After the NHS reforms had been announced, and before the pause and listening exercise, I was sitting at dinner next to a well known journalist. He asked me what I thought of the NHS reforms. “The devil is in the detail” was my simple response.
Getting the NHS reforms right is imperative for us, as Conservatives in government, and as users of the NHS ourselves. The aims of the reforms are absolutely spot on – to make the NHS more patient focussed, to involve more clinicians in commissioning, and to use competition to improve services and to increase value for money. I had concerns that some of the details of the reforms needed changing to ensure these aims were delivered in reality. In this article I highlight a few of the areas raised in the listening exercise that are important – to ensure the aims of the reforms are delivered.
As I have said in other articles, clinical commissioning is vital. To a certain extent this is already happening – but to a variable extent. Clinical networks in cancer, heart disease and stroke drive commissioning for those services in most parts of England. Some practice based commissioning groups have been very effective in driving forward improvements in care. PCTs all have clinical executive committees (mostly made up of GPs) which input into and approve PCT commissioning plans. If the reforms can get more engagement from GPs in particular (who spend most of the NHS budget by referring patients and writing prescriptions), this will go a long way to ensure gaps in service provision are identified – and value for money measures will be more likely to succeed. We must not however lose the input and specialist expertise of consultants from hospitals and the small branch of public health doctors who specialise in evidence reviews, cost effectiveness, needs assessment and service evaluation.
Competiton vs Hospital Closures
Nick de Bois and others are right in arguing strongly for competition in the NHS. To a certain extent this is already present, with a raft of private providers now providing a range of routine treatments for the NHS, and available through Choose and Book. As Conservatives we understand the importance of competition. I do however have concerns that Monitor was originally going to be asked to promote competition. When I go to the high street to do my shopping I don’t want my hands tied as to what kind of shop I go into. The same should be so for the NHS commissioner. Conservatives have long argued that targets (which focus on process) should be replaced by measures of outcome. This should be the case here. The outcome Monitor should be measuring should be the commissioning of high quality and value for money services. The NHS is inter-dependent. Norman Tebbit was right to highlight the cost of training on the NHS and the risk of cherry picking by private providers– taking the easier, less complicated cases and leaving the more difficult and loss making ones for the NHS providers to pick up. I am certain this will be addressed.
It is more complicated than just that, however: if, for example, diabetes, gastroenterology and respiratory services in an area are provided in the community by a private provider, this might mean there are not enough medical consultants to provide an on call service for the local acute hospital. This could lead to the closure of the A&E and the downgrading of the hospital. Commissioners need to be able to ensure that they are able to take these factors into account when agreeing contracts. Having their hands tied is not going to make for good or safe commissioning.
One of the earliest concerns raised about the reforms was the issue of accountability and conflicts of interest. A strict set of guidelines are needed to address conflict of interest – ideally GP consortia should not be allowed to commission from services that they have a significant personal financial interests in. Having other clinicians and public health doctors on the boards of consortia will also help, as well as Monitor scrutinising value for money decisions.
Another concern raised was the early indications that consortia would not have to have meetings in public and would be exempt from the Freedom of Information Act. These are vital tools to allow the public to hold consortia to account.
Choice and Consortium Boundaries
In my view the patient (the final “end user”) should be able to make the choice – the choice of who their commissioner is (as is possible in the private sector – patients shop around amongst BUPA, AXA, Norwich Union and more). This would make commissioners the ones competing for patients and the budget that goes with them, incentivising them to commission the most patient focussed services they can for their budgets. However, this is unlikely at the moment. Choice for patients will for the time being continue to focus on non-GP services that have already been commissioned by consortia, mostly hospital and community care. This is because the GP consortia are being set up on the basis of geography and not patients’ choice.
If GP consortia based on geography are here to stay for the time being, consideration should be given to co-terminosity with top tier local authorities. These local authorities are the providers of social care and joint commissioners with the NHS of mental health and other services. Moreover the Health and Well Being Boards will be based on top tier boundaries. Many of the problems with services for the elderly and disabled occur where the boundaries of accountability between the NHS and local authorities are blurred – often with neither taking responsibility for the patient. If we have to have consortia based on geography rather than patient choice, then more integrated and value for money services would be possible if they could work jointly with a local authority which shared virtually the same population. Under these boundaries, Health and Well Being Boards could take the lead in ensuring robust joint working arrangements for the local population.