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Guest editorial Wednesday 28 July 2010: Things can only get better

Irwin Brown of the Socialist Health Association reflects on an alternative to Equity and Excellence.

On the face of it, the aim of the current government is the same as that of the previous one - to keep our model of NHS.  We all apparently agree the basic design, but “reform” is necessary to deliver world-class outcomes and better patient experience whilst reducing the level of funding.  

Like the caricature plumber, the coalition government has decided the work on reform so far has been all wrong and is launching a huge programme based on reorganisation and marketisation, both of which we would argue have consistently failed to do anything other than add cost on the various previous occasions they have been tried.  

What about radical stability?
There has been a decade of constant change in the NHS with policies and organisations coming and going.  Often policies conflicted with each other, had unintended consequences and were never fully implemented.  Staff are tired and cynical.

So instead of redisorganisation and a dash for the market actually designed to increase instability, why not try a different approach?

The shock of the old
How about less change and a period of five years of working with what is already in place so far as possible and stopping anything unnecessary?  This would have the immediate advantage of ensuring a lot less work for the management consultants, corporate lawyers and senior managers with incomprehensible job roles.

Many of the themes set out in E&E as if they were new are a bit vague, and could easily be seen as things towards which the NHS is already committed to working.

In theory, we have a cunning plan, labelled QIPP (surely an overspending three-letter acronym?), which over 3 years will deliver the cost savings of £20bn, made necessary by the guarantee of real terms increases in funding.

QIPP brings quality improvements, reduces unnecessary outcome variations and shifts some care from acute to primary care settings.  It may not be credible but it is as credible as any other plans for change are likely to be.  A lot of good people, including many clinicians, have put a lot of work into it.  

We now have the Draft Structural Reform Plan, which adds a further huge complex programme over the top of QIPP making it QIPPR.  Even neutral observers, who know the track record of delivery of DH initiatives, will be sceptical that all this can be done.

The real danger will be the financial situation will deteriorate – or, perish the thought, some patients may be affected.

So instead, ban all new initiatives and allow the NHS to deliver the QUIPP agenda without massive distraction and the total alienation of most NHS staff.  Important developments highlighted in E&E around the outcomes framework, greater patient involvement, improved information flows, extending choice and reducing the democratic deficit can easily be accommodated.

If QIPP works, then at least a major step has been taken in the right direction.

Sadly, a few unresolved issues would remain.  We have a semi-market system which does not work and which adds costs, but which is embedded.  We have PCTs which have already started to break up - and which anyway nobody likes. We have the need for greater patient involvement and greater democratic accountability.  We have to find a way to integrate care across all domains of health and into social care.

Two changes would help.

First, a return to block funding to give stability and end the expensive and failed experiment with markets, even if work continues to develop an effective and credible system for payment by volume adjusted for quality.  This would release perhaps 5% of current expenditure to be used to improve quality rather than on bureaucracy.  In five years, the NHS might be ready to have another go at markets.

Second, move the commissioning function currently within the doomed 150 PCTs into the 80 Tier One local authorities.  The function would be hosted at first and collocated with social services commissioning; but with a medium-term plan, led by the local authorities, to move to fully integrated care commissioning once the issue of “social” care funding is resolved.

Develop and extend the role of Practice Based Commissioning to involve GPs and push on with fully delegated but real budgets; but do this through development and agreement rather than imposing major change on many reluctant GPs and inventing a whole raft of new systems.  

The provider part of PCTs would move into other trusts, local authorities or remain as standalone trusts with a planned path to FT status – but no new organisations. Keep as many staff as possible in the NHS family, which is what they want.

Missing links
There would still be an urgent need to define a better organisational failure regime than the current (as yet, unused) version; a need to reform the governance of FTs, to make them credible as community ownership models; and a need to use the professional bodies and clinical regulation to help drive quality improvement through reducing variation.

Oh, and we still need the information revolution.

This is still a huge programme for change but it fits far better with the ethos and values of the NHS. It frees up resources locked into bureaucracy and management caused entirely by the flawed “market” system. It reduces the number of organisations, instead of inventing a whole lot of new ones. It allows time for reform to work.

It should allow the huge reservoir of talent, experience and knowledge already within our NHS to actually be more sensibly directed at improving patient care.