The NHS: from good to great? Hmm…
Civitas, 10 December 2009
From good to great. The latest ‘vision’ for the NHS. But if it is one, it is wholly unclear. Rather, it is a typical mish-mash of government rhetoric, loud on promise, short on reality. Read the introduction and tell me what the vision is…
…so far as I could work out it’s an NHS that protects frontline services; that is preventative; that is committed to Lord Darzi’s vision of safe, quality care; that upholds patient rights enshrined in the NHS Constitution; that gives ‘power to the people’; that makes better use of IT; that supports innovation; that is sustainable; that tackles inequality; that supports effective collaboration; that keeps staff healthy; that is true to age-old mantra of universal, comprehensive care ‘free-at-the-point of use’; and, oh, that is productive. That’s going to capture hearts and minds like nothing else.
But even with the lack of vision, the most worrying thing is the lack of urgency. The NHS is in big trouble. In two years time it will be facing the most austere time in its history. Forget the £15-20 billion flouted by David Nicholson. With the NHS much closer to the ‘slow uptake’ scenario in Sir Derek Wanless’ three flight-paths, this will feel more like £40 billion, once rising demand is accounted for. This should have been drilled home. It was not. Instead the shortfall is almost skated over; it’s all going to be ok because staff productivity will rise to the level of the best (£3.5bn), procurement will improve and back-office functions rationalized (£1.8bn); long-term conditions will be better managed (£2.7bn) and we’re well on our way even before we get there.
But how do we get there? By collaboration, of course. And increasing integration. By giving all staff a guaranteed job, despite the fact that over 60 per cent of the NHS’ cost base is pay (the pay freeze may well be offset by the increased NI). By – quoted from the document – finding a ‘more engaging, less polarising ways of making change happen than we have in the past.’ Encapsulated in the measures outlined below:
■ ensuring that payment systems support improved quality and efficiency;
■ helping staff through change;
■ strengthening regulation and dealing with failure;
■ creating leaner, stronger commissioners;
■ integrating services and supporting high-performing organisations;
■ streamlining the reconfiguration process; and
■ driving innovation.
Worse, some of the document seems to reflect what can only be described as a fantastic misunderstanding of how incentives currently play. ‘The tariff payment system must incentivise the shift of care out of hospital settings if this is what patients want. This will mean limiting the payments providers receive when activity exceeds planned levels’. No it doesn’t. This just makes the incentive to shift care into hospitals weaker; it doesn’t incentivise the reverse – which would require tackling the quandary that GPs bear no cost (saving) for patients admitted due to poor care (prevented from going into hospital by having good care).
And second: ‘as a single, integrated system, the NHS is also able to drive nationwide progress in a systematic and fair way that would not be possible in a more fragmented or market-based system’. Wrong. As it’s set up the NHS is fragmented and is a market-based system. Providers (that are foundation trusts) are quasi-autonomous, and supposed to be competing for patients in electives and for contracts elsewhere – both with NHS and with non-NHS providers (the result of another thing hallowed in this document… patient choice of provider).
In fact, it is recognition of this, and the power this lever offers to drive performance and achieve exactly the results desired, that is missed. Ok, the NHS ‘preferred provider’ debate is, at least, clarified. And there is a re-statement, at least, of the idea that ‘commissioners have a legal duty to secure the best services, in terms of quality and productivity, for the people they serve’. But rhetoric is revealing: the word ‘competition’ is not mentioned once.