Liberating the NHS the new Health White Paper on “equity and excellence” could turn out to be, in Chris Ham’s prophetic words today, the “biggest organisational upheaval in the health service, probably, since its inception”. This is about England only of course: the contrast with the other three countries in these islands will now be even starker.
Shaping the new order
Speaking in the Commons this afternoon as the document was published, Secretary of State for Health Andrew Lansley said his objectives were putting patients right at the heart of their care, putting clinicians at the heart of decisions about services and achieving health outcomes comparable of our neighbours.
We are to have an outcomes framework identifying what the health service should achieve and it will be up to the professionals (in collaboration with the public and patients if Lansley is serious about “no decision about me without me”) to say how it should be achieved in each part of the country.
Some of the other highlights of the new order include:
- A payments system that acts as a driver for quality, safety and integrated care not just a reward for activity (very welcome)
- Decision making as close to patients a possible, including patients with long term conditions having budgets (we hope for health AND social care combined) to make real choices about their care.
- Real, local accountability: Local Authorities will agree local strategies to integrate NHS, public health and social care together. (fine, assuming councillors rise to the challenge and there isn’t likely to be extra money for cash-strapped authorities)
- Consortia will commission NHS services in line with the local health plan agreed with the local Council; this is how GPs will lead bottom up redesign of services:“GPs are senior professionals in public service and paid well for that.” No opting out.
- Patient choice over treatment options, including the consultant-led team that treats them, based on a torrent of information to guide informed choices
- Choice of GP practice and power to control our own patient records. (no practice boundaries)
- Patient voices will be heard and acted upon by Healthwatch as a national body working through local healthwatch incorporating the current LINks (across health and social care which is essential)
- An English NHS “liberated from command and control”, including all NHS Trusts to be Foundation Trusts with power in the hands of their employees and users: “Our ambition is to create the largest and most vibrant social enterprise sector in the world.” (could help with getting assets off the government’s balance sheet and sort the pensions issue too)
- Any willing provider in the health care marketplace, provided they deliver to NHS standards and prices
- A more powerful Monitor as economic regulator and CQC as the guardian of safety and quality standards
- The NHS Commissioning Board holding the national GP contract, managing performance, allocating resources to commissioning consortia and leading specialised commissioning (big job all of that, any applicants on the horizon?)
Liberation is a double edged sword
MAC’s initial reaction to all of this – our deeper thoughts are for later – is that what Mr Lansley is proposing – and the devil will be in the detail of the coming consultations and the autumn Health Bill – could certainly be “liberating” both in an innovative but also in a chaotic sense (think Pandora’s box) – and probably at the same time. The phrase “constructive discomfort” comes to mind.
But there’s a catch. The NHS in England must save recurrently some £20bn by 2014 – “every penny saved will be a penny reinvested for the benefit of patient care” Mr Lansley said. That takes many steady eyes and hands on the job and some well placed voices are wondering if now is the right time to pursue wholesale root and branch change which will be very distracting in our largest and most expensive public service? Managers fashioning lifeboats for themselves may have concerns other than achieving efficiency savings.
The reforms to commissioning and accountability aim to be Cromwellian in thoroughness and speed. Andrew Lansley seems to be taking Tony Blair’s approach further and faster than anyone thought possible, but the difference is there seems to be a map this time. Our modern day “major generals” (aka Strategic Health Authorities) are being marched off to the Tower awaiting termination – or as Mr Lansley termed it “disempowerment of bureaucracies” – by 2012, to be followed by PCTs by April 2013.
As we move towards then, will the crowd be shouting “behold the heads of tyrants” as we breath the free and pure air of GP commissioning, or will we just be too distracted to care? And will there be anyone left in PCT land by then to turn off the lights, cancel the milk and put the cat out?