special report – reforming the nhs in england

Reforming the NHS in England

S P E C I A L R E P O R T

Published by Global Business Media

Infi nite Demands – Finite Resources

GP Consortia and Management

Reorganisation or Re-disorganisation?

Bones of Contention

The “Future Forum”

Likely Amendments to Proposals

Quality of Care and Vocation

Will Reforms be Successful?

Ensuring Free and Fair Healthcare for All

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SPECIAL REPORT: REFORMING THE NHS IN ENGLAND


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Contents

REFORMING THE NHS IN ENGLAND 3By Leslie Paine

Infi nite Demands – Finite Resources 3

GP Consortia and Management 3

Reorganisation or Re-disorganisation? 3

Bones of Contention 4

The “Future Forum” 4

Likely Amendments to Proposals 4

Quality of Care and Vocation 5

Will Reforms be Successful? 5

Ensuring Free and Fair Healthcare for All 5

References 6

WWW.PRIMARYCAREREPORTS.CO.UK | 1

Reforming the NHS in England

S P E C I A L R E P O R T


Infi nite Demands – Finite Resources

GP Consortia and Management

Reorganisation or Re-disorganisation?

Bones of Contention

The “Future Forum”

Likely Amendments to Proposals

Quality of Care and Vocation

Will Reforms be Successful?

Ensuring Free and Fair Healthcare for All









IHM poster.indd 1 16/5/11 10:16:19


2 | WWW.PRIMARYCAREREPORTS.CO.UK











IHM poster.indd 1 16/5/11 10:16:19

Demonstrate and develop

your management skills by

joining the IHM’s

Accredited Manager

Programme

The programme is fast becoming a nationally recognised symbol of

excellence in healthcare management across

the country

Join the programme and

Enhance your CV and/or strengthen your management team

Demonstrate your commitment to the persuit of excellence

Individuals join the programme every February, June or October.

Organisational cohorts can be bespoke to meet local need.

For further information, please email [email protected]

The programme will be academically accredited

Reforming the NHS in EnglandBy Leslie Paine

Infi nite Demands – Finite ResourcesAccording to the Coalition Government, unless we do something about rising healthcare costs in England, the founding principle of the NHS – care that is free to all who need it when they need it – will become unaffordable(1).

Sounds awful. Until you remember that the NHS has always been unaffordable. In the sense that fi nite resources (which it has) can never meet the infi nite demands of disease and accident, no matter how hard you try, without the interjection of some form of priority-setting or rationing system. Something that the NHS has been doing since its inception and doing pretty well, particularly over the last ten years according Anna Dixon, Director of Policy at the King’s Fund in London. As she puts it in the Spring 2011 edition of the NAPC Review: “The NHS has made signifi cant progress over the past decade (Thorlby and Maybin 2010) with some of the highest levels of public satisfaction ever recorded (Appleby and Robertson 2011)”(2).

Its budget of course has been considerably increased down the years – 2.5% of Gross Domestic Product in 1949, 8.5% today. But, in the Government’s view, that won’t work any longer. “Just putting in a little money and carrying on business as usual, is not good enough” the Prime Minister says. “Fail to modernise and the NHS is heading for crisis.”(1)

GP Consortia and ManagementAnd by modernisation of course he means at the moment the abolition over the next two-three years of all the existing Primary Care Trusts and Strategic Health Authorities, and the transference of their commissioning responsibilities (widened to include the possible employment of private providers) to a countrywide network of GP Consortia.

By this means and a demand for so-called ‘effi ciency savings’ in administrative costs of £15-20 billion by 2015, the Government aims to achieve a cut in the number of NHS managers,

which Ruth Spellman, the Chief Executive of the Chartered Management Institute, estimates at 45%. Although, as she reminds us, the new arrangements will also need good management and leadership, the key to which will be the retention of those staff with good skills and the support of those with new managerial responsibilities (3).

But while we will all say amen to that, everyone knows that patients come to doctors and hospitals to be treated not administered. To patients, therefore, the managers are ‘enablers’. They are not the men and women behind the NHS guns, they are the men and women behind them.’ And their basic jobs are to create and maintain the environment and facilities which allow the front line troops – doctors, nurses, therapists – to deploy their skills to the very best of their abilities.

Reorganisation or Re-disorganisation?That said, what line should we take regarding the proposed reforms? How can we know whether the English NHS, altered as the Government

Leslie Paine OBE, has worked in the NHS for 35 years and was a hospital Chief Executive for 25 years, at Addenbrookes in Cambridge and the Maudsley and Bethlem Royal in London.

The new arrangements

will also need good

management and

leadership, the key

to which will be the

retention of those staff

with good skills and

the support of those

with new managerial

responsibilities.



wishes, will give better value for money than the one it replaces? This is a subject on which everyone has an opinion but to which no-one has a complete answer. Proponents of the proposals presage their outcome as a world class health system. Opponents say they’ve heard it all before and suggest that it is more likely to result in re-disorganisation than reorganisation: a set of good intentions that will pave, as good intentions are said to do, yet another road that will lead somewhere far removed from heaven.

The many doubters perched on the middle ground of the argument warn of ‘more haste, less speed,’ recommend evolution not revolution, and speak of pilot studies. And since the roll of doubters is long and impressive, it is worth looking at it and its concerns a little more closely. The names on the list include the British Medical Association, the Royal College of Nursing, the Royal College of Surgeons, the Chartered Society of Physiotherapy, the Society of Radiographers, the Liberal Democrat Party, the King’s Fund, the health unions, health charities such as Diabetes UK and the British Heart Foundation, and individuals like Baroness Williams of Crosby, Lord Winstone, and – more importantly – a fair number of GPs and their patients, especially the older ones.

Bones of ContentionThe bones of contention that concern this array of critics range from GPs who don’t want to be commissioners and would like to be able to decide on their patients’ needs without having to be concerned about the cost; and hospitals that don’t want to lose services to the community and have their budgets cut; to anti-centralists who fear that the powers of the proposed NHS Commissioning Board and the NHS economic regulator Monitor will be much too wide-ranging in a reform which is supposed to devolve power to local clinicians. Above all else though, the objection that is most common to the ranks of the doubters is that the reforms open the way to the privatisation of the NHS by stealth. A fear far from allayed by the recent remarks of the new chairman of Monitor, David Bennett, who favours more competition in the negotiations regarding medical services with the NHS contracting system operating on much the same lines as procurement in the defence industry.(4)

The “Future Forum”So what is likely to happen in practice? I believe that there will be some amendments to the Bill, with the scheme as originally presented being altered as a result. Indeed, the Bill’s progress

through Parliament is already paused to allow for fur ther discussions with patients’ representatives and NHS staff (especially nurses) via a Future Forum chaired by former Chairman of the Royal College of General Practitioners, Dr Steve Field.

The Government sees the new Forum as a channel for the thoughts and opinions of patients and staff and Dr Field has already said that, since listening to the NHS people on the ground is vital, he sees the new group as a real chance for these people to have their say in helping to shape the future of the service. The Future Forum will focus on: - the role of choice and competition for

improving quality- how to ensure public accountability and

patient involvement in the new system- how new arrangements for education and

training can support the modernisation process

- how advice from across a range of health care professions can improve patient care.

Speaking at the Forum’s launch, the Prime Minister assured the public that any good suggestions to change the current legislation which arise from the discussions will be accepted, but reiterated his view that modernisation of the NHS is essential if we want a truly world class service.

The Health Secretary insisted that good progress towards modernisation had already been made such as the 6,500 GP practices and 90% of Local Authorities signing up to play their part in improving services for patients.

Likely Amendments to ProposalsAs for the results likely to be recommended by the Forum when it reports in the early summer, Dr Field has already commented on some obvious needs that it must address – such as stopping the ‘cherry-picking’ of NHS services by private companies, the protection of workforce training, and the addition of hospital doctors, nurses and other health professionals to the new GP Consortia.

Obviously, despite such changes, the Government will proceed with its basic plan, because, in a time of financial freeze and widespread cuts, they need the savings that reduced hospital care and the abolition of the PCTs and SHAs will bring to have more money to spend on maintaining and improving frontline services.

And there are reasons, I believe, for hope that they may be right.

Giving GPs the purse-strings to buy secondary care certainly adds to their responsibilities, but it also has a ring of common-sense about it, as

Above all else though,

the objection that is most

common to the ranks of

the doubters is that the

reforms open the way to

the privatisation of the

NHS by stealth.











IHM poster.indd 1 16/5/11 10:16:19

Demonstrate and develop

your management skills by

joining the IHM’s

Accredited Manager

Programme

The programme is fast becoming a nationally recognised symbol of

excellence in healthcare management across

the country

Join the programme and

Enhance your CV and/or strengthen your management team

Demonstrate your commitment to the persuit of excellence

Individuals join the programme every February, June or October.

Organisational cohorts can be bespoke to meet local need.

For further information, please email [email protected]

The programme will be academically accredited

do any arrangements whereby the Consortia and Local Authorities are linked closer together in partnership, not only for social care but because otherwise Public Health will be solely in the hands of Councils and the Department of Health.

Quality of Care and VocationThe reform is also very much in line with the World Health Organisation’s 30-year old Global Strategy for Health for All (5), whereby all countries, whether developed or underdeveloped, are called upon to remember that health resources are limited and that the total health needs of a population cannot be met by modern technological hospitals practicing scientific medicine alone. Primary Care must form the hub of any true national health system, using all the resources at its disposal – public and voluntary – to concentrate not just on curing ill health but equally on its prevention and the encouragement of self-help and healthy living.

The Strategy also stressed that while any care is better than none, the quality of care which a service provides is as, and perhaps more important than, the quantity, with quality relying heavily on one factor as far as all types of healthcare staff are concerned – Vocation. Those involved in the present reforms would do well to remember this.

Will Reforms be Successful?So, is the restructuring going to be successful? We can but wait and see. Meanwhile, an encouraging pointer for the Government comes from Cumbria (6) where GPs have had control of their own budgets since the latter days of the last Labour Government. There, PCTs are virtually abolished, the area’s nine community hospitals have been saved, the average stay in the two local main hospitals has been reduced from 36 to 10 days, and standards of patient care have risen. But in Cumbria the local doctors joined the scheme by choice. They were not forced. Something for the Health Secretary to note perhaps. Evolution, not revolution.

Ensuring Free and Fair Healthcare for AllMeanwhile, there remains the question of Privatisation. Do the Government’s proposals take us a step towards privatising the NHS or not? Personally, I don’t think so. The new Consortia will be able to commission outside providers (charities as well as profi t-making) for some clinical services if they believe that that is clearly the most effi cient use of funds and the most suitable for their patients. Just, I imagine, as PCTs can do today if they wish. This I would see as reasonable competition in a publicly

funded service as long as it does not breach the basic NHS principle of equal treatment for all free at the point of provision. And, private providers are prevented from creaming off the more profi table services and leaving the NHS to deal with the more diffi cult, more complex and more expensive services and the problems of staff training

And the Consortia will know as well as we do that the best insurance scheme for a truly national health system designed to meet the total healthcare needs of the people, is one based on taxation. In addition, both they, and a large number of their patients are well aware that moving away from paying for care through their taxes will very likely, in the end, mean paying even more in health insurance, and will carry with it the danger of ending up with an American-style system whereby those who can afford it have top class private health insurance and those who can’t – who are likely to be the poor, the long-term sick and elderly – are forced to rely on a minimal, third-rate public service to cover their essential needs.

And, bearing in mind the current outcry against poor standards of some care for the elderly and complaints against nurses to the Nursing and Midwifery Council reaching record levels (more than 3,000) last year, I can’t see any British Government doing that, or the British people allowing them to do so, even if they wanted to.

Private providers are

prevented from creaming

off the more profi table

services and leaving the

NHS to deal with

the more diffi cult,

more complex and more

expensive services

and the problems

of staff training.



References:1 ‘The NHS will sicken unless we modernise”. Article by David Cameron in The Times, Saturday, January 31st 2011.

2 “What do the Government’s Reforms mean for the NHS?” Article by Anna Dixon, Director of Policy,

The King’s Fund, London, in the NAPC Review Spring 2011.

3 “Good management must be at the heart of NHS reforms” Article by Ruth Spellman, OBE, Chief Executive,

Chartered Management Institute, in eGOV Monitor Blackberry, 02/02/2011

4 “A spoonful of competition is ordered to revitalise NHS” Chris Smyth, The Sunday Times, 25th February 2011.

5 “Hospitals and the healthcare revolution” by LHW Paine and F Siem Tjam, published by World Health Organisation,

Geneva, Switzerland, 1988.

6 “Take it from Dr Shake-Up, this works,” Margarette Driscoll, The Sunday Times, January 23rd 2011.

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