowed to political pressure’. [Go to note 37]
NHS slow to adopt medical technologies says Association of British Healthcare Industries
The Association of British Healthcare Industries (ABHI) says that the NHS is too slow to adopt new medical technologies in its election manifesto. This reinforces a report last year to the DTI, which described the NHS as "risk averse" and "inhibited the take-up" of medical breakthroughs.
The ABHI's director general calls for the incoming government to continue the support to the NHS but create an environment where the adoption of new technologies was rewarded rather than perceived as a risk to meeting short-term targets. [Go to note 38]References
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