The NHS White Paper is welcome to those of us who know the NHS needs to change. Health outcomes in the UK are worse than many other countries that spend just as much or less per head than the UK does for its health care. However, politicians also need to be mindful of the fact that research has shown that the UK public think their health care system needs changing less than in other countries.
The US trust fund, The Commonwealth Fund, conducted research drawing from a large sample of the public in the UK, Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the US. Their recent research showed the UK had the highest rates of confidence amongst the public that they would receive the most effective care if they fell ill, and was the country where the smallest proportion felt changes to health care services were needed. Therefore any changes need to take the public with them, and be responsive to patients’ needs.
Various reforms since Margaret Thatcher’s time have attempted to bring the market to health care – but a true market depends on decisions on funding being made by the end user that has a stake in the outcomes. Reforms to date have not made the patient the decision maker – at worst it has been managers who make the commissioning decisions – under the best model to date (fund-holding) it was small GP practices.
The current white paper seeks to emulate some of the benefits of GP fund-holding. However, as with everything in public service delivery, success or failure lies in the model of implementation. The current proposals seem to be heading in the direction of large GP consortia, based on geographical area. This means that although a patient will technically have a choice of GP – and therefore their consortia – in reality all the practices in their area will part of the same consortium, so offering no real choice for patients. As the consortia are planned to be large, the link with patients will be more distant than in fund-holding times.
NHS “choice” is currently only really available when the decision has been made to refer for routine or urgent care to hospital. As most health care occurs in settings other than the hospital, this does not reflect significant patient choice and empowerment. In fact, it is in areas such as continuing care and rehabilitation that the NHS most needs to improve.
Moreover, there is very little choice for patients about how the NHS budget in their area or consortium is allocated. We all understand that there will always be a limited pot of money – the NHS could swallow every tax payer pound spent on the NHS, education, defence, and welfare easily – and still need more. Every pound spent on one thing in the NHS is a pound not spent on another. That is why patients should be able to choose how that money is spent on their behalf, so they obtain a service that would be most valued.
Very much like the idea of the parent passport for school choice, patients need to be able to take their notional budget to a consortium that spends their allocated population’s budget in a way that suits the patients that choose to join that consortium. If the patient doesn’t like the consortium their GP is linked to – they should be able to move to another GP consortium that spends their budget in a way that is more suitable way for their needs.
For this reason, GPs should be able to join any consortia they want – and there should be a choice of consortia within each geographical area. Otherwise, how can patients move their notional budgets (by moving their GP) and bring real accountability directly to the patient? Most take it for granted that parents and children should have a choice of school – taking into account when making that choice how the schools spend their money, their teaching methods, their educational outcomes, and other factors. For some reason this level of choice has so far been denied to patients in the NHS.
I make one other point. Only a small proportion of GPs will ever be interested in commissioning. These are the ones who were the early fund-holders. They are the ones who currently are on the PCT Clinical Executive Committees, their Boards and on the Practice Based Commissioning Boards and committees. It will likely be the same GPs involved this time.
Because of the size of consortia (about 500,000 population coverage), most GPs will not get involved in the detail (or even the strategic direction), but will rely on their employed managers to do most of the work – similar to how PCTs currently work (PCTs are in theory steered by their clinical Board and Executive members). Only by making these consortia directly accountable to patients (via patient choice of consortia) will this system be any different in reality to the current PCT model.