Special Report – Reforming the NHS in England

SPECIAL REPORT

Reforming the NHS in England Infinite 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 Reforming the NHS in England Polyclinics and the Future NHS Reform 2011 – The Big Picture NHS Reform 2011 – From the Patient’s Perspective

Published by Global Business Media

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SPECIAL REPORT: REFORMING THE NHS IN ENGLAND

SPECIAL REPORT

Reforming the NHS in England Infinite Demands – Finite Resources

Contents

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

FOREWORD

2

Martin Richards, Editor

Reforming the NHS in England Polyclinics and the Future NHS Reform 2011 – The Big Picture NHS Reform 2011 – From the Patient’s Perspective

Published by Global Business Media

Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom Switchboard: +44 (0)1737 850 939 Fax: +44 (0)1737 851 952 Email: info@globalbusinessmedia.org Website: www.globalbusinessmedia.org Publisher Kevin Bell Business Development Director Marie-Anne Brooks Editor Martin Richards Senior Project Manager Steve Banks Advertising Executives Michael McCarthy Abigail Coombes Production Manager Paul Davies For further information visit: www.globalbusinessmedia.org The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated.

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REFORMING THE NHS IN ENGLAND

3

By Leslie Paine

Infinite 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

References POLYCLINICS AND THE FUTURE

7

By Leslie Paine

A Radical New Primary Care Model Opposition From a Number of Sources Evaluating the Model

NHS REFORM 2011 – The Big Picture

9

By John Hancock

The Impact of an Ageing Population The Political Perspective Second Thoughts Striving for Greater Public Accountability The Roles of the Private Sector and Charities

NHS REFORM 2011 – From the Patient’s Perspective 11

By John Hancock

The System Needs to Cater for a Wide Range of Patient Needs Patients Should Benefit as a Result of Less NHS Bureaucracy More Treatment of Long-Term Conditions in Home Environments Potential Savings through Patients Being Treated at Home Rather Than in Hospital The Downside – Possible Increase in the Cost of Drugs and Less Investment in Research The Impact on Hospitals Uncharted Waters – The Results May Not Be Known For Years to Come

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SPECIAL REPORT: REFORMING THE NHS IN ENGLAND

Foreword

T

he NHS Reform Bill 2011 represents the largest shake-up in the National Health Service in England since it was created in 1948. This

Report looks at the proposed major changes, the impact on the current structure, how the proposed changes will affect the working practices of GPs and the impact on patients.

The Report opens by examining the arguments for and against the proposed changes, their possible effects, whether they are likely to be successful and whether they represent a creeping move towards privatisation of the NHS in England.

The second piece looks at how the concept of Polyclinics represents a radical new model in primary care. It sets out some of the key proposals and describes the views of a number of major organisations concerned with primary care that oppose the proposals. Despite this opposition, both the Government and NHS London believe that polyclinics will transform primary care and increase NHS productivity by the transfer of routine outpatient appointments and minor injuries attendances from hospitals to the community.

The possible effects of the proposed changes on an ageing population are considered in the third piece. This goes on to look at the various political discussions and arguments that have taken place that have resulted in modifications to the original proposals stemming from recommendations by interested groups. Throughout the proposals lies the need for public accountability. This is to be achieved through the creation of a proposed new oversight body, Monitor, which would have a duty to promote competition.

In the final section, the possible effects of the proposals on patients are reviewed. The over-riding aim is to ensure that patients benefit as a result of less NHS bureaucracy. Considerable savings stand to be made by carrying out more treatment of long-term conditions in home environments. However, the drug companies argue that the greater work-load that would fall on them having to serve thousands of GP commissioning consortia rather than 145 regional PCT’s, will considerably increase their costs which would need to be passed on to the service.

In summary, these are radical changes which will take a huge input of effort and funding to achieve – and it may be many years before it can be known whether or not they have been successful.

Martin Richards Editor

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SPECIAL REPORT: REFORMING THE NHS IN ENGLAND

Reforming the NHS in England

By Leslie Paine

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.

Demonstrate and develop your management skills by joining the IHM’s

Infinite Demands – Finite Resources

Accredited Manager Programme The new arrangements will also need good

Demonstrate and develop

your management skills by

According to the Coalition Government, unless we do something about rising healthcare costs joining the IHM’s 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 finite resources (which it has) can never meet the infinite 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 Join the programme and... The programme is fast over the last ten years according Anna Dixon, Director of Policy at the King’s Fund in London. becomingteam a nationally Enhance your CV and/or strengthen your management As she puts it in the Spring 2011 edition of the Demonstrate your commitment to the pursuitrecognised of excellence symbol of NAPC Review: “The NHS has made significant excellence in healthcare progress over the past decade (Thorlby and Maybin 2010) with some of the highest levels of which Ruth Spellman, the Chief Executive management across Chartered Management Institute, public satisfaction ever recorded (Appleby and of the Individuals join the programme every February, June October theorcountry estimates at 45%. Although, as she reminds Robertson 2011)”(2).

Organisational cohorts can be bespoke to meet local need.

Its budget of course has been considerably us, the new arrangements will also need Join the programme and For furtherand information, please increased down the years – 2.5% of Gross good management leadership, the key toemail education@ihm.org.uk Domestic Product in 1949, 8.5% today. But, which will the retention of thoseaccredited staff with The be programme will be academically Enhance your CV and/or strengthen in the Government’s view, that won’t work any good skills and the support of those with new your management team longer. “Just putting in a little money and carrying managerial responsibilities (3).

Demonstrate your commitment But while we will all say amen to that, everyone on business as usual, is not good enough” the IHM poster.indd 1 16/5/11 10:16:19 to the persuit of excellence Prime Minister says. “Fail to modernise and the knows that patients come to doctors and hospitals to be treated not administered. To NHS is heading for crisis.”(1) patients, therefore, the managers are ‘enablers’.

GP Consortia and Management They are not the men and women behind the Individuals join the programme And by modernisation of course he means at NHS guns, they are the men and women behind every February, June or October. the moment the abolition over the next two- them.’ And their basic jobs are to create and three years of all the existing Primary Care Trusts maintain the environment and facilities which Organisational cohorts can be and Strategic Health Authorities, and allow the front line troops – doctors, nurses, bespoke to meet local need. the transference of their commissioning therapists – to deploy their skills to the very best responsibilities (widened to include the of their abilities. possible employment of private providers) to a For further information, please Reorganisation or countrywide network of GP Consortia. email education@ihm.org.uk By this means and a demand for so-called Re-disorganisation? ‘efficiency savings’ in administrative costs of That said, what line should we take regarding the £15-20 billion by 2015, the Government aims to proposed reforms? How can we know whether The programme will be academically accredited achieve a cut in the number of NHS managers, the English NHS, altered as the Government

management and

Accredited to which will be is thefast becoming a The programme Manager nationally recognised symbol of excellence retention of those staff Programme in healthcare management with good skills and across the country leadership, the key

the support of those

with new managerial responsibilities.

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SPECIAL REPORT: REFORMING THE NHS IN ENGLAND

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.

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 Contention The 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 4 | WWW.PRIMARYCAREREPORTS.CO.UK

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 Proposals As 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

SPECIAL REPORT: REFORMING THE NHS IN ENGLAND

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 Vocation The 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.

Private providers are prevented from creaming off the more profitable services and leaving the

Demonstrate develop NHSand to deal with your management skills by joining the IHM’s the more difficult,

Accredited Manager Programme more complex and more expensive services

Demonstrate and develop

your management skills by joining the IHM’s

Accredited Manager Programme

and the problems The programme is fast becoming a nationally recognised of staff training. symbol of excellence in healthcare management across the country

funded service as long as it does not breach the basic NHS principle of equal treatment for the programme and... The programme is fast all free at the pointJoin of provision.

And, private Will Reforms be Successful? Enhance providers are CV prevented fromstrengthen creaming off the becomingteam a nationally your and/or your management So, is the restructuring going to be successful? more profitable services and leaving theto NHS to pursuit Demonstrate your commitment the of excellence recognised symbol of We can but wait and see. Meanwhile, an deal with the more difficult, more complex and excellence in healthcare encouraging pointer for the Government comes more expensive services and the problems of (6) from Cumbria where GPs have had control of staff training management across their own budgets since the latter days of the last And the Consortia join will know as well as every we February, June Individuals the programme October theorcountry Labour Government. There, PCTs are virtually do that the best insurance scheme truly Organisational cohorts canfor beabespoke to meet local need. abolished, the area’s nine community hospitals national health system designed to meet the Join the programme and For further information, have been saved, the average stay in the two total healthcare needs of the people,please is oneemail education@ihm.org.uk local main hospitals has been reduced from 36 based on bothaccredited they, and Thetaxation. programmeIn willaddition, be academically Enhance your CV and/or strengthen to 10 days, and standards of patient care have a large number of their patients are well aware your management team risen. But in Cumbria the local doctors joined that moving away from paying for care through Demonstrate your commitment the scheme by choice. They were not forced. their taxes will very likely, in the end, mean paying IHM poster.indd 1 16/5/11 10:16:19 to the persuit of excellence Something for the Health Secretary to note even more in health insurance, and will carry with perhaps. Evolution, not revolution. it the danger of ending up with an American-style system whereby those who can afford it have top Ensuring Free and class private health insurance and those who Individuals join the programme Fair Healthcare for All can’t – who are likely to be the poor, the longevery February, June or October.

Meanwhile, there remains the question of term sick and elderly – are forced to rely on a Privatisation. Do the Government’s proposals minimal, third-rate public service to cover their Organisational cohorts can be take us a step towards privatising the NHS essential needs. bespoke to meet local need. or not? Personally, I don’t think so. The new And, bearing in mind the current outcry Consortia will be able to commission outside against poor standards of some care for the providers (charities as well as profit-making) for elderly and complaints against nurses to the For further information, please some clinical services if they believe that that is Nursing and Midwifery Council reaching record email education@ihm.org.uk clearly the most efficient use of funds and the levels (more than 3,000) last year, I can’t see most suitable for their patients. Just, I imagine, any British Government doing that, or the as PCTs can do today if they wish. This I would British people allowing them to do so, even if The programme will be academically accredited see as reasonable competition in a publicly they wanted to.

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SPECIAL REPORT: REFORMING THE NHS IN ENGLAND

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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SPECIAL REPORT: REFORMING THE NHS IN ENGLAND

Polyclinics and the Future

By Leslie Paine

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.

A Radical New Primary Care Model

Demonstrate and develop your management skills by joining the IHM’s

This last point was also taken up by the Royal College of General Practitioners who Demonstrate and develop Lord Darzi announced his Polyclinic project for condemned the proposed polyclinics on the capital in a Healthcare for London Report two grounds – neither GPs nor patients were your management skills by published in mid-2007. The key proposals in involved in their planning, and the centres what Pulse magazine described at the time as a threatened the de-stabilisation of existing high joining the IHM’s “radical new primary care model” were listed by quality GP practices. that journal as follows: The King’s Fund questioned the plans for – Most GP practices to be relocated in polyclinics, several reasons. each with up to 25 GPs, serving populations of – Access to services could be made more about 50,000. difficult especially in rural areas and in urban – Up to 50% of outpatient treatment to be locations where the polyclinic was not near a moved into polyclinics also housing consultant transport centre. specialists, diagnostics, community services, – Putting healthcare professionals together in dentists and pharmacists. the same building would not on its own – Polyclinics to offer urgent care 18-24 hours a produce more integrated care or a higher day, and routine GP appointments in evenings quality of service. the opportunities programme for and... The programme is fast and on Saturdays.

– While polyclinicsJoin offered – Polyclinics could be owned and run by the moreyour integrated and patient-focused becomingteam a nationally Enhance CV and/or strengthencare your management NHS, large GP practices, private companies such opportunities only be realised with pursuit Demonstrate your would commitment to the of excellence recognised symbol of or foundation trusts. considerable investment of time, effort and excellence in healthcare – Existing GP practices will be encouraged to resources into their planning and development. re-locate.

The primary focus therefore should be on management across The reaction of the healthcare world was developing new pathways, Individuals join thetechnologies programmeand every February, June October theorcountry not difficult to forecast. Lord Darzi’s cat was no ways ofOrganisational working rather than new buildings. cohorts can be bespoke to meet local need. sooner out of the bag than it was among the The Patients’ Association, like the BMA, feared Join the programme and For further please pigeons. The Patients’ Association, the King’s that polyclinics wouldinformation, disrupt the close andemail education@ihm.org.uk Fund, the BMA, the Royal College of General highly valued relationship GPs and their The programme will bebetween academically accredited Enhance your CV and/or strengthen Practitioners and the Liberal Democrat Party patients, particularly those patients with long-term your management team were among the critics, along with large or complex conditions.

Demonstrate your commitment numbers of individual GPs andIHMsomething like The Liberal Democrats criticised the proposals poster.indd 1 16/5/11 10:16:19 to the persuit of excellence a million of their patients who signed a petition as part of the Government’s obsession with against the proposals. imposing models of care from the centre rather than encouraging local decision-making.

Opposition From Finally, some public health experts, making Individuals join the programme a Number of Sources the point that the roots of health lie outside the every February, June or October.

Here is what some of these doubters had to say. medical field, suggested that Darzi Polyclinics The BMA opposed the idea of polyclinics on the were primary care centres of the wrong sort.

Organisational cohorts can be grounds that larger clinics were already emerging As one put it in an article published in bespoke to meet local need. where needed; that forcing the introduction of September 2009, “Knowing what we now the new centres was wasteful and costly, and do about the determinants of disease that the proposal would undermine the doctor- and the promotion of wellbeing, and if we For further information, please patient relationship. It also suggested that the are serious about redressing inequalities email education@ihm.org.uk design of the proposals appeared deliberately of health in moving from the traditional to disadvantage existing GPs from applying reactive primary health care model to a new to run the clinics, leaving the way open for the pro-active community and wellbeing The programme will be academically accredited privatisation of GP services. framework… the current concept of polyclinics

Accredited Manager Programme

Accredited The programme is fast becoming a Manager nationally recognised symbol of excellence in healthcare management acrossProgramme the country

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SPECIAL REPORT: REFORMING THE NHS IN ENGLAND

The Patients’ Association, like the BMA, feared that polyclinics would disrupt the close and highly valued relationship between GPs and their patients, particularly those patients with long-term or complex conditions.

8 | WWW.PRIMARYCAREREPORTS.CO.UK

totally misses the point and should be shunted into a siding where it belongs.”

Evaluating the Model Despite this barrage of criticism, both the Government and NHS London are still firm in their resolve that Polyclinics are the way forward for the Health Service in the capital.

These new centres, they say, will transform primary care and increase NHS productivity by the transfer of routine outpatient appointments and minor injuries attendances from hospitals to the community – as recently recommended by two of the country’s leading Think Tanks, Demos and Policy Exchange. Patients will have a greater range of higher quality, more convenient health services. Pressure on overstretched A&E Departments will be relieved and ultimately health inequalities reduced.

But, as Dr Tom Coffey stressed in his excellent article on ‘Polyclinics and Polystems – The Vision and the Model’ published last year “they are a London solution to a London problem.

So convinced are the supporters of the proposal that its benefits will be forthcoming, that the talk is already of 100 polyclinics across the 31 London Primary Care Trusts by 2015.”

Before that happens, however, as Dr Marilyn Plant explained in an article that appeared at the same time, the Polyclinic model is to be evaluated in a two-year study led by the London School of Hygiene and Tropical Medicine and the Picker Institute. Their report should be ready by January 2012.

SPECIAL REPORT: REFORMING THE NHS IN ENGLAND

NHS REFORM 2011 – The Big Picture

By John Hancock

Demonstrate andculture. develop a consumer driven But thereyour are twomanagement skills sides to every story some argue a byand joining thethatIHM’s

In a country with a population of around 60 million, an organisation with a workforce of 1.4 million and spending some £100 billion a year is a significant matter. The UK’s National Health Service is a pillar of British culture that has been compared to a religion. That may be no exaggeration, given the passion with which people revere and defend it. So, NHS reform is a task to which governments accord the sort of respect that ordnance experts give to ticking bombs.

consumer driven culture will simply become a market where the loudest, most savvy and Demonstrate and develop pushiest will thrive at the expense of those whose voice is less strident and who may your management skills by also be more needy. Looking at his proposals before they even reached the White Paper joining the IHM’s stage, Andrew Lansley may have thought this a fairly straightforward matter. He won’t think that today.

The coalition government’s original health The Impact of an reform proposals published at the beginning Ageing Population of 2011 sought to turn NHS management on And, there is another ticking bomb in the room. its head by handing control of the bulk of its Over the past 25 years the percentage of the £100+ billion budget to GPs buying services UK population aged 65 and over (the heaviest for their patients as they deemed necessary.

NHS users) has increased from 15% in 1984 to While the process was to be overseen by a 16% in 2009, an increase of 1.7 million people. new NHS Commissioning Board the idea was the programme and... The programme is fast Over the same period the percentage of the to create a serviceJoin responsive to consumer population under age 16 (the next cohortEnhance of (patient) needs. becomingteam a nationally your CV and/or strengthen your management taxpayers) decreased from 21% to 19%. At In turning the drivers of the system to upside Demonstrate your commitment the pursuitrecognised of excellence symbol of this rate, by 2034 23% of the population will be down, the government planned to scrap all 10 excellence in healthcare aged 65 and over while only 18% will be under Strategic Health Authorities (SHAs) in England 16. This does not bode well for the NHS. While and the 152 Primary Care Trusts (PCT’s). management across it’s not just size and cost that matter, they are Instead groups of GPjoin practices would form ‘GP Individuals the programme every February, June October theorcountry very important. consortia’ which, after their establishment from Organisational cohorts can be bespoke to meet local need.

Because healthcare solutions are always April 2012, would take over the commissioning Join the programme and For further improving and their costs rising, NHS inflation of healthcare services.information, In an ultimate please reversal email education@ihm.org.uk is higher than general inflation. An ageing of the current systemwillit be was proposed that the The programme academically accredited Enhance your CV and/or strengthen population, the costs of new drugs and the Health Secretary should no longer have your management team development of new treatments, plus modern accountability for the health service but that even Demonstrate your commitment lifestyle factors such as poorIHMdiet, smoking, that would be devolved to local GP consortia. poster.indd 1 16/5/11 10:16:19 to the persuit of excellence alcohol consumption and drug abuse mean that demands on the NHS are constantly rising. Second Thoughts So, while the NHS budget has been ‘ring fenced’ The whole package, finding £15-£20 billion in from current public sector austerity, it still needs efficiency savings, losing most of the current Individuals join the programme to find savings simply to be able to stand still, to NHS architecture and putting consumers, through every February, June or October. ensure continuation of the levels and quality of their GPs, in the driving seat, was more than service. For that, the NHS has to make savings many in the NHS could stomach and a storm Organisational cohorts can be of up to £20 billion by 2015 or, put another way, of protests led the government to embark on bespoke to meet local need. become 4% more productive each year: and that a pause and consider period during which the for an organisation whose productivity has been NHS Future Forum was tasked with reviewing the declining for more than a decade. Reform is not reform proposals.

For further information, please Ministers listened; the Future Forum thought a management option but a necessity. email education@ihm.org.uk and made its recommendations which the The Political Perspective government has largely accepted, accordingly Another driver of NHS reform is political, seeking modifying its plans. So how will the NHS The programme will be academically accredited to replace the service’s producer led ethos with modernised by the new proposals look?

Accredited Manager Programme

Accredited The programme is fast becoming a Manager nationally recognised symbol of excellence in healthcare management acrossProgramme the country

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SPECIAL REPORT: REFORMING THE NHS IN ENGLAND

One objective of the reforms, stronger public accountability, will be served by lay members joining clinical commissioning groups and by foundation trusts now having to hold public board meetings.

According to the Department of Health website one thing that will be unchanged is the NHS duty to promote a comprehensive health service free at the point of delivery. Also, ultimate accountability will remain with the Secretary of State. Beyond that, GP consortia will now be called ‘clinical commissioning groups’ with at least one nurse and one specialist doctor joining each group.

These groups will be supported by clinical networks advising on specific areas of care such as cancer, while new ‘clinical senates’ will provide what is coyly referred to as multi-professional advice on local commissioning plans. That means that hospital medical staff will still have a say in what services may be provided. Both consortia and senates will be hosted within NHS Commissioning Boards.

Striving for Greater Public Accountability One objective of the reforms, stronger public accountability, will be served by lay members joining clinical commissioning groups and by foundation trusts now having to hold public board meetings. Health and well-being boards within local councils will also be able to refer back local commissioning plans that do not support the local health and well-being strategy and there will be clearer duties across the system to involve the public, patients and carers.

One matter which exercised protesters was the notion that a proposed new oversight body, Monitor, would have a duty to promote competition. Under the revised proposals its duty will be to protect and promote the interests of patients. While it may bring elements of competition into the service that will no longer be an end in itself. In particular the new plan includes safeguards against price competition, cherry picking and privatisation of health services.

Equally the timescale has been extended so that commissioning groups will not be established until April 2013.

This remains one of the most radical plans in the history of the health service and will be implemented during the most financially and structurally challenging period the NHS has faced.

Most services will still be the responsibility of the new clinical commissioning groups but some services such as dentistry and certain specialist areas like neurosurgery will be controlled by a national board set up to oversee the new system.

The Roles of the Private Sector and Charities While competition is no longer an overt objective of modernisation, there will be a greater involvement from the private sector and charities, particularly in elective procedures. And in specialist areas such as mental health the role of non-NHS providers is 10 | WWW.PRIMARYCAREREPORTS.CO.UK

already significant. Currently some one pound in every £20 spent in the NHS goes to a non-NHS provider and this will almost certainly increase. But ministers have agreed to introduce competition in a more managed and balanced way.

The important thing for the NHS now is to move forward. Challenging times lay ahead with some 20,000 management and administration staff being made redundant from health authorities, PCT’s and the Department of Health during the next two years. These redundancies will account for a significant part of the estimated £1.4 billion cost of the reforms. But while there has been a pause nobody should be in any doubt that the NHS in 10 years’ time is planned to look a great deal different from the NHS today.

SPECIAL REPORT: REFORMING THE NHS IN ENGLAND

NHS REFORM 2011 – From the Patient’s Perspective

By John Hancock

Demonstrate and develop management skills Patients Should Benefit as your a Result of Less Bureaucracy byNHS joining the IHM’s

The public doesn’t judge the NHS by normal standards. Many probably don’t even understand why the NHS needs reform: but the institution has to some extent been the architect of its own troubles. According to a 15 March 2011 report by the House of Commons Public Accounts Committee, “between 2000–01 and 2010–11, NHS [annual] funding will have increased by 70% to £102 billion, an average real term increase of 4.5% a year.” However, productivity fell during that same period by 0.2% a year. Viewed through this prism, the taxpayer met considerable cost increases for falling productivity. In any normal debate this would clinch the argument for reform but you cannot have a normal debate about the NHS. What people care about is the patient experience, a much less straightforward matter.

Some opponents to reform would say that, in this system, the ‘pushiest’ patients would Demonstrate and develop do best at the expense of the more elderly, infirm or vulnerable. However in May 2011, your management skills by 42 GPs representing over 1000 practices in shadow commissioning consortia wrote to the joining the IHM’s Daily Telegraph to say exactly the opposite.

Their letter stated, “One of the most important elements of the reforms is that they are the first significant attempt to coordinate all aspects of care – primary, secondary, community and social – into a coherent and seamless whole...

If successful, there will be enormous benefits to the most elderly, infirm and vulnerable people in our community whose care is often currently too fragmented.” Many GPs welcome the fact that any decisions about their patients would in future programme and... The programme is fast be in their patients’Join bestthe interests rather than The System Needs to Cater for Enhance a having your to be filtered through NHS bureaucracy. becomingteam a nationally CV and/or strengthen your management Wide Range of Patient Needs Demonstrate Another argument add that, if they are pursuit your would commitment to the of excellence recognised symbol of The problem is that there is no such thing as a accountable for the costs of treatment, GPs excellence in healthcare standard patient experience. Some people arrive will be much more committed to preventative at hospital bearing the injuries of an accident or programmes, less costly than cures but often management across attack with immediate needs but rarely requiring observedIndividuals more in the join breach the practice. thethan programme every February, June October theorcountry long-term treatment. Those who do require Organisational cohorts can be bespoke to meet local need. longer term treatment will join people who have More Treatment of Join the programme and For further information, please email education@ihm.org.uk Conditions presented at their GP’s desk with symptoms that Long-Term Environments the GP may be able to identify immediately or in Home The programme will be academically accredited Enhance your CV and/or strengthen could need to refer to a specialist. In either case It is also felt that people with long-term conditions your management team the patient will then enter a system designed such as asthma or diabetes would benefit from a Demonstrate your commitment to cater for a variety of prognoses, a range of system that potentially could bring the NHS into IHM poster.indd 1 16/5/11 10:16:19 to the persuit of excellence outcomes and the selection of appropriate their home. This group account for about 70% of treatments leading to full recovery, managing a the NHS budget, largely because they are often in hospital. A more patient centred approach long-term condition or end of life care.

The move to GP led commissioning was would encourage them to learn and practice a Individuals join the programme intended to put the patient firmly into, if not the degree of self-care to manage and control their every February, June or October. driving seat, then the front seat. The idea is that, conditions. For instance, many diabetics could with their doctor, the patient can discuss the improve their own quality of life by monitoring Organisational cohorts can be best treatment for their condition and choose their blood glucose levels, a relatively simple and bespoke to meet local need. the most appropriate delivery unit (hospital, inexpensive procedure. clinic or local health centre) where the treatment can be effected. In this way delivery will be Potential Savings through For further information, please coordinated not around the needs of producers Patients Being Treated at email education@ihm.org.uk (hospitals, doctors, nurses, etc.) with the patient Home Rather Than in Hospital having to navigate through the system, but Also an increasing number of treatments could around the needs of patients with producers be delivered in GP surgeries or local health The programme will be academically accredited centres. A procedure that might once have having to adapt.

Accredited Manager Programme

Accredited The programme is fast becoming a Manager nationally recognised symbol of excellence in healthcare management acrossProgramme the country

WWW.PRIMARYCAREREPORTS.CO.UK | 11

SPECIAL REPORT: REFORMING THE NHS IN ENGLAND

Hospitals may well begin to specialise and focus on particular groups of treatment where they can become centres of excellence.

involved a journey to hospital, waiting, undergoing the procedure then having to make one’s way home or spend the night in hospital, can now often be completed as a 20 minute procedure in the surgery or health centre near the patient’s home or place of work. Some of this, of course, is down to advances in medical techniques that have seen what were once major operations become little more than keyhole surgery. But some of it is also down to a mind-set that wants to deliver the service in a way that best suits the patient’s needs and not that is most convenient to the organisation.

The Downside – Possible Increase in the Cost of Drugs and Less Investment in Research On the other side of this argument, while some criticisms might be put down to a defensive attitude on the part of producer interests, other concerns are of a more concrete and commercial nature. Pharmaceutical companies have expressed concerns that having to deal with thousands of GP commissioning consortia rather than 145 regional PCT’s will considerably increase their costs which would need to be passed on to the service. Also a proposal within the reforms that would set payment for drugs according to the benefits to patients and other factors, such as whether the medicine is innovative or particularly effective would, say the pharmaceutical companies, remove the incentive for them to invest in research in any area except where they can be certain that the product will meet these criteria. For patients, it could be a two edged sword.

The Impact on Hospitals Hospitals may well begin to specialise and focus on particular groups of treatment where they can become centres of excellence. Such ‘super hospitals’ would pull together high quality teams and be able to afford equipment that more generalised institutions perhaps could not: but the other side of that coin would be that patients would have to travel further to get treatment – as would their families, to visit them.

Similarly, the idea of being able to attend a GP surgery near one’s place of work rather than home seems attractive as a way of being more easily able to fit a visit to the doctor into the day until you consider how would a GP in, say, central London make a house call on a sick patient who was a commuter living in Brighton?

Uncharted Waters – The Results May Not Be Known For Years to Come And if the reforms are barely understood or, worse still, misunderstood the fallout could be 12 | WWW.PRIMARYCAREREPORTS.CO.UK

considerable. In a 16 June 2011 report in HR Magazine David Woods wrote ‘according to Naomi Saragoussi, principal in Mercer’s health and benefits business: “the devil is in the detail.

While the government has accepted the criticism of its policies and the plans to make the NHS more competitive appear to have been watered down, some areas lack clarity. It may be difficult for the consortia not to take a more commercial approach and prioritise more cost-effective treatments, despite their good intentions. We will have to wait and see.”’ The article also highlighted the possibility that PMI (private medical insurance) schemes will see growth as those who can afford to migrate away from the NHS, do so.

This is not an easy matter and, whatever the intentions of those on both sides of the argument, the proof of this pudding will be in the eating. The quality of the ingredients and the efficacy of the recipe may only become evident when patient outcomes start to be noticeably better (or worse) in as much as five to 10 years.

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