Liberation root and branch style
Posted: 13 July, 2010 by Andrew Craig
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.
Cromwellian thoroughness and speed
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?
I have real concerns about GP commissioning not relieved in any way by watching the debate on Newsnight yesterday where the panel of around ten people contained no-one who represented the patient voice – although of course several GPs who were utterly convinced that they knew better than anyone what patients needed and wanted. We have to stop this persistent conflation of what GPs think is good for their patients with what patients themselves want. They are not necessarily the same thing. How do GPs know what patients want/think/experience? How many GP practices have patient groups – and where they exist do they make a difference? Every time you ask patients what they want they come back with the same issues. Two of the biggest issues are evening opening and rude receptionists yet somehow nothing ever seems to get done about these particular wants. So with the GPs in charge will patients necessarily be better off than they are now? It certainly is by no means a foregone conclusion!
well it is early days but it would be nice to know whether they mean “commissioning” or “procurement” and at what level in this “new” two tier arrangement the “commissioning” will be done….ie the analysis, horizon scanning, planning services for the future3. This will no doubt be placed with the “top” brainbox end of a consortium…with people imported from PCT’s and SHA’s OR that lot will be abandoned in favour of intellectuals from the USA or even Price Waterhouse. Whatever…it will look a bit like a PCT except it will not have the usual governance by retired captains of industry, accountants and estate agents….or will it. Also I can’t make out how the accountability will work. And Finally …Public Health to Local Authorities….some of us have argued for this for 20 years…but how will this now relate to the new NHS. Plenty of work for you Andrew and colleagues….
Of course I was being my usual naive self. Planning will not be necessary as the market rules and responds to demand.For examle 4 neonatal beds needed in Borchester? And the market will respond and provide them with ready made consultants SPR’s Nurses and all the necessary hardware.(assuming of course that the local hospital has not been declared bankrupt) Its very difficult to escape from my old fashioned views on planning and cvollective responsibility.I promise to try to get modern in my thinking.
Excellent and thoughtful piece, loved the historical analogies with the tyrants….it will be interesting to see how local authorities manage–Southwark where I live spent £10 million on consultants last year and have 5000 staff. Anyone who is interested in cooperatives and the government’s commitment to them, please look at http://www.conservativecoops.com Marjorie Thompson, Chair, Conservative Cooperative Movement
National Voices has turned the policy blizzard into an easy-read “plain English” version of how the changes will impact on everyday service users which the Department of Health has published called Improving the NHS: what can you expect?
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117981
Thanks Jeremy and NV colleagues for this, it is really helpful.