To win the next election outright, avoiding a Labour government, or even the Labour/ Lib Dem government under Ed Miliband and Simon Hughes described by Tim Montgomerie, the Conservatives need to deliver on what matters to the public. The economy and confidence in our economic credibility is always vital, but as this improves, voters will further prioritise public services when considering who to vote for. Education reform a la Gove has turned out not to be controversial, as it has been shown to work, and also makes sense. Reforming the NHS will always be difficult – issues are far more complex – but without support from those who work in it and consensus on the evidence this could prove to be one reform too many for the Conservatives.
Most doctors and other health professionals want to provide high quality services, and want to work in a system that allows them to do this. They recognise the need for reform, but the majority of those I speak to are weary of constant re-organisational upheaval – and we certainly had a number under the last Labour government. I personally know dozens if not hundreds of doctors who voted Conservative at the last election, partly because of the promise of no top down re-organisations. Evolutionary rather than revolutionary methods to achieve these aims would probably have been much more popular than the current health reforms which the NHS chief executive said are so large "you can see them from space".
It is easy to portray the BMA, Royal College of Nursing and Royal College of Midwives' opposition to the health bill as a product of grievances on pay and pensions, as they are trade unions as well as professional bodies. But I've spoken to many people in the BMA and although pensions are a big issue for them, that isn't the reason for opposition to the Bill. Last year the BMA voted to work constructively with the government, as did the Royal Colleges. Now they have moved to outright opposition. Now the Royal College of Radiologists and the Royal College of GPs have voted to oppose, after 98% of RCGP members surveyed said they wanted the Health and Social Care Bill to be withdrawn. The Faculty of Public Health is surveying it's members after an Emergency General Meeting voted against the reforms, and the Royal College of Physicians are holding an emergency meeting too. The Royal College of Surgeons have stated they have concerns, but will continue to work to improve the Bill. These are not trade union bodies, but represent their members' views regarding health care delivery.
It is a shame that this is happening. Both the government and health professionals agree that commissioning should be clinically led. Both agree that management costs should be kept to the minimum, and that success should be judged on the basis of health outcomes. Most professionals would agree that competition can be a force for good, in terms of driving up quality and delivering value for money. But the demand for healthcare is potentially limitless and will probably always outstrip what a country can afford. This is why it is important to ensure that demand for ineffective or inefficient care is not artificially escalated by perverse incentives, and that every pound spent in the NHS is spent wisely to get the best results for patients. There are many very highly skilled professionals (the good, experienced senior managers, clinical leaders and public health doctors) who work in commissioning organisations, ensuring that every pound spent is designed to produce the maximum results in terms of lives saved and quality of life gained, and to ensure that decisions are backed by thorough review of the evidence of effectiveness of different services and provided in the most efficient and effective way. They work through clinical networks where possible to get consensus and cooperation from frontline clinicians.
A recent analysis published in the Journal of the Royal Society of Medicine looked at different Western health systems. It ranked the NHS as the most efficient and effective – the outcome measure used was reductions in death rates (PDF). The study demonstrated that the US spends a much higher percentage of GDP on healthcare, but the UK was the country with some of the biggest reductions in death rates. Bureaucratic costs were higher in the US – in other words, the NHS was far more cost-effective. They stated:
"A relatively huge bureaucratic burden is needed to monitor the costs, behaviour and risks of customers, as well as the immense legal costs required to control payment [in the USA]. This may be a factor contributing to the relatively worse US clinical outcomes – these integral market failures when applied to healthcare at a national level. … Paradoxically therefore, a mainly ‘Public’ health system, such as the majority of other countries, including the NHS, are at a national level, likely to have less productive inefficiency, as it avoids the inherent market failures related to profit-making, necessary in the ‘Private’ insurance system. Although theoretically a ‘Private’ system, such as the USA, relies on competition to reduce costs, but because of these inherent market failures of ‘asymmetric information’ and ‘adverse selection’ factors, there will always be inherent market weaknesses within the whole system, which may go some way to explain the differences in the observed cost effectiveness results of the USA and the UK."
This is the crux of much of the professional concern. Most agree competition is good, but commissioners need to be able to work effectively, without having their hands tied, on managing their budgets to achieve the best health outcomes. One major concern about the current Bill is that private companies could take over commissioning support functions, where financial rather than professional considerations affect commissioning decisions, leading to costs being driven up by perverse incentives. They are concerned that conflicts of interest (such as commissioners buying services that they may have a financial interest in) and unmanageable levels of providers for every possible part of a care pathway will lead to cherry picking, reductions in quality, gaps in provision and a reduction in cost-effectiveness.
The other major concern is about "integration". Recently a BMJ paper showed how in just one decade, the death rate from heart attacks in the UK has halved. This reduction followed the publication of the National Service Framework for Heart Disease and the establishment of Cardiac Clinical Networks. I was in fact clinical lead for one such network for a few years during the time period studied. Working groups of doctors from hospitals, general practice and public health worked with managers and patients to transform services in particular for the crucial first few hours after a heart attack, and to make sure that all patients with heart disease were managed long term with the right treatments and investigations. This was true integration, where all parties reached a consensus on what needed to be done locally, and everyone understood and played their part in the care pathway. The easiest change came where there was strong clinical leadership and re-design of care was straightforward and evidence-based. The most difficult changes to bring about were where there were financial incentives against cooperation. Joined up services and coordination of care were vital. Health professionals are concerned that competition between providers will reduce cooperation, communication and coordination of care such as this, especially if there are perceived financial conflicts of interest.
Instead of more and more amendments to the Health Bill, perhaps it would be better to move straight to clinical commissioning by simply replacing PCT cluster board members with GPs and other local health professionals, voted for by their colleagues. High quality commissioning managers, clinical networks and public health specialists that support commissioning should be retained in these clusters – transparently commissioning integrated care with no financial conflicts of interest. Competition at provider level does need to be further encouraged to drive up quality and maintain value for money, but commissioners should not have their hands tied by potentially perverse rules.