Freedom. Fairness. Responsibility. And the NHS.
Civitas, 20 May 2010
Freedom. Fairness. Responsibility. The sounding words of the coalition document, released today. But do these words (most particularly the last one) not, then, require at least a mention in the section on the NHS of the scale of the productivity challenge facing the health service… and perhaps a few ideas of what to do about it?
Instead, one could read the section and assume the boom time is continuing. Real terms increases in funding are assured. All is well. And not only is all well, we can spend the couple of pages devoted to the NHS to structural tinkering (despite the pledge of no more ‘top-down reorganisations’), the usual shopping list of pledges (albeit briefer than the typical post-election spree) and, hopefully inadvertently, numerous contradictions.
Let’s start with the most obvious. ‘We want to free NHS staff from political micromanagement’. A promise made by pretty much every government and health minister time and again throughout the NHS’s history, which has never been delivered. As the former health minister Enoch Powell reflected some forty years ago, a £102.7bn central budget going through HM Treasury to fund the NHS means no government will leave it alone (this observation, at least, was on the mark).
And so we have the accompanying set of demands in the coalition document. There are many, such as developing a 24/7 urgent care services everywhere in England; ‘making the NHS work better by extending best practice on improving hospital discharge… enabling community access to care and treatments’ etc.
But this is the best; a simply brilliant turn of phrase. ‘We will stop the centrally dictated closure of A&E and maternity wards, so that people have better access to local services’. The problem is that these ‘centrally dictated closures’ are predominantly decisions of Primary Care Trusts – or coalitions of them working under Strategic Health Authority umbrellas – the local commissioners that the coalition want to otherwise empower. The central direction by and large has not come from the DH or government. But now it is: to keep them open, apparently regardless of their quality and viability. Oh, and not to mention the fact that the aforementioned pledge to ‘enable community access to care and treatments’ if done properly would obviate the need for much chronic disease management and significant amounts of the emergency care provided in hospitals…
Added to the confusion is the new right of local authorities to refer any proposed closures of local services to the Independent Reconfiguration Panel (previously only ministers could)… possibly increasing local democratic accountability, but hardly consistent with ‘freeing staff from political micromanagement’. What it almost certainly will do is put a further break on an already sclerotic process that PCTs must go through to engineer change in the make-up of services.
… which leads nicely onto the structural tinkering. The comments of the poet James Russell Lowell that ‘compromise makes a good umbrella, but a poor roof’ seem apt here. On the commissioning side of things (the purchasing of health care done by PCTs), the Lib Dems wanted to increase accountability by converting PCTs into locally elected health boards. The Tories apparently wanted to improve PCT performance by introducing a supervisory ‘independent board’ (also meant to take politicians out of the running of the NHS).
We’ve now got a bit of both. An ‘independent’ (don’t bank on it) board to ‘allocate resources and provide commissioning guidelines’ (vague definition, not good for direction); but with PCT boards now populated by ‘directly elected individuals’, appointees of the local authority and CEO/principal officers ‘appointed by the Secretary of State on the advice of the new independent NHS board’. And then there’s GPs to add to the mix, whose power is to be ‘strengthened as patient’s expert guides through the health system by enabling them to commission care on their behalf (a power they already have open to them through practice-based commissioning, but which few are using).
Maybe it will work. But it seems more like a recipe for deadlock, complicating the already confused lines of accountability that exist in the NHS. Who, in light of conflicting views, will have the ultimate say? Everyone has the power of veto; no-one seems to have the power of action.
And action is what will be needed in the coming years. Without wanting to sound sensationalist, all is not well. Even with a one per cent or so increase in real terms funding for the NHS each year of parliament (it will not be more than this, given the state of public finances), the best estimates are that just to maintain existing standards of care in the face of inflation and rising demand the NHS will have to get around four to five per cent more for its money year-on-year.
As documented on the blog last week, the scale of this challenge is exceptional by the standards of any industry. It is even more so in a service sector industry like the NHS, where, in the last ten years of plenty, productivity hasn’t taken centre stage, but fallen by three per cent between 2001-08. So, less of the tinkering, more of the thought on how to deal with this… please.