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Editor's blog Monday 28 February 2011: Our Saviour - Trappist on price competition; reality issues; RIP commissioning

"I’m saving the NHS by giving it to patients and the staff of the NHS"

Andrew Lansley, Any Questions, 25 February 2011

The transcript of the NHS reform-related sections of the most recent Any Questions reveal a few choice points on the current thinking of Our Saviour Andrew Lansley.

1. 'I will deny thee eight times' - Our Saviour is silent whether GPs can choose between providers of equal quality on the basis of price
Our Saviour Lansley gamely tried his "quality is what will drive competition in the NHS" schtick, and was pressed by chair Johnathan Dimbleby on whether commissioners would be able to choose providers on price.

Our Saviour initially flailed away at Labour's inept volume guarantees in its ISTC deals, but then repeatedly refused to answer Dimbleby's question that when quality is equivalent, could GPs choose provider on price?

Lansley refused to answer this question eight times.

Nevertheless, his non-answers contain an interesting formulation of words: "Any Willing Provider doesn’t mean you choose the private sector over the public sector provider. It means whoever can meet the quality of care that you’re looking for and whoever can provide that to NHS standards within NHS prices, then they should be able to provide that service".

At last, on the ninth time of asking, Dimbleby rephrased to the simpler question of whether Our Saviour had any view himself: "is it a matter of indifference so far as you’re concerned whether it (provision)’s public or private if certain criteria are satisfied?"

Our Saviour deigned to reply, "If the quality is satisfied, absolutely, because what we’re looking for is the best quality".

2. Our Saviour struggles with reality
That's reality as in 'real terms' funding. The Kings Fund's iridescent chief economist Professor John Appleby patiently explained this one back in December 2010, since when inflation has continued to climb.

Yet Our Saviour replied to PAC chair Margaret Hodge's comments"the NHS is not being kept even at a level, in real terms –" by stating, "Yes it is".


3. RIP commissioning: long live pathways
Out Saviour has often in the past spoken about prescribing and referral as 'commissioning', leading to a widespread view that he does not actually understand the cyclical, iterative, plan-do-study-act nature of the job.

In this broadcast, Our Saviour said an extraordinary thing: "GPs, by and large, believe that they, frontline health professionals with the responsibility for their patients and their population, are actually best placed to design the services, even if somebody else is then responsible, on the basis of the design they’re looking for – at agreeing the contracts and monitoring the contracts".

This is insane, at several different levels.

The first is that as soon as you talk about GPs by and large designing services, you are telling people that many GPs will be heavily and regularly involved in commissioning - which Our Saviour and his colleagues have in fact been at great pains to deny.

Our Saviour even says elsewhere in the transcript that this "doesn’t mean they (GPs) turn into managers" - but it does, Saviour. It does mean just that. Because as your previous line states, "the people who are at the front line making decisions about your care should be the people who are in charge basically of the resource decisions".

That is management.

Following that approach also means missing the massive potential win of getting clinicians from all across the NHS involved in pathway design, perpetuating the acute-community split with awful consequences.

Likewise, Our Saviour's phrase "agreeing and monitoring contracts" sounds like easy-peasy work - and yet those aspects of commissioning have proven to be anything but, in an era of growth funding and support from the finest management consultants Mark Britnell could recommend. Partly because commissioning was under-powered and under-resourced; partly because FTs were well-resourced in the event of contract challenges; and partly because outcome measurement is still in its infancy.

The game has not changed - and indeed will get harder once all providers are FTs, with legally-binding contracts.

Finally, most GPs appear to understand that integrating care along pathways is the way to improve healthcare.

If it is to be an Any Willing Provider world, based on Monitor chair's adoption of Our Saviour's idea of NHS reform being akin to deregulating and privatising utilities, then integrating care along pathways will become more difficult - as the CCP issues mentioned in the above link demonstrate.