Wednesday, 19 January 2011

NHS reform - there is another way

Slowly the public is beginning to understand the massive implications of the NHS white paper the Government released in July last year. With the Health and Social bill published today even the right-wing press, more in tune with the Government's thinking, are nervous about endorsing the plans whole-heartedly. This is a clear indication of how risky the plans are - no one is quite sure the outcome of this massive shake-up, although everyone is agreed that it will be the biggest change faced by the NHS since its creation in 1948.

During their election campaign the Tories promised no more top-down NHS reorganising, and in a bid to justify this policy u-turn David Cameron claimed this week that "we can't afford not to modernise". However, I believe that considerable reforms can still be made without jeopardising the entire structure of the NHS, especially when it is undergoing a period of austerity on a previously unheard scale.

Last year I spoke to Cumbrian GPs for a piece for the Guardian. Cumbria has been slowly devolving commissioning power from Primary Care Trusts to GPs, with GPs responsible for the vast majority of the money since April 2010. And I found that in Cumbria it is working well. GPs have focused on providing local care for their patients. They now treat more patients in their home by developing a network of mobile nurses; they have allowed routine blood tests and minor operations to be done in GP surgeries; they have worked on improving how patients manage long-term illnesses to help cut hospital emergency admissions.

I didn't expect to be so impressed by 'clinician-led' commissioning but I was. It improved patient treatment and it made best use of the budget that was available. The Cumbrian GPs were strong advocates for their patients and when this fervour was combined with budget management it naturally resulted in GPs thinking more wisely about how best to spend their money.

But Cumbria's experience has not yet involved private companies. They are effectively running their businesses as not-for-profit community interest companies. As such the spending decisions were genuinely managed by GPs and not enforced upon them by private companies such as United Health, which a Houslow GP consortium has brought in to manage its patient referrals. In response to concerns raised during the NHS white paper consultation phase, it is very telling that health secretary Andrew Lansley amended his proposals so that the person with overall responsibility for a GP consortium's budget need not be a GP. In fact, a cynic might say that the reason GPs are being forced to take on commissioning so quickly, (in less than half the time Cumbria has spent introducing the change) is so that they will be forced to turn to private companies for help, allowing the Government to make such companies the 'enemy' if its proposals don't work out so well.

Perhaps most crucially Cumbria has not begun to tackle the issue of competition that the Government is so keen to impose on the NHS - it wishes to open up patient care to 'any willing provider'. In fact, from what I saw, there was even less competition in Cumbria because it placed a large focus on improving the care pathways between primary care (GPs) and secondary care (hospitals). For example, GPs are helping to man A&E wards and they are using new computer software to gain an overall view of patient care. This helps them ensure hospital patients are admitted for as long as they need before having their care transferred to their home in the local community. As such, GPs are forging closer relationships with local hospitals, which in my mind precludes competition from private providers. It is working for patients (I spoke to one man who avoided a three month hospital stay by receiving daily intravenous antibiotics in his home from visiting nurses) and it is saving money - the budget for hospital emergency admissions has been cut by 6% in 2009 to reflect its 6% fall in caseloads.

But when I specifically asked one doctor about introducing competition, a doctor who describes himself as "evangelical" about clinician-led commissioning, he agreed it was the aspect of the proposed reforms that he'd be most likely to challenge the Government on. He also commented that now waiting lists have been brought down to 18 weeks or less there is not such need for competition. It is interesting, then, that the Government started talking about introducing competition into the NHS around the same time that it scrapped waiting list targets for hospitals.

Perhaps media confusion surrounds the Coalition's proposals because one half of the reforms that focuses on GP commissioning and seems innovative, and if allowed to evolve over a longer period of time than currently demanded by Lansley (which will allow GPs the time and space to consider options other than enlisting private management companies), may well provide the best bang for the buck in the NHS. But the other half of reforms that focuses on competition is incredibly worrying. The Mirror today highlighted how many Tory donors have direct links with the private healthcare market. The Guardian yesterday spoke about the key clause in the reforms that allows private healthcare companies to undercut market-rate tariffs. This is sheer folly. A giant healthcare company can afford to write off huge losses while waiting for NHS hospitals to go under through lack of funding, before raising its prices once it has won itself a dominant position in the market.

The Health and Social care Bill is released today. Spend some time reading newspaper reports about its content and ask yourself if this is what you want for your NHS. In my opinion, the best way forward is to follow Cumbria's lead. Involve GPs in commissioning, but at a pace that works for them; improve care pathways between primary and secondary care, devolving more treatment to local areas if possible; phase out PCTs, replacing them with GP consortia that have a better understanding of patients and treatment options; maintain Strategic Health Authorities so that GPs are still guided by the state and not private companies who have their shareholders interest at heart.

The NHS white paper released last year was called 'Liberating the NHS' - I can't help but think that what this really means is that the proposals liberate the Government from having to manage the NHS at all.

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