Liberating the NHS … whether it likes it or not
pharmafile | December 22, 2010 | Feature | Sales and Marketing | GP consortia, NHS, NHS board, NHS reforms, value-based pricing
When health secretary Andrew Lansley announced plans in July to abolish the management structure of England’s health service, and hand power to new GP consortia by 2013, NHS groups were stunned, and gave muted responses.
Now, as details of the plans emerge, and the scale of the task sinks in, many within the health service are voicing grave doubts about the plans. Critics say the new blueprint, Liberating the NHS, will in fact create needless upheaval just as the health service faces up to a massive financial challenge.
So just what is at stake, and how much will voices of protest influence the final masterplan for change?
Lansley’s vision for the NHS
At the heart of the White Paper are plans for England’s GPs to take charge of deciding how an annual sum of around £80 billion is spent through commissioning patient services.
In doing away with primary care trusts (PCTs) and strategic health authorities (SHAs) by 2013, Lansley hopes to save the health service money, and eliminate a management structure he believes has failed to produce improvements in patient care, and has stood in the way of clinicians improving services. However, while many doctors have expressed frustration at NHS management over the years, it is also clear that many GPs are not eager, or indeed well qualified, to take on the commissioning role.
Lansley had observed the failure of Labour’s practice-based commissioning, and before that, the fundholding system of the last Conservative government in the late 1990s. One of the main reasons why neither were fully successful was that doctors could, and did, opt-out of the system. Lansley has learnt this lesson by sweeping away the management structures, and in their place will make GP consortia the statutory bodies with legal responsibility for commissioning.
Also central to Lansley’s plans are for greater competition between existing NHS providers, and new competition from private providers – under the banner of ‘any willing provider’.
One of the most striking reforms is to allow patients to register with any GP practice, regardless of their location. This is intended to generate competition for patients, and drive up standards of patient care, but many doctors fear this will mean the unravelling of the current system.
Dr Clare Gerada, was recently appointed the chair of the Royal College of General Practitoners, and has spoken out against the reforms from the outset. She says GPs risk being ‘corralled and de-professionalised’ by having commissioning responsibilities foisted upon them.
She told the doctors’ publication Pulse that GPs would bear the brunt of criticism for shortcomings in the system.
“I am concerned GPs will be blamed for over-referring and over-prescribing, and forced to limit prescribing, use referral management centres or not be able to refer to named consultants, or consultants at all, under the guise of demand reduction.”
Another leading doctors’ association the BMA warned the reforms would only be a success if other clinicians, such as hospital consultants, were also brought into the process, and that engagement with the public and patients had to be meaningful and not tokenistic. It also said consortia must have sufficient management and administrative support to take on the additional responsibilities.
Another measure aimed at fostering a market place within the NHS is the new role for Monitor. Currently the regulator for independent acute foundation trusts alone, Monitor will now become the regulator and promoter of competition across the entire system, intended to increase greatly the limited in-roads private companies made into the system under Labour’s reforms.
‘Any willing provider’
The BMA and others fear Monitor’s new role will shift the emphasis toward cost rather than quality, and could undermine efficient collaboration across primary and secondary care.
“There are proposals in the White Paper that doctors can support and want to work with. But there is also much that would be potentially damaging,” says Dr Hamish Meldrum, chairman of Council at the BMA. “The BMA has consistently argued that clinicians should have more autonomy to shape services for their patients, but pitting them against each other in a market-based system creates waste, bureaucracy and inefficiency.”
The BMA also suggests the scale and speed of the reforms do not take into consideration the size of the task, and the financial squeeze already facing the health service. It says it questions whether the aims of reducing bureaucracy and empowering clinicians could have been achieved through ‘less disruptive structural change’.
Many other groups have raised concerns about the reforms, and their introduction coinciding with the NHS having to find £15-20 billion in efficiency savings over the next few years.
The think tank The King’s Fund said in its official response to the White Paper that the argument in favour of making the changes now “has not been made”.
The think tank’s chief executive Professor Chris Ham said: “We question the need to embark on such a fundamental reorganisation as the NHS faces up to the biggest financial challenge in its history.
“I hope ministers will think again about the plans for implementing these proposals”.
Rather than abolising SHAs and PCTs from 2013 and switching commissioning responsibility to GPs from the same date, it advised ‘a more measured approach’.
Lansley felt compelled to answer the King’s Fund concerns directly: “Reform isn’t an option, it’s a necessity in order to sustain and improve our NHS. The reforms are far reaching but they also build upon existing designs.
“Our plans give the NHS and patients a clear direction for the next five years and beyond. We believe that both purpose and pace are vital to improve services for patients.”
The government published the final draft of the health bill on 16 December. It contained some moderately significant amendments in response to the 6,000 responses to its consultation, but has made no major concessions to its critics.
Inevitably there is speculation that Lansley is under pressure from within his own party, or even from the prime minister David Cameron to moderate the pace and scale of reform.
The prime minister had succeeded in persuading the electorate that the Conservatives wanted to see the break up of the NHS, a perception which had counted against the party in previous elections. Once put in place in 2013, the coalition will have just two years to prove all the upheaval was worthwhile.
In November, a group of MPs from all the major parties warned the changes could be damaging, and urged a more measured approach be taken. The All Party Parliamentary Group on Primary Care and Public Health (APPG) said abolishing layers of NHS management too quickly could threaten the success of the reforms, and recommends greater reliance on existing structures. It urged: “We recommend the government re-think the scale and pace of structural reforms and approach it in a more measured way that will ensure continuity of management and leadership.”
It recommended that PCTs should remain in place for longer, but be merged and reduced in headcount terms, to enable a transfer of commissioning powers to consortia at a ‘more progressive rate’. The Department of Health is due to provide ‘substantial further detail’ about the health bill by the end of December, and this document will demonstrate just how much Lansley has been swayed by the criticism of his plans.
Consortia and the pharmaceutical industry
In many areas of England, GPs and their primary care trusts are not waiting for the final guidance, and are already forging ahead with plans. Despite the considerable resistance shown by doctors’ leaders, the diversity of the profession means there are handfuls of entrepreneurially-minded GPs who are indeed eager to seize the opportunity. Labour’s similar practice-based commissioning system has been in place since 2005, meaning that there are already pockets of proto-consortia scattered around the country.
Two of the first pilots in England are within the current Cambridgeshire PCT area. The first is Hunts Health, involving nine practices around Huntingdon, and the other is the Borderline Commissioning Consortium, made up of four practices in the Yaxley and Whittlesey area, near Peterborough.
The NHS Alliance, which represents GPs and other primary care health professionals is helping to set up pilots in other parts of the country. It says between 20-40 consortia will be the first pathfinders, with practices chosen from existing SHA regions in England, due to be announced in December.
For the pharmaceutical industry, the return of purchasing power to frontline primary care doctors is ironic, given that it the industry has spent most of the last decade adjusting to the diminished influence of GPs, and the growing power of PCTs.
However the arrival of consortia is unlikely to be a cause for celebration for the pharma industry, who will face a confusing and disordered environment in which to do business while the reforms go through. Once in place, the ‘localism’ underpinning the system will almost certainly mean a resurgence in local variation, including ‘postcode prescribing’, which pharma spent many years campaigning against.
As with all organisational reform, much of its success depends not on the theoretical strategy, but on its practical implementation, and this may produce a very different picture to the one being sketched out by the health secretary.
Among the key questions for pharma is how closely the planned NHS board will regulate clinical practice, and of course how value-based pricing – set to be introduced in 2014 – will affect its access to the market.
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