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Editor’s blog Tuesday 13 July 2010: Confusions & contradictions in the White Paper 'Equity And Excellence: Liberating the NHS'

A cleverer man than I, with more experience of policy matters (yes, I know it doesn't narrow the field that much) once pronounced, "beware alliteratively-titled policy documents. They're invariably not very good".

How right he remains.

Joining the undistinguished field of 2009's Necessity, Not Nicety and From Good To Great, we now welcome  Equity And Excellence: Liberating the NHS.

As a White Paper, it's very ambitious.

Unfortunately, as a White Paper, it's also not very good. It would have made an excellent Green Paper, though.

Emmental, and biscuit contraception
The document's flaws are in two main areas: those of Emmentalesque holes; and of biscuit contraception (the bits that are fucking crackers).

Emmental 1 - The magic power of FT status
James Gubb of Civitas, whose recent report warned of the downside risks to performance of a new NHS redisorganisation, pointed out in a chat this morning that the White Paper is seeking to push hospitals out of the NHS, while genuinely binding GPs into it for the first time.

It's a good point. The assumption is that once all providers are FTs, they will be fine because on balance, FTs perform better than non-FTs.

Is this smart?

Well ... up to a point, Lord Copper. There is faulty logic at work here, based on the assumption that post hoc equals propter hoc. Which it doesn't.

FTs have to be good performers to achieve FT status. The assessment process can be imperfect, as the events in Mid-Staffs proved so spectacularly (with the added impact of the five local commissioning PCTs merging into one).

FTs also get into lesser (but still significant) trouble - Basildon and Thurrock, Colchester, Milton Keynes.

Moreover, of the 22 providers whose registration with the Care Quality Commission carry conditions, 12 were FTs.

FT status is not a panacea. FTs also get things wrong. I accept Bill Moyes' thesis that it is now more likely that swift action occurs in a failing FT, and agree that Monitor became more interventionist towards the end of his tenure.

However, I would also observe that Bill is not there any more.

Emmental 2 - Democratic legitimacy
The document also promises the democratic accountability (originally envisaged via PCT board elections in the Coalition Agreement) - now via local government.

Which is an interesting choice. Participation in local elections is not high - although if reconfiguration proposals in the form of service closures make headway, May 2011 could see a fertile crop of 'stop the closure' candidates.

So maybe the NHS reform could boost local democracy, and the document's desire "to strengthen democratic legitimacy at local level" could be met.

However. This reform is about commissioning for outcomes, and choice and competition.

It is wholly unclear from the document how GP commissioning consortia in general, and the NHS Commissioning Board in particular, will derive their democratic legitimacy.

We must of course admit that the NHS doesn't have much democratic accountability as it stands, except of a very 'quick and dirty' sort: if your PCT or provider lets you down, enlisting your local MP often gets quick and effective action. It's not pretty, and it jumps queues, but it works.

Democratic legitimacy will matter to consortia whose decisions will be changing and perhaps closing services. Public opinion may favour the views of clinicians over those of managers, but those who want every facility kept open as it is and where it is are going to have a field day with this.

(It also gets politicians out of the pain of closing things. Blame the GP commissioners!)

The NHS Commissioning Board "will have a key role in promoting and extending choice and control. It will be responsible for developing and agreeing with the secretary of State guarantees for patients about the choices they can make, in order to provide clarity for patients and providers alike, ensuring the advice of Monitor is sought on any implications for competition.", says the document.

Likewise "to avoid double jeopardy, it (the Board) will take over the current CQC responsibility of assessing NHS commissioners and will hold GP consortia to account for their performance and quality".

This makes Mr Lansley's querulous assertion on yesterday's Newsnight that the Board will not need to be seriously big seem unlikely - as does its impending duty to negotiate all contracts in primary care).

But what do we have on democratic legitimacy for the Board? It "will involve patients as a matter of course in its business, for example in developing commissioning guidelines".

I wish I could say that filled me with confidence. The new "health and wellbeing boards" outlined in 4.16 on page 34 don't sound wildly impressive.

Emmental 3: Choice of commissioner vs. geographical basis
"The Government will ... give every patient a clear right to choose to register with any GP practice (underlining to mark their emphasis) they want with an open list, without being restricted by where they live"

Ooo-kay. So. That gives us choice of commissioner, via choice of GP practice. It also gives practices who don't want to risk taking on new choice-hungry (and thus possibly assertive) patients an incentive to close their lists.

But wait: "GP consortia will need to have a sufficient geographical focus to be able to take responsibility for agreeing and monitoring contracts for locality-based services (such as urgent care services), to have responsibility for commissioning services for people who are not registered with a GP practice, and to commission services jointly with a local authority. The consortia will also need to be of sufficient size to manage financial risk and allow for accurate allocations".

Ummmm. Right. So, can people choose their commissioner via their choice of GP or not?

Biscuit Contraception 1: Value-based pricing risk-sharing arrangements for drugs, and nastiness to NICE
It is as if the BMJ's report into the beta interferon risk-sharing arrangements had not shown it to be a costly failure. A serious policy document should not have ignored this.

Evidence-based policymaking, anyone?



As we have said various times before, the logical direction of travel of the proposed National Cancer Drugs Fund is to undermine NICE. Which is A Bad Idea.

Biscuit Contraception 2: Cutting NHS management costs by over 45% by 2014
There are two chances this will succeed.

The first will be to use a definitional trick - reclassifying management time as core clinical activity.

The other - if the Government want to see delivery of their plans to:
"expand the validity, collection and use ... (of) PROMs, other outcome measures, patient experience surveys and national clinical audit"
"revise and extend quality accounts to reinforce local accountability for performance, encourage peer competition , and provide a clear spur for boards of provider organisations to focus on improving outcomes"
"ensure that information about services is published on a provider basis"
launch "an NHS Outcomes Framework (which) will be translated into a commissioning outcomes framework for GP consortia, to create powerful incentives for effective commissioning"

- while also getting soon-to-be-abolished PCTs and SHAs to save £4 billion a year is a very, very slim chance indeed. Because, unless there is a prolonged double-dip of recession, leading to significant deflation, every single one of the above-listed activities is a management function.

And they will not happen unless people are paid, incentivised and performance-managed to do them.

Biscuit Contraception 3: GP commissioning consortia will drive up quality of general practice, but not hold the contracts
The document suggests that "consortia ... will not be directly responsible for commissioning services that GPs themselves provide, but they will become increasingly influential in driving up the quality of general practice".

I would quite like to know how that will work. By osmosis?

One final thought: the two unspoken elephants
There are a pair of elephants in the 'Equity And Excellence' room. Let me introduce you to them.

The first elephant is called "Culture". He is a sad-eyed beast, who casts a long shadow. He knows that he has a huge influence on the second elephant, whose name is "Behaviour". This elephant is impossible to control, and she does what she wants despite orders to the contrary.

The White Paper is not going to mean very much to these two elephants, because it has made the basic mistake of failing to acknowledge their presence and importance.