Julia Manning is Chief Executive of 2020health.org, a web-based, centre-right think tank for Health and Social Care which uniquely focuses on bottom-up policy development by front line professionals.
Maybe I wasn’t watching, but I can’t remember this much speculation, hype and opinion-mongering around a health white paper as there has been around Andrew Lansley’s first article expected today. So feverish has it been that it wouldn’t be surprising that a new condition – repetitive speculation syndrome – arises. There are two key reasons for this excitement. One is the subject – putting GPs in charge of commissioning up to £80bn worth of NHS services – and the other the context – an NHS that is tasked with finding £20bn of operational savings over the next 4 years in order to meet anticipated demand.
Considering practice-based commissioning (PbC) was pronounced dead last year by many of its creators, in true Doctor Who style, ‘regeneration’ is ensuing but the next death – in the form of the failure of a universal GP commissioning strategy – is already a source of conjecture in some quarters.
This is somewhat premature, possibly immature. Do we really think things should stay as they are?! Primary Care Trusts (PCTs) reluctant to test new pathways that could benefit patients; ‘Payment by Results’ (PbR) meaning power remaining with the big Hospital Trusts and GPs only gaining bureaucracy not control to improve patient care? And how can we predict a crash before we know how the track is going to be laid? We won’t have long before the White Paper reveals its particulars, but there are certain details that we believe are vital for success. Mapping the ground over which the tracks should and should not be laid and the essential signalling that should be incorporated, I came up with ten essentials.
1. Say what you mean
And the first has to be ditching the word ‘commissioning’ – or at least agree precisely on what we mean GPs should do. “Practice-based”: yes, simple, and in the interests of continuity should be retained. ‘Commissioning’ – well – what are we talking about? Buying, selling, planning, strategy, monitoring, evaluating, performance management, specialism appraisals, data collection, reconfiguration, IT systems? The successful PbC models we have seen have been where practices have analysed a service or pathway, designed and implemented something more focused and efficient. In other words they have planned and procured successfully. Patients have benefitted and money has been saved. This is precisely what clinical leaders are excited about, but they do not have the capacity to undertake nor should be burdened with all the other roles simply because they can’t do it all and should focus on what they do best – improving care for their patients.
2. Mean what you said
So secondly I hope that having already announced the demise of ‘strategic health authorities’ (SHAs) and the birth of the NHS Independent Board (and regional boards), Andrew will not top down start to reorganise Primary Care Trusts. The previous announcement on the public being able to join PCT boards has to count for something. Yes PCTs will need to downsize but for GPs to be able to take over planning and procurement they are going to need support from the organisations who have historically had the lion share of the role and who will still need to provide some of the other aspects of commissioning including the strategic Public Health advice, performance management, specialist services and evaluation. Now there are already private companies who can provide some of this support and there will over time be a natural attrition of some PCTs as GP consortiums chose other support organisations and smaller PCTs become coterminous with councils and share resources. This sort of bottom-up evolution is what should be enabled by the white paper.
3. Be frank about sustainability
The third crux will be whether there will be an admission that tracks cannot be laid in every direction. OK, the White Paper won’t do this but it could hint that following Papers will address NHS scope. And GPs should have more power under PbC to advise patients when their minor ailment does not warrant an appointment. Untenable demand has arisen as the NHS has expanded to unquestioningly subsidise every societal and cultural choice. I have outlined before what I see these demand ‘giants’ as or arising from: neglect (ignorance and loss in the cachet of caring); risk (displacement, waste and fear); drift (disease mongering); commoditisation (blurring of the line between therapy and enhancement) and conflict (the simplistic rejection of partnership). If we don’t tackle these resource-draining demands then the NHS is simply unsustainable, no matter who plans the services.
4. Get rid of the old
Fourthly, no new tracks can be laid over old. If a new service in designed, the old has to go. This is not the level at which choice operates – the best has to trump the good and alternatives cannot co-exist because ‘that’s what we have always done’.
5. Adopt Treasury plans to reflect costs and benefits
Fifthly, reciprocity. If money spent on health results in savings in the welfare budget, or vice-versa, this needs to be reflected and incentivised in the relevant budgets. At the moment it isn’t. The possible mechanism for achieving this is the DEL-AME switch. DEL is Delegated Expenditure Limits and AME is Annual Managed Expenditure. Currently, money in the AME budget cannot be used to pay for programmes for e.g. getting people back to work through, for instance, faster access to diagnostics or support from an organisation like Tomorrow’s People. Under the Treasury’s plans, savings – or projected savings – made in benefits can be transferred to the DEL budget to pay private and third sector providers on the ‘payment by results’ plan. This could be a first, and vital step, on the road of resolving the condundrum of who pays being different from who benefits within healthcare.
6. Don’t blame the technology
Whereas it has become fashionable to knock technology as the costs-rising-culprit, I believe that the evidence shows many examples where the incorporation of technology shows improved and reduced cost and there is a huge amount of untapped potential. A clear sixth signal could be sent in the White Paper that it will incentivise this. Technology has enabled quicker recovery, faster diagnosis, intelligent communication, more appropriate treatment and therefore cost savings, though not always within the health budget (see above). Of course there are the exceptions such as the dust gathering Darzi robots at £500m a pop. But I worked for years alongside ‘early adopter’ GPs who even without the responsibility of PbC looked for ways of streamlining and pro-actively caring better for their patients with Long Term Conditions using available technology. Passing responsibility for health services to the frontline should inspire service procurement that is more efficient and more effective. Doctors will want to see patients for fewer, higher quality consultations and technology can facilitate this.
7. Freedom to thrive, transparency to reassure
Seventhly, returning to the evolution theme, clinical leaders willing to take the time to lead their consortiums will come up with different ways of delivering local services. The White Paper needs to be detailed enough to signal what they are responsible for, and the framework of accountability, without prescribing the exact process. Different systems will evolve around the country determined by historical activity, competence and relationships between clinicians and managers. What will be vital however is that this process is transparent. For confidence to be built at all levels, including crucially with patients, the process must be clear.
8. Realistic timeframes
None of this can happen overnight. Various timelines have been imagined. So our eighth point is that bearing in mind the level of changes proposed, unreasonable pressure should not be applied with a timeframe of anything less than two years. As long as wholesale reorganisation of other structures is not imposed at the same time (notwithstanding this could happen naturally), the fact that PbC is already a familiar concept to GPs means that the usual reduction in productivity that can result from reorganisations is not inevitable.
9. Accountability at last
The “A” word has already been mentioned. Accountability is not a popular word in the NHS and its absence has led to mediocrity thriving and failures left until they are catastrophes. So it’s interesting that there has been such a panic around ‘accountability’ only now service planning is being devolved to the front line. Why was no one that bothered before? It will make sense for the consortium leads to be accountable to the PCT – or even the GMC – and they to the regional board, and of course there will be failures as there have been failing PCTs and NHS hospital trusts. How refreshing though is the thought that if through transparency and accountability, a consortium that doesn’t deliver adequate care for the public is taken over by another! (Note the Paper needs to give them the freedom to raise the funds to do this). Welcome to the real world! Far better for systems to be in place that spot failure quickly and address the issues or allow for takeovers than leave the public at the mercy of cover-ups and inadequate care.
10. Don’t miss this chance
Above all I hope that this White Paper will be the radical opportunity to bring clinical leadership to the fore of the NHS as never before. A few thousand savvy GPs (the Consortium leads) now have the opportunity to shape care as never before. Those who succeed will be groups who understand the importance of relationships (with other hospital staff, management support and their patients), who listen to the strategic advice they are given, who insist that they are not there to pick up the pieces for every permutation of lifestyle, who engage the public, delegate to other competent professionals (optometrists, dentists and pharmacists, nurses) and embrace technology.
Whether the White Paper will allow the freedom and autonomy for this radical new vision to thrive will be revealed very shortly…