NHS reform: after the pause, the rewind?
pharmafile | June 3, 2011 | Feature | | Andrew Lansley, NHS reform
The government’s six-week ‘pause’ in the passage of the controversial Health and Social Care Bill has now come to an end, but it must now decide just how to reconcile the existing legislation with the flood of opinions.
The pause was necessary because the Bill, which looks to abolish PCTs and replace them with GP consortia, had become deeply unpopular.
Health secretary Andrew Lansley had not helped its cause by trying to fast forward his reforms – and his plans for increased competition in particular look increasingly likely to be watered down.
The Bill was at the committee stage in the House of Commons but, if major amendments are made, it may need to return to MPs to be looked at anew. This means the deadlines for frontline change – including the key handover year of 2013 – will most likely be extended or replaced with a phased reform. In order to engage with the health service, the pause was filled with a ‘listening exercise’ – essentially a consultation on the reforms mid-way through the passage of the Bill.
Despite difficulties in attending events and murmurs that this was a token gesture, health officials have received around 15,000 website responses and 720 letters during the consultation period.
This will now be looked at by an independent Future Forum, headed by Professor Steve Field, former head of the Royal College of GPs, who will make his own report on what changes will be needed based on the consultation’s responses.
This is due for mid-June, with the government saying they expect to publish their decision on the Bill in July.
There have been myriad views from all quarters – from think tanks and GPs to nurses and politicians – who have added their own views on the government’s Bill, often putting forward starkly different proposals to those outlined in Lansley’s legislation.
Although there were many competing interests, a general pattern of consensus on key issues has emerged, with two major issues taking precedence.
The first is the need to expand the responsibility for commissioning. Under the current Bill, GPs would have exclusive control of the budgets, but many organisations – including GP bodies – are calling for multi-disciplinary team of primary and secondary care health professionals to decide how the NHS budget is to be used.
The second, and even more contentious issue is that surrounding competition and the role of Monitor. Deputy Prime Minister Nick Clegg is opposing Monitor becoming a regulator of competition, and has pledged to limit the place of competition within the system. While many other groups share similar concerns, Conservative MPs are now rallying behind Lansley, arguing that competition is the only way to ensure greater efficiency in the system.
Many groups are also pointing out that the scale and complexity of the reforms are distracting from the more pressing issue facing the NHS – the Nicholson Challenge, which has charged the health service to make £20 billion in savings by 2015.
This, the majority of respondents agree, should be the primary focus of the NHS – how these savings are to be made is more important than who will be making them.
Almost all respondents have asked for the Bill to be scaled back, with the notable exception of the NHS Alliance, whose members were due to gain greater control in the NHS from the government proposals.
Their leader Dr Michael Dixon has said the Bill shouldn’t be watered down and has asked the government to in fact strengthen the role of GPs in commissioning services – a suggestion that looks increasingly unlikely to prevail.
Confederation backs call for phased approach to reform
The NHS Confederation says there needs to be a ‘significant overhaul’ of the Government’s proposals, calling for a better focus on the challenges the NHS now faces.
In a comprehensive response to the consultation, the NHS managers’ organisation advocated a number of changes to the current plans, including replacing the ‘Big Bang’ approach to reform with a phased move from the existing system into the new.
The Confederation’s says some aspects of Lansley’s reforms have real merit, including the introduction of clinical commissioning, the empowerment of local government to improve health and well being, and the focus on outcomes rather than inputs.
But it says that the case for the breadth of the Government’s reforms “has yet to be clearly made.” The proposed changes are not ‘‘sufficiently focused” on the problems facing the NHS, such as the financial squeeze, too much variability in the standards of care, and the need to better integrate services for patients.
The Confederation says the Government can achieve coherent reform by requiring organisations to operate demonstrably in the public interest and to align financial incentives so that organisations behave in a way that ensures the right services for patients. Mike Farrar, the NHS Confederation’s new Chief Executive, said: “We are absolutely in favour of reform because it is crystal clear that we cannot go on as we are. But we are determined to do more to ensure the NHS concentrates its fire power on the issues that will make a difference to patients – getting better value for the taxpayer, treating people with dignity and closing the gaps between services. And these are the issues we would like the reforms to address.
“We also need to ensure that the sum of the parts adds up to a coherent healthcare system that is 100% behind patients, not pulling in different directions. Achieving all this will mean listening more to the people responsible for delivering healthcare. We all believe in democracy and the right of politicians to define policy for the NHS. But it needs to be underpinned by a good understanding of how that policy could be implemented, and we need a little more pragmatism right now.
“So, for example, let’s have more competition when current providers are delivering a poor service. But let’s make sure we can also integrate services where that is what is right for patients. Let’s leave no one in any doubt that all these new NHS bodies are working in the public interest and ensure they are held properly accountable for doing so.
He added: ‘‘And let’s deliver this organisational change at a flexible pace, driven by the realities of what is achievable in each area, not arbitrary ‘big bang’ timescales.”
On the issue of accountability, the Confederation stresses the importance of consortia and the NHS Commissioning Board complying with the Nolan principles of public life and to have boards with independent members who meet in public and publish their papers. It recommends that consortia are held to account by the National Commissioning Board for the outcomes they achieve but also through Health and Wellbeing Boards to ensure that the priorities and plans they set reflect the needs of local people.
Competition and economic regulation
The Confederation says it is fully supportive of competition and economic regulation, but only where it can be shown to benefit patients and the taxpayer. It says competition and integration need not be contradictory, and competition is vital to avoid the ‘capture’ of patients by poor quality service providers. On the issue of education and training, the Confederation says ‘major change’ is needed to address the ‘‘significant mismatch between what patients need now and what is actually being provided”. It emphasises the importance of ensuring that the future workforce will be able to support new models of care. The Confederation says that the voice of employers must therefore be given proper weight alongside the views of clinicians.
The Confederation says a flexible timetable for the transition to new consortia will help minimise the risks associated with such significant reorganisation when the NHS is charged with making £20billion in savings. This could involve consortia taking a staggered approach to taking on full responsibilities, while alternative NHS bodies oversee commissioning in places where consortia have not yet been established.
PCTs should stay on, says Nuffield Trust
Meanwhile health think tank The Nuffield Trust says there is a strong argument to keep primary care trusts (PCTs) beyond April 2013, when they are currently due to be abolished.
England’s 152 PCTs have already merged into just 30, ‘clusters’ and many stakeholders believe that abolishing them in two years time would deprive the health service of must needed stability and experience.
The Nuffied Trust says GP consortia will take a long time to get up to speed on commissioning and will need the help of PCTs to do so.
The think tank’s response to the consultation says: “Previous history suggests that commissioning consortia will take years to develop effectively.
“There is a strong case for assuring that PCT clusters have a longer term future beyond 2013. This would allow them to develop consortia and integrated provider networks, commission services not in the purview of specific consortia, and provide strategic leadership for service changes.”
The Trust said it believed commissioning consortia should only take on responsibilities gradually, depending on their capacity as judged by the authorisation process. Dr Jennifer Dixon, director of the Nuffield Trust, said: “It is critical that disagreements over the Bill, albeit important, are settled as soon as possible so that political and managerial effort can be redirected towards the phase 1 agenda – achieving effective financial control and maintaining the quality of care in the coming four years.”
The Trust says plans for a new Monitor to encourage competition are sound, but stresses the government should be cautious with its powers over the next five years.
The Trust says that increasing collaboration between providers in healthcare could achieve as much or more benefit for patients than competition. Therefore, the over-riding duty of Monitor should be amended to manage the healthcare system by promoting competition and collaboration, the Trust concluded.
Ben Adams
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