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Editor's blog Thursday 3 March 2011: Doctors against reform; risks in reconfiguration; and no hair shirts with FURs

Two major new policy interventions emerge today, in the light of yesterday’s U-turn by Our Saviour And Liberator on price competition. And one cracking news story on GP refurbishments.

The first is the publication of a major new survey by IPSOS MORI for the BMA, which finds that among those 1,645 polled, even the minority of doctors who generally back NHS reform plans – which was around 18%, in the sample selected - believe that competition will lead to fragmentation across the service.

Respondents said that:
- Increased competition will lead to the fragmentation of services (89 %)
- Increased competition will reduce the quality of patient care (65 %)
- The move for all NHS hospitals to become foundation trusts will damage NHS values (65 %)
- The proposed system of clinician-led commissioning will increase health inequalities (65 %).

If the responses to the BMA survey are representative of the profession overall, they imply that suggests that doctors’ views on reform fit three categoriesing to their views on the proposed reforms.
- A third (33 per cent) are broadly opposed
- Around a fifth (18 per cent) are broadly supportive
- Just over a third (36 per cent) say they are waiting to see what happens.

Further questions among those in the 18% of  ‘pro-reform’ respondents show that 67% think increased competition will lead to fragmentation of services.

Overall, 88 % of those surveyed believe the reforms will lead to increased competition, while 21 per cent believe this will improve the quality of NHS care.

In an interesting corrolary, a survey of health policy people at a seminar today found that 81% of delegates say the NHS needs more competition; but only 38% favour NHS price competition.

Curiously, given these views on more competition, 78 per cent of seminar delegates said that vertical integration between primary, secondary and community services) should be positively encouraged.

Which makes you wonder what the NHS Co-operation and Competition Panel would be there for in the New World.

Shutting hospitals, south-east London-style
The second document is the Kings Fund’s Reconfiguring Hospital Services: Lessons from South East London.

Policy folk have known for ages that London is over-hospital-ed, but after the U-turn of the last Government over the Healthcare For London plan (which health select committee chair and ex-health secretary Stephen Dorrell characterised as the moment the last government failed), the decision to do something about it was more bottled than chardonnay in Burgundy.

The Kings Fund report, based on detailed analysis of proposed reconfiguration in South East London, suggests that:
Market forces alone are unlikely to result in improvements in quality of care for patients in many hospitals, and could result in deterioration in some cases.
The transfer of commissioning from primary care trusts and strategic health authorities to GP consortia increases the risks of deterioration in quality of care for some patients and a widening of the quality gap between best and worst performers.
Reconfiguration that improves quality of care and reduces costs may require consolidation of services across hospital sites. Decisions about reconfiguration will need to weigh the resulting improvements in health care outcomes against the potential costs of reduced competition and choice.

So who’s going to shut things?

PCT clusters, going out in a blaze of glory?

The “not shy” NHS Commissioning Board?

Comfortable practices?
Meanwhile, Health Service Journal’s indefatigable data diva news editor Sally Gainsbury has an excellent FOI’d exclusive on how some PCTs allowed GP practices to spend their practice-based commissioning underspends – freed-up resources (FURs) - on a variety of what look like core requirements.

Gainsbury found that £1 million was spent on basic general practice equipment, including stethoscopes and chairs; and a further £1.6 million on physical refurbishments, including carpets, decorating and car park resurfacing (health policy always comes back to car parking).

The HSJ story is based on 50 PCT areas FOI’d. 29 of these approved items that would generally be viewed as ‘core’ to the provising of primary care.

Now the sums in question - £3.9 million in total, mainly in one financial year – are not huge. The NHS annual revenue budget being (as it is) about £100 billion.

But it is symbolic. And it does point the way to the future of financial responsibility. Accountability must go with it: open book accounting needs to become an organising principle for those who use public money in commissioning.

‘Commercial in confidence’ has a nasty history of hiding bad value deals, as ISTC and PFI students are aware.