Professor Alan Maynard OBE considers how a potential Conservative administration might go about dealing with the NHS. Integration, evidence, less PCTs and reforms to QOF (including a pay-related one for secondary care teams) all crop up – as do the possibility of public sector pay cuts.
The outcome of the 2010 general election remains very uncertain after the Labour meltdown and the Tories failing to take a significant lead in the recent June elections.
Nevertheless, the pundits all expect a Tory victory next year. If and when this transpires, what should they do with the NHS?
The strengths and limits of targets
Firstly, they should note that not all of Labour’s “continuous revolution” unleashed on the NHS since 1997 has been useless. Part of the Labour legacy is that “targets” have become a pejorative word. However, targets have improved patient in terms of elective waiting times, access and care for cancer, cardiology and other services and A&E waiting times.
Yet some of the targets have been less than successful, particularly in primary care. Whilst we are all supposed to be able to see a GP in 48 hours, this tends to be unevenly provided; with some practitioners and PCTs saying this is for emergency care. Such classification makes us all “urgent” - or if frustrated by the GP receptionist, we trot off to the local A&E where we get care in (at most) 4 hours.
This is a nice case of diverting demand from poor primary care, where investment should have focused on nurse substitution rather than the expensive and poorly-targeted quality and outcomes framework (QOF) which accompanied 2004’s new GP contract.
Reworking the QOF
The QOF has to be wrenched out of the hands of medical trades union the BMA and NHS Employers, to ensure that practices` are accessible and deliver those services which are needed by patients and which are demonstrably cost-effective ways of delivering improved population health.
NICE’s proposed involvement in overseeing the process of reviewing and developing QOF indicators (producing annual 'menus' of evidence-based, cost-effective indicators; setting time limits for new indicators after which they should be reviewed; and creating thresholds for indicators based on information about uptake) is only a small first step in this direction, since QOF indicators do not take into account the cost-effectiveness of a service or approach.
If an activity has become part of standard clinical practice, then NICE should decide that there should be no further need to provide an incentive.
A secondary care QOF
As they do this, the Tories need to develop a secondary care QOF. This needs to target financial incentives at consultants and their teams.
The current incentive reforms – such as commissioning for quality and innovation (CQUIN) and patient-reported outcome measurement (PROMs) are targeted at hospitals overall, rather than at changing the behaviour of the major decision-makers in hospitals: consultants.
There is little evidence that CQUIN and PROMs reduce costs and mortality. So complementing them with a consultant-and-team-QOF would be wise for any government seeking to induce the delivery of improved efficiency.
’These rewards should be both positive and negative i.e. good performance should generate rewards and poor performance should lead to penalties of pay cuts’
The consultant-and-team-QOF should not repeat the GP-QOF failures of being both expensive and poorly targeted. The Tories should start with using the existing Clinical Excellence Award system to reward “quality and innovation”. These rewards should be both positive and negative: good performance should generate rewards; and poor performance should lead to penalties of pay cuts. The latter should be small but indicative, so as to exploit reputation and induce accountability and change.
Redisorganising the NHS
The Tories say there will be no ‘redisorganisations’ of the structure of the service. They then propose the demise of strategic health authorities. So what should be done to the organisational structure of the NHS?
Any administration looking for expenditure cuts or reallocations must focus on PCTs, and specifically on their failure to deliver what was hoped of them in terms of purchasing economies.
Weak purchasers and strong providers - plus ca change
All purchasers - public and private - have little impact on providers. For instance in private insurance markets, the insures accept premia increases of two to three times the rate of general inflation and pass the costs on to consumers, who are remarkable passive and ineffective in the use of corporate and individual funds! PCTs are like private insurers: accepting of provider dominance and inefficiency.
The NHS purchaser-provider split was a Conservative invention in 1989. The principle of the purchaser-provider split was sensible. The practice has been weak, with pathetically inadequate “redisorganisations” by Milburn and other which have had little demonstrably beneficial effect for patients or taxpayers. Abolishing or downsizing the number of PCTs would save hundreds of millions of pounds, and therefore must be attractive to any incoming administration.
’The principle of the purchaser-provider split was sensible. The practice has been weak’
The Tories might disguise this switch with renewed focus on GP fundholding. Labour has fiddled whilst Rome burned with practice-based commissioning - a form of castrated GP fundholding! The Tories intend to be more radical.
Time to try vertical integration?
However, before they rush off down this route, the Conservatives should pause and address the nonsense of the 1911 National Insurance Act, which divided primary and secondary care by focusing reform on funding GPs to care for the working population.
There is an urgent need to experiment with the vertical integration of primary and secondary care.
Should GPs take over the local hospitals? Or should the hospitals take over local GP practices? The challenges are 1) how to incentivise integration and 2) how to ensure that the results of such changes are evaluated to inform policy development.
Can the Conservatives demonstrate caution and wisdom in progressing these changes? Or will they go the way of all their predecessors: rushing in where angels fear to tread, and later regretting their haste?
Capital crimes and maintenace headaches
Two other acute problems faced by any incoming administration are capital investment and maintenance expenditure. When confronted by revenue constraints, NHS maintenance is even more neglected by managers seeking financial break-even to stay in their jobs. Just how is the maintenance backlog being managed in primary and secondary care?
The economic rationale behind the private finance initiative (PFI) was always questionable because the State can usually borrow more cheaply than the private sector.
’Where is the evidence that the financial expense of guaranteeing profits to PFI consortia is more than compensated for by information that the private sector delivers capital projects more efficiently? Answer: there is none’
Where is the evidence that the financial expense of guaranteeing profits to PFI consortia is more than compensated for by information that the private sector delivers capital projects more efficiently? Answer: there is none, but both major political parties adhere to the belief that if they assert it is so, it will be so!
Such faith-based policy making is no substitute for evidence - but that is hidden by “commercial in confidence” considerations reminiscent of hiding details of MPs expenses for years! Surely public and private users of the taxpayers’ funds should be equally accountable for their use?
All these changes can be “oiled” by public sector pay cuts that are a means of increasing “real” funding to the NHS, as the Tories have undertaken to do. Such cuts will give short-term support for reform efforts; but if this opportunity is missed by half-baked, evidence-free radicalism, God help patients!