Not quite far enough Mr Cameron

James Gubb, 21 June 2007

There are aspects of the new Conservative White Paper on health to applaud, but they are, by and large, pretty much restricted to the supply-side. That advocated for commissioning is quite a different matter.

Encouraging every NHS Trust to become a self-governing Foundation Trust (FT), lifting restrictions on FTs’ borrowing arrangements and an unambiguous (sounding) commitment to allow any provider from the independent or private sector to offer services to NHS commissioners, should all help to ‘liberate the supply of healthcare and bring about effective competition’ as the document says. This is welcome.
As is the pledge to scrap top-down performance targets, which would free up providers to focus much more on responding to patient needs and demands, rather than artificially diverting their attention to one particular aspect of care and often seeking out ways to cheat it at that.
Cameron et. al. are also entirely right to focus attention on the necessity of securing public access to high-quality information on health outcomes and standards of care. Patients need such data to make choices over providers, and commissioners need it to focus their purchasing of services on health outcomes and quality, thereby holding providers to account in contracts. NHS organisations should also come to view data collection as a vital tool for attracting patients and for piloting innovation.
And the Conservatives also posit some useful ideas for payment by results (which, incidentally, would be greatly assisted by better quality information in any case), in particular that the tariff ‘should increasingly be set on the basis of the costs delivered by the more efficient providers – and that providers should also be entitled to offer discounts to it’. This would allow some competition on price and help drive up efficiency. So far so good, but interestingly the White Paper stops short of: a. scrapping any tariff and allowing true competition between providers on price rather than just information on comparative performance or b. (an idea that was given some attention in their Public Services Improvement Policy Group, but for some reason not transferred here) linking the tariff to quality and outcomes. As is correctly observed in the PSIPG paper, payment by results is not really payment by results at all; it is payment by activity. It gives the example of how a hospital admitting a stroke patient aged over 59 will be paid £4,293 for care with further payment if the hospital exceeds 57 days – ‘payment is linked to admission and length of stay, rather than to quality, efficiency or outcome’, matters that are more important to any patient.
But criticism of the White Paper should properly be aimed at the commissioning side of things where, in truth, the whole thing becomes a bit of a mess. In particular it reads as being hamstrung by prior commitments given by Cameron to ‘rule out any more such pointless organisational upheavals which have done so much damage to the NHS’, because it is precisely organisational change that it seems to want.
The masterstroke so far as the Tories are concerned is creating an independent NHS Board to oversee the commissioning of NHS services and put an end to political interference in the NHS. It seems they can’t go wrong here – the idea is very trendy amongst policy wonks, and, crucially, the BMA. But the fact is, it is unlikely to change much. It is surely right, for a start, that politicians should have a significant interest in what is being done with £92 billion of taxpayers money. They will also still set the budget for the NHS, so an independent NHS board will not necessarily solve the boom-bust patterns of funding the NHS has had to endure throughout its history. Moreover, commissioning decisions the NHS Board takes will not be purely technical, they will be inherently political so long as the NHS is funded by general taxation and, as such, the Board will almost certainly suffer from the same itch to micromanage as the government has done. What is more, the fact that the Tories propose the Board to be appointed by Ministers makes something of a mockery of the drive of the White Paper towards greater accountability for the NHS. Yes, there should be more consultation with health professionals about the direction of reform and over controversial decisions, but this could be in the form of a strong consultative body instead. It is also another layer of bureaucracy that the NHS could well do without, particularly because the White Paper envisages the commissioning role to be done through ‘Primary Care Commissioning’, i.e. GP practices. In this case, we have (and this is in the document) the NHS Board charged with the allocation of NHS resources, the promotion of patient choice, patient and public involvement in healthcare, safe and high-quality health services; i.e. performance management. Yet we also have a designated role of SHAs as ‘the performance-management of PCTs’, and a designated role of PCTs as ‘the performance management of GPs and primary care commissioners’. This begs the questions how much performance management do you want?!
This is not a matter for joking with – its consequences could be disastrous. You cannot have a market for healthcare if only the supplier side (the hospitals) are playing game. An insightful report this week released by the NHS Confederation comes out against the idea of an NHS Board for the simple reason: that independence and innovation are more about relationships than structures. The more hierarchy and layers you put in a system, the more communication is likely to be corrupted, the more likely it is that a dependency culture will evolve and the more likely it is that policy production will be for the worst performers. More particularly it means that commissioning will probably never really be performed in the interests of patients, rather in the interests of logistical, protectionist and cost containment objectives. In essence this means a continuation of the current dire situation the NHS finds itself in of ‘falling productivity, excessive bureaucracy and lamentable leadership and management’ highlighted in the introduction to the Tories’ White Paper: presumably the very system they want to be getting away from.
Yet there is no explicit statement either that what we are dealing with is a market for healthcare; again a highly dangerous situation according to a publication this week by the King’s Fund (Windmill 2007). This report states unequivocally that without having the political expediency to admit we have a market and continuing down the contradictory route of performance management and a half-hearted market will leave the NHS ‘in the worst of both worlds: the costs of a more competitive market without the benefits’. The Tories, while happy to liberalise the supply side, seem a lot more candid on strong, patient-led, commissioning. Yes, they advocate primary care commissioners allowing clinicians to act as the patient voice and hold real budgets (bringing commissioning much closer to the patient than through PCTs), but there are so many mentions of performance management one has to wonder what the real outcome will be. There is, for example, little discussion of how to encourage truly impartial commissioning (other than stopping PCTs from providing services to avoid conflicts of interest), or of any failure regimes.
One interesting suggestion they do make however, is to allow ‘those living with long-term conditions to exercise wider choice and voice in the care they receive [through] the widespread use of individual budgets’. The implication being that healthcare is optimised through actually giving the patient the money to spend, which can only really be done universally through an insurance system: then the ‘NHS’ would have a proper incentive to serve its patients.