Guest editorial Sunday 18 July 2010: Socialist reflections on the White Paper

Reflections on ‘Equity And Excellence’

Irwin Brown,  Socialist Health Association,  July 2010

The ‘Equity And Excellence’ White Paper is actually so vague in essential areas that it should really be a Green Paper.

In support are  promised a further set of documents and a lengthy letter from NHS CE Sir David Nicholson to NHS chief executives.  At least 10 consultations are promised, as well as consultation on the WP itself.

Further major documents are promised, too, such as impact assessments - and crucially in September, the specification around how GP consortium-based commissioning will work.

The results and analysis of the consultation will be published at the same time as the Bill promised for some time this year.  A further Bill is also promised on public health - but it appears to be about organisations rather than policies.

From what we know, we can probably agree with some aspects.  We regret some opportunities that have been missed, and we  disagree with some aspects on principle.

We have great reservations about some things which have yet to be spelt out.  We also fear that implementation could be chaotic, especially given the poor track record of the DH.

General
In many ways this is not so great a change, and it is strange that it is portrayed as radical.  If you think of GP Commissioning Consortia (GPCC) as a form of PCT, and Regional Offices of the Indpenednt Commissioning Board  as a form of SHA, then not much has changed - especially if the consortia are set up as statutory bodies.

The rhetoric around evidence-based decision making; outcomes, not outputs; better information which is more accessible; clinical leadership; more choice; greater patient involvement; integration with social care; more involvement of local authorities; and patient-centre care are not new.

All the major system components were being progressed anyway (just more slowly):
• Commissioner / provider split
• PCTs to lose their provider arms
• Move to all FT providers, more competition with non-NHS providers
• Two regulators and various failure regime(s)
• More services subject to tariff and greater flexibility around pricing and tariffs
• Payment follows patient adjusted for quality.

Motivation
This huge re-disorganisation just to have one more go at making the quasi-market system work is not sensible unless there is a greater objective.  That could well be the aim to create a system of independent autonomous commissioners and independent autonomous providers, none of which are actually NHS bodies and all of which can retain any surplus (profit?), determine their owns terms and conditions and without the nuisance of democrat interference.  

Inherent contradiction
Much is always made of professionalism and the dedication of clinicians, and of how we should devolve decision-making to them.  The market-based system, now being rapidly rolled out deeper into the NHS, is actually based on the premise that financial incentives and penalties are the strongest motivators of clinical behaviour, and not professionalism.

Thus the way to reduce A&E admissions, reduce unnecessary hospital referrals or to reduce unacceptable variations in outcome is not to be through peer review and support; but by financial mechanisms.  We don’t improve poor-quality services: we let the market shut them down. QIPP is also in danger of having people believe that quality and costing less is the same thing.  

Inherent contradiction (2)
Looking at what is being proposed by the DH in its structural reform plan, you can already see how reform and change will be driven through using the usual top-down, management by shouting, methods.  In order to devolve power, it first has to be ruthlessly centralised!

The power that will reside in the new commissioning board and its offshoots is substantial; it will be interesting who is put on the board.

Currently, notionally independent SHAs performance-manage NHS trusts and even “manage” FTs by managing their commissioners.  The commissioning board and its regional offices will be no different in function, but with no illusion of local independence, and will be the regulator as well for the GP consortia.

Cost savings and funding
Whilst real-terms increase in NHS funding has been promised, the reality is that major cuts in expenditure are required.

There are undoubtedly many areas of the NHS which could be made more efficient and where the same outcomes could be achieved at lower cost; but implementing changes in the NHS has proved very difficult - and the block put on reconfigurations shown by the new Health Secretary over NHS London’s reform plans make things even harder.

Much has been made of the increase in management and bureaucracy over recent years (ironically, without mentioning the obvious fact that most of this is due to the development of a market system).  We are spending 10 – 14% of NHS expenditure on the infrastructure of the market system; although the DH does not know exactly how much.  This is likely to increase under the WP proposals.  

SHAs and PCTs did not create the bureaucratic nightmare or botch every implementation - even of quite sensible policies.  A starting point for the reform programme should be major reform of the DH, starting at the top – not just redundancies for the workers at the bottom.

Sack everyone with a title or honour, after imposing major reductions on their severance terms. Tell them it’s “the new politics”.

Major simplification of parts of the market system could bring savings: for example, by axing the bits that clearly do not work.  Stable “block” funding for public health, community care, emergency care, and some aspects of primary care – rather like the stability in the basic GP contract!

A 3- or 5-year moratorium on new initiatives and restructuring would save a lot of money, effort and waste.  

Reasons to be cheerful? One-two-three!
We have a definitive acceptance (at least for now) that the Tories and Liberal Democrats in the Coaltiion government support our model of an NHS based on need and largely free at the point of use, though they omitted - paid for out of general taxation.

They have also kept New Labour’s NHS Constitution. The principles they enunciate, although vague, are sensible enough.  Some grudging acceptance of the role of local authorities and the idea of wellbeing rather than just healthcare should be acknowledged.

Missed opportunities
If we must have massive upheaval, tens of thousands of redundancies, services and facilities shut down, years of uncertainty and high-risk, then it ought to have been for something more worthwhile.

The policy under way means that effectively, major opportunities are to be missed. Among these are the following:
• It is time to simply accept that we need free social care for all on the NHS model.  We will never get integration until there is one care system not two armed camps with totally different cultures.  All the meaningless demarcations between social, community, primary and secondary care have to be removed - despite the vested interests.
• We must do something about professionalism, with tighter regulation and accreditation so the clinicians themselves lead the way in improving outcomes, promoting best practice and reducing unnecessary variation.
• We must do far more to create the mechanisms which put greater emphasis on prevention and healthy living, so we stand a chance of getting near to the Wanless Reports’ (2002-3) ‘fully engaged’ scenario.  The WP was too slanted towards fixing things; too little about prevention.  We need something truly radical in the Public Health Bill, perhaps a much larger and increasing slice of expenditure devoted to public health.
• We must have integrated commissioning of care - at least at a strategic level  The only way this can be achieved is to make Tier One Local Authorities the strategic commissioners.
• We must have democratic control over how our tax money is allocated, and what priorities are determined. Health is the only bit of the public sector without it.  Integration of commissioning in local authorities gives this democratic control.
• If we have to have all providers as foundation trusts (FTs), then they should be genuine community ownership organisations - not the sham we have now.  Greater freedoms around,(for example, private patient income) make then more providers to the NHS, and less part of the NHS.

GPs - real budgets, real risks and consortiaGPs know a lot about the healthcare and other needs of their patient population, and in their role as gatekeeper for expensive acute services, they heavily influence resource allocation.  

Their active involvement could greatly improve commissioning.

The WP appears to accept that GPs only respond positively to financial levers - so they are forced into consortia, which take some of the risk around commissioning and which gain rewards for success.

The debate was well established within the GP community around real budgets for PBC groups and some early pilots have been tried.  The issue is simple: what financial risk is taken by the GPs.

Some GPs are entrepreneurial and want a chance for profits in exchange for taking some risk. Others do not want to put practice profits at risk by being involved in commissioning.

One PBC group had a “real” commissioning budget of £230m: what if, in mid-March, they find they needed £235m and the money has run out?

Under PBC, the PCT could step in - but the WP says no bail-outs.  In the good old days, running out of funds meant lengthening waiting lists or otherwise reducing access – but this is no longer easy or acceptable

Individual GPs will thus, it seems, be at personal risk of hundreds of thousands of pounds;  just due to normal variations in budgets.

The financial risk issue leads to insurance, risk pooling, partnerships with the private sector (who take some or all the risk) and to additional costs in the system.

The political risk
Worse, though, might be the political risk.  Commissioners have to lead consultations and service reconfigurations.  PCTs used to take the political risk around cutting services, poor-performing services or limiting access to certain drugs or treatments.

How will GPs enjoy being centre-stage in this political spotlight?

Aspiring GP commissioners might take a look at the 11 competencies required to see just why even the chief executive of the NHS has little belief in their capacity or capability - even if they have the desire to take the risks.

Recipe for chaos? The Myth Of Less Bureaucracy
When the promised Impact Assessments are produced, the provenance of expected savings will be far clearer.

Claims so far appear to overstate savings, as they ignore the fact that PCTs have major provider functions which also have to be managed and administered, and that SHAs are far more than line managers between the DH and trusts.  

Genuine large savings come from axing whole organisations, or whole services or whole functions:  in reality, the WP does little of this.

The label of PCT may go, but there will be as many new organisations set up as FT providers with all the overheads that implies.  The commissioning functions will still be done and the transaction volumes will go up with 500 commissioners where there used to be 152; with more services subject to payments by results; and with more complicated split tariffs.

Tariff may well become a basis for negotiation rather than being fixed.  This is going to increase bureaucracy and management costs; not reduce it.

Even SHAs do some useful things, such as (providing a strategy!) the scrutiny of capital or
high-risk projects, which will have to be done somewhere.

The best SHAs acted as co-ordinators and centres of excellence far more than as a layer of top-down management.  They were also a parking place for some necessary ongoing functions - especially around workforce issues.

It has to be assumed that transaction level staff in commissioners will have to be TUPEd to the new consortia.  However, many very senior staff will be made redundant at huge cost - only to reappear elsewhere as consultants, interim managers or employees within all the new private sector support organisations which are already lining up the emerging market.

In summary
In summary, what do we face?
Huge transition cost for little reduction in ongoing expenditure, but many changes of label.

It’s “the new politics”.