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Editor's blog Thursday 7 October 2010: The First Law Of Holes - stop digging

The First Law Of Holes is that when you find you're in one, you really should stop digging.

Health Secretary Andrew Lansley is very unlikely to do this, although it is now blindingly obvious that he is in one. The consultation responses to his White Paper - and it really is very much his White Paper - have been polite about the underlying concept of patient-centricity and clinical input into commissioning; but almost uniformly on a spectrum from cautious to negative about its actual detail and implementability.

Fresh onto the pile today is this response from the Kings Fund.

'Liberating The NHS: the right prescription in a cold climate?"supports the government’s aims but questions whether fundamental reforms are needed at this time .... real strides have been made in the past decade in improving performance through investment and reform. While more remains to be done to strengthen the performance of the NHS, the means used need to be proportionate to the problems to be addressed".

We are not talking about an organisation that opposes reform or change. We are talking about the UK's best-known health-specific 'think-tank'. The document's authors Chris Ham and Anna Dixon rightly point out that "the case for reorganising the NHS needs to be clear and convincing to justify taking these risks, and this case has not been made".

Dixon and Ham suggest a gradualist approach, "building on existing arrangements ... giving GPs more control over real budgets as they demonstrate their ability to lead on commissioning; progressively streamlining the organisation of the NHS instead of undertaking radical restructuring; ensuring continuity of management and leadership to minimise disruption and instability; and encouraging increased collaboration alongside competition", going on to emphasise the importance of learning from integrated systems.

The document explores four likely scenarios as a consequence of going ahead with the plans in Equity And Excellence: stasis; a more market-oriented system; an integrated system; and disintegration.

It goes on to point out that "the skills and capabilities to ‘commission’ services such as assessing need, using data to analyse utilisation and predict risk, managing financial and insurance risk, involving patients and the public, and monitoring and managing the performance of providers will be essential. These skills need to be valued in the transition and made available to consortia either directly or through commissioning support organisations. The management allowances allocated to consortia must be sufficient to provide GP leaders with high-quality support".

However, it adds that evidence suggests that consortia will not want to commission certain services which would be better commissioned locally (such as joint commissioning with local authorities and other partners for services such as learning disabilities and mental health, and the reconfiguration of specialist services like stroke care and trauma services). The future locus of commissioning for these in the New World is unclear. It points out that reconfiguration of stroke services in London has been under the aegis of the strategic health authority.

The PFI's the limit
On Monitor's new role in economic regulation, it warns of " a risk that if the economic regulator moves to introduce best practice and ‘efficient’ tariffs too quickly without taking account of historical capital and deficits then some providers, particularly those with large PFIs, may fail".

It says of the weaknesses in commissioning, "reasons include shortages of skills and resources to support commissioning and the inherent complexities of the healthcare market compared with other sectors. This suggests that organisations that are only commissioners of services may find it difficult to negotiate on equal terms with providers. To expect GP commissioners to succeed where previous approaches to commissioning have struggled to make a sustained impact would be a triumph of hope over experience".

It also describes the need to ensure the GPs interest in providing integrated, community-based services that they are also involved in commissioning should not be stymied, provided that transparency in choice, information and declaration of interests prevail.

Change for change's sake
The document'c conclusion states, "challenges confronting the government in taking the White Paper forward are partly technical – can the design of the reforms be completed to the point where they are coherent and credible? – and partly political – will ministers have the courage of their convictions and be willing to follow through the logic of the market and allow unsuccessful providers to fail?"

It also points out that "high-performing health care organisations around the world. These organisations rarely give priority to organisational change. Rather, they focus relentlessly on ensuring that there is consistency over time in the strategies they pursue and stability in leadership": the opposite of what is being proposed in the White Paper. It signs off with a quote from US healthcare reform pilot Don Berwick's speech on the 60th anniversary of the NHS, which warns that the NHS's Maoist 'perpetual revolution' of change "drains energy and confidence from the workforce, which learns not to take risks but to hold its breath and wait for the next change".

This document is a considered and sober response. And unfortunately, it looks as if the Coalition Government in general and the Health Secretary in particular are in 'la-la-la-not listening!' mode.