Using a sledgehammer to crack a nut
Civitas, 22 December 2010
Trawling through the 167 pages of the Coalition Government’s response to the consultation on the NHS White Paper ‘Equity and Excellence: Liberating the NHS’, one cannot help but agree with Phil Collins’ recent comment piece in The Times… just why is the Secretary of State making NHS reform so hard for himself?
Despite a few significant contradictions (like n administrative cap on commissioners or including in the ‘liberation’ of foundation trust hospitals new powers for the Secretary of State to demand information from them), there is much to applaud. By and large, Lansley gets it: that for the NHS to meet its productivity challenge it will need competitive challenge from new providers with new ideas.
And so, the consultation response is explicit about the need to create a competitive ‘social market’ in the NHS, through the principles of any willing provider and impartial commissioning; and through the extension of patient choice. Recognising, also, the fact that markets in public services, typically, are only as good as the regulatory framework they are placed in, much attention is paid to reforming Monitor, reconfigured as an economic regulator, with the function of supporting continuity of vital services, yes, but also promoting competition. It will have teeth: including the power to fine providers that indulge in anti-competitive practice, and the power to direct commissioners to open up markets.
There is also a big emphasis on rolling back the ability of the Secretary of State to micromanage, with additional freedoms for foundation trusts (in essence, Monitor’s compliance regime being dropped, with responsibility passed onto FT governors) and the removal of the Secretary of State’s general power of direction over NHS bodies (as well as a ‘duty’ to maximise autonomy). Finally, recognising the power of published information in driving performance, there is a concerted and long-overdue effort to provide for a comprehensive set of indicators on clinical performance (via the NHS Outcomes Framework and NICE quality standards).
But then it all becomes a bit of a dog’s breakfast. One word, commissioning. All PCTs – the current geographically-based commissioners of care in the NHS, in charge of how the NHS budget is spent in 151 regions of England – are being abolished in 2013, to be replaced by consortia of general practice (of which every general practice in the country must be a member). Now, there is nothing wrong with the aim of greater clinical involvement in commissioning: it is a key weakness in PCTs. PCTs, too, have by and large not done a great job (in some cases to put it mildly).
But what is problematic is mandating that all PCTs be abolished across the country, by 2013, in favour of organisations by and large starting from scratch. If you need an idea of how difficult this will be, and how risky it will be at a time when the NHS finances will be squeezed like no other time in its history, look no further than the Government’s own Operating Framework for the NHS in England 2011/12. ‘This is a broad and complex agenda… I do not underestimate the scale of what lies ahead’, says Sir David Nicholson, NHS Chief Executive, in the introduction.
The problem, really, is twofold. One, as the Operating Framework well recognises, there is a very real risk of a loss of financial control in transition – either as attention is diverted to putting in place new structures and systems, or as things fall through gaps in organisational responsibilities. In order to deal with this, then, ‘a tight grip on finances is required’ (Operating Framework words). This, in plain English, means a tight central grip on what commissioners are doing, and how they are spending their money. PCTs are being herded into larger clusters to manage their demise (not good news if you look at the past evidence of PCT mergers on performance). In reality they will be little more than local enforcers of the DH; as evidenced by the ‘reform’ framework they are to be assessed against. The new NHS Commissioning Board, supposedly the vehicle for liberating commissioning, is to be headed up by none other than Sir David Nicholson himself: more of an old-skool ‘command and controller’ than a ‘liberator’ in the Lansley mode. And QIPP – the DH’s programme for efficiency savings –the first thing new GP consortia are to be engaged with during the transition, is earmarked for ‘tighter grip’. The language of the Operating Framework, at times, could not be more different than the White Paper response.
The second point is that, with such wholesale change, it is very unlikely that you’ll see too much of the new competitive impulse that Lansley has correctly identified as a big route out of the NHS’s productivity dilemma. Why? Because this requires strong commissioning, not the entire commissioning system being in flux. It is no accident that the number of tenders issued by PCTs has dropped off sharply since the publication of the White Paper. And neither is it enough to simply rely on the potential of expanding patient choice; or, for that matter, introducing competition law. The latter won’t be properly operational until at least 2013. And, for the former to be effective, it requires alternative options; i.e. new entrants. It is naive to expect private and voluntary sector organisations, that need to justify their existence, to jump into a politically uncertain market without any guarantee of income and rely on GPs offering patients an impartial choice. (This is not to mention potential difficulties with the BMA’s stance on competition, and the impact of GP’s having clear provider interests.)
The biggest concern, however, is this: that once we get to the point where GP consortia are operational, all but the most entrepreneurial and trailblazing will be subsumed in the very same centralised, restrictive and unsupportive structure as currently besets PCTs. And then the NHS truly will be stuck with regard to driving productivity: waiting lists will have returned and care will be rationed.
Let’s be clear, I’m not taking issue with GPs being involved in, or leading, commissioning organisations, but with the way in which this reform is being advanced. To start with, as the recent Civitas publication Refusing Treatment showed, there is much that could be done to make the market in the NHS more effective without significant structural change (including many of the measures mentioned in the opening paragraphs of this blog).
More widely, while some (or even many) GP consortia may well do a better job than PCTs, it is highly unlikely that all GP consortia will do a better job than the best PCTs: organisations should be assessed by their worth, rather than political imperative. It would be, in essence, far better to lead reform on a human scale: allowing the undertaking of the small-scale experiment, the watching of results, the mimicking of what works and the discarding of what doesn’t.
What might this entail for commissioning reform? First, take the shackles off PCTs and assess commissioners by the outcomes they achieve, not processes followed. Second, enable entrepreneurial GPs (such as the 52 GP “pathfinders”) and other organisations to take over PCTs following a rules-based procedure and failure regime, not central mandate. Third, allow commissioning organisations to change organisational form and governance structures, including to mutuals or cooperatives. Fourth, work towards a system where patients could choose who they want to commission their health care, rather than the state deciding it for them.
With such an approach the NHS could build on the best of what currently exists, and focus on what it should be doing: improving quality and driving productivity.