Tom Smith introduces a new daily analysis of health policy debate that will appear exclusively on Health Policy Insight at teatime each day.
While press summaries give readers a clue about the surface of debate our new summary aims to scratch beneath the surface and make sense of what is being discussed. It aims to set the reports in context and compare commentary across the British print and broadcast media. Each day the press is full of discussion about health policy, partly reflecting the current highly charged political atmosphere, but also a fair amount of uncertainty about the aims of policy, how different elements link together or don’t, and more crucially how policy should be taken forward and by whom.
Conservatives accuse Labour of shaky economic thinking on polyclinics
The Conservatives claimed today that government plans for polyclinics will leave a £1.4bn “black hole” in public finances. The calculations are based on Conservatives calculations are based on 271 clinics (1 in each PCT plus 150 in London) that will each be staffed by 25 GPs.
The shadow health secretary, Andrew Lansley’s line - “Alan Johnson hasn’t done his sums properly” - is a response to the health secretary’s claim earlier this week that no surgery will close because of polyclinics. Lansley’s point is that if these new centres are additional then we are heading for much greater costs – the plan is predicated on the coming together of practices.
As with other issues in health policy, the debate is a lot to do with semantics. Would three practices coming together be described positively, as a voluntarily merger, or more negatively, as as the closure of two practices?
Government ministers are getting angry with the ‘misrepresentation’ of their position. Ben Bradshaw said this morning, “there has been a lot of irresponsible scare-mongering over recent months that the Government is planning to close local GP surgeries”.
Health minister Ben Bradshaw reiterates there is no central plan
He was speaking in Kirkyby in Ashfield at the opening of a new health centre. His words imply that the new centres will be additional, with no closure of GP practices. He said the new “GP led health centres – one in every primary care trust area – are in addition to existing services and people will be able to use them while remaining registered with their own GP”.
This suggests that current practice levels could be maintained and that the new centres are likely to be akin to the King’s Fund preferred ‘hub and spoke’ model, where the new larger centre serves as a central resource for GP practices.
The formulation of policy is fluid and changing all the time. Perhaps in Lord Darzi’s review we will see a shift away from the arguments related to the co-located model, suggestive to many of forcing GPs out of practices and, if they don’t, threatening them with the prospect of a commercially run centre.
The political implications of polyclinics
Polyclinics are certainly political and polarizing, as the Health Service Journal pointed out last week. A piece in the Evening Standard, last evening, warns that the introduction of polyclinics could see Labour fall even further behind in the capital. They quote Geoff Martin of London Health Emergency, a veteran campaigner against private involvement in the NHS. He said, “I want to know how polyclinics will be funded and whether the rumours are true that they will be run by private companies like United Health. I want to know what the risks are for local people. “Core Labour supporters will be really angry if big American healthcare organizations make a fast buck out of our GP services. “If Darzi tells me that he is up for more cuts and more privatization, I will warn him that Labour will cruise into oblivion in London”.
Khailish Chand replies to criticisms of GPs
Last week Polly Toynbee expressed little sympathy for GPs. To paraphrase, she said, ‘yes, polyclinics will destabilise GPs, but that’s the point. Any GP who can’t be bothered to join something that would offer better services are precisely the people that should be destabilised’.
Lancashire GP, Khailish Chand asked for a right to reply and it was published today: ‘how dare you imply that we GPs don’t care for our patients’. He said that Polly Toynbee misunderstood the criticisms of GPs and was naïve about the promise of polyclinics. ‘While it is true that some people who have a minor self-limiting illness might find a polyclinic useful for a quick in-and-out solution,, she ignores the patients who use general practice most, those with a long-term illness, the elderly, parents with young children, and the housebound’. Chand continues, Toynbee should take note of the many thousands of patients who are signing the BMA’s petition to support NHS general practice surgeries. They don’t want public funding to move from GP practices to commercial companies that are accountable primarily to their shareholders’.
Nick Clegg says local authorities should fund private consultations if local people cannot access a GP appointment within 48 hours
Lib Dem leader Nick Clegg waded into the polyclinic argument yesterday. He declared “the great experiment in big government solutions”, failed. “But recent instructions from the government that PCTs must implant a GP-led health centre or polyclinic in every community suggests that government policy is still heading in the same failed direction”.
Although a number of papers yesterday trailed what he would say, they missed some radical elements that were picked up by those who heard the speech. As the Guardian noted, Clegg is able to go farther than Cameron as the Conservative leader treads cautiously not daring to appear against the NHS in anyway.
In the speech, Clegg is suggested where patients cannot get a GP appointment in 48 hours that their local authority should finance a private consultation.
Clegg said the system works well in Denmark. He did not say how much the state spend on private consultations or whether the psychological incentive insured that all patients are seen within a couple of days.
Allyson Pollock reminds GPs that she said this would happen
Clegg’s suggestion would not please Professor Allyson Pollock whose most recent book, ‘NHS Plc’ alleged that the NHS was deliberately being privatized and that we are at risk of losing a resource we will never recover.
Pollock is not fully supportive of the GP position. ‘After 11 years of stealthy privatization in the health service, it is little surprise that doctors are up in arms over polyclinics – themselves a cover for commercialization’. She says the NHS ‘is now the world’s laboratory for privatisation’
‘This commercialization of services leads to the blurring of boundaries about the funding and responsibilities of care; once NHS services have moved into the commercial sector there will be no limits on what the private sector can charge for: boutique care for those who can pay, and small-print restrictions for those who cannot. The debate has already begun with proposals to introduce co-payments or top-up charges for those who can afford to pay for care not provided by the NHS.
She sounds glad to be back in Scotland. English ‘voters face a dilemma: the temptation is to punish Labour at the ballot box, yet the Conservatives health proposals advocate the abolition of the secretary of state’s unqualified duty to provide a universal health service’. While Scotland and Wales are trying to forge a new path, taking steps to dismantle their markets, the English electorate is between a rock and a hard place’.
Welsh to use panels to set priorities
Talking of Wales, there are reports that the Welsh Assembly is moving yet further away from the English on matters of prioritization. While administrations all over the world are battling with how to allocate precious resources, they are going about it (or ignoring it) in different ways.
According to the HSJ today, ‘The Welsh Assembly Government has announced plans to establish a panel made u of members of the public to decide which specialist treatments should be provided by the NHS
Further amendments to the Health & Social Care Bill – sharpening the patient and user focus
Regulation is a UK-wide issue and the rapidly emerging differences between the four nations has been a cause of tension in developing proposals to change medical regulation. There has been less of an issue with organizational regulation as different countries have their own powers in that area.
The new regime for the English NHS is passing through the UK parliament at present. It has been a very political process.
Various aspects of organizational regulation have become very political during the drafting and early passage of the bill. First there was an argument about how the new system of registration would be introduced and how much of the NHS it would cover. An early iteration of the government’s position first saw a role for the regulator in ruling on completion disputes, but as a result of lobbying, in the end this was given to SHAs to rule upon. Subsequently, however, a national body specifically for this purpose has been proposed, the Competition and Collaboration Panel. There was then a row about whether the regulators should be merged and the benefit and (lack of) cost-savings this would accrue.
The politics continues. Ever since the Bill was published, at the end of last year, the Picker Institute have been arguing for a more explicit duty to patients from the regulator. They have recently campaigned with Which? And the National Consumer Council and an article in Guardian Society today by Picker’s head of policy and communication, Don Redding, celebrates government agreement to introduce amendments to make the new Care Quality Commission more focused on the consumer interest.
‘One key amendment gives the CQC a “main objective…to protect and promote the health, safety and welfare of people who use health and social care services”. ‘Another key change is that the CQC will be required to publish, after consultation, a statement covering how it will involve service users and carers. This must cover dialogue about the way services should be provided and the way the Commission should operate; how it will pay due regard to service user and carer views; and how service users and careers will carry out regulatory work.
Don Redding raises ‘two cheers’ for the changes. It would be three, but ‘one change the government has yet to concede is a high-level statutory service user panel to advise the CQC’s board’.
Even if this isn’t conceded the Picker Institute will continue to battle for it: ‘if this is not forthcoming, again we can employ the “user involvement” statement as a channel to argue the need on a non-statutory basis’.
Support for the Carers strategy, but questions about the different it can make
Post-Blair, the government is also talking up the empowerment of patients and carers in a slightly different way. Recent reports, for example, suggest that the NHS Constitution will set out what people can expect from the NHS, in terms of waits and advice and so on.
The Brown government is beginning to take a greater interest in ways to reduce strains on welfare, trying to recreate a joined-up public policy approach. The carers strategy on Monday is the latest example, signed by seven different secretaries of state, including health, work and pensions, and education and skills. The report proposes that GPs do more to care for carers – apparently two-thirds are unable to find an opportunity to visit a GP about their own health concerns due to time constrainsts and a general lack of flexibility to leave the house’ (Guardian). It also suggests an expert carers scheme and it makes loose and vague proposals to develop care budgets.
In Prime Minister’s Questions today, Gordon Brown said it was time for government to think about carers and, responding to a question on the subject, said that money was being available to fund respite care and training for carers who want to get back into the labour market. He said government was looking at issues and would report back to parliament. Earlier in the week, in launching the strategy, he made it clear that this policy had to be linked to the debate on the future funding of social care.
The broad aims of the plan have been welcomed by Carers UK and other groups, but there is a sense it is slightly muted, perhaps because the proposals are at the edges and because it is not clear which agency – across the seven departments sponsoring the strategy – will take this forward or, if different parts are responsible for different things, how different agencies will work together.
Another problem is that carers often have low incomes. The Princess Royal Trust for Carers and Crossroads Caring for Carers were disappointed that the Government do not intend to increase attendance allowance – a benefit paid to carers. “We remain concerned that funding is a critical issue at a local level with many areas experiencing cuts in provision. “Carers will be bitterly disappointed that government is not taking immediate action to rectify the local level of carer’s allowance or the difficulties in claiming it”.
Today was not exceptional in its coverage of health stories. Each day the debate rages as different bodies try to influence the outcome of health policy.