Comment: Changes to NHS reforms will be in the details
The government’s listening exercise may result in a bill with less of a gap between the principles behind change and the reality of their implementation.
By Neil Churchill
David Cameron has urged voluntary health organisations to help the government reassure people that its NHS reforms are not about privatisation.
He told a listening event for health leaders at Downing Street that “your organisations, which are hugely trusted and understood by the public and by users of your organisations, can help us make the argument that change, that choice, that diversity is not about privatisation, it’s actually about improving healthcare”.
I was one of those health leaders, attending what was billed as one of the first listening events as the government pauses to reflect on its reform plans. What are the chances that the health charities will heed the prime minister’s call?
In some ways, charities are potentially natural allies of the reforms.
First of all, we believe that charities can indeed play a much bigger part in delivering effective healthcare. For us, the NHS has always been a mixed economy of public, private and voluntary sectors and we are more likely to see plurality of provision as being in the interests of patients. Indeed it is no surprise to see the chief executive of ACEVO, the charity leader organisation, chairing the review’s workstream on choice and competition.
Second, the charity world welcomed the principles underlying the NHS reforms. Patient choice and control are at the heart of what we believe in and the NHS has been slow in giving patients real clout, despite the fact that many people with chronic conditions know as much about their health as their doctors do. It makes sense to measure and reward genuine outcomes (though many of us would keep a few more of the targets which have been effective in improving certain standards which matter to patients like waiting times).
Third, and most importantly, patient groups generally endorse the need for further reform. Although we recognise the improvements the NHS has made, we are worried that the service is still not as good as it needs to be and there are unacceptable variations in quality. The shocking findings of the recent ombudsman report into services for older people underscored the need for continued reform. Personally I count myself a late convert to GP commissioning, and can see that in the right hands it could be a powerful means to enhance the ‘front end’ of healthcare – primary care.
Why then the hesitancy?
First, there is concern about the scale and timing of the re-organisation. As Health Service Journal recently argued, if the answer to your problem in improving the NHS is a reorganisation, you are probably asking the wrong question. Research consistently shows that reorganisations distract managers from the core task of delivering better care. It is especially risky in an environment in which we are seeking an unprecedented four per cent productivity improvements each year. Rather than abolish primary care trusts (PCTs), Andrew Lansley could have replaced their boards with GPs. But it is too late for alternative approaches. NHS managers want an end to the uncertainty which won’t be provided by giving PCT clusters another six or nine months of life.
Second, although health charities want to play a bigger part in health delivery, we know that what matters to patients is integration. If competition fragments the system, then it will disadvantage patients. Even the most carefully designed and well run services will fail to deliver real outcomes if they are not fully integrated into locally planned care pathways. That’s why we have been arguing for the incentives to collaborate to be at least as good as the incentives to compete. Patients groups may not be as troubled as the health unions by the principle of competition or ‘contestability’ as Labour described it but we are concerned about how its extension will be designed, managed and regulated.
Finally, there is the question of detail. As a matter of principle, Andrew Lansley has provided space for local clinicians to determine how they plan to implement his reforms. But the result has been a lack of detail about what the new system will look like which has created a number of concerns. For example, although the intention of the legislation is to put patients at the heart of the NHS – ‘nothing about me without me’ – there is no assurance that patients will have any role in the governance of GP consortia or the NHS commissioning board. The British Medical Journal has also pointed out that the bill extends powers of charging – giving consortia a general power to change for services and foundation trusts the power to charge for hospital accommodation. The reasons for these changes have not been adequately explained or justified.
So how much change do we expect? Is the pause about listening or about public relations?
There will certainly be changes to the language of the reforms to reflect the reality of what is being proposed. For example, the intention was never that GPs alone would be responsible for commissioning. I remember health minister Anne Milton describing the importance of nurses being involved at an early stage of the reforms. The health select committee was right to point out that commissioning must involve a variety of clinicians.
But as that was the original intention of the reform, it’s not clear how it got lost as the vision got translated into the white paper which in turn became the bill. Similar observations can be made about other reforms – and the language has already started to change, with ‘any qualified provider’ replacing ‘any willing provider’. We may yet see the return of contestability for competition.
But politically, there must be substantive changes too.
Professor Steve Field, who leads the review, is an impressive figure with a powerful vision for a better NHS. He doesn’t want commissioning to entrench the status quo in primary care, he wants it to be a powerful tool for improving primary care, especially in disadvantaged areas where the NHS has sometimes failed its patients. He will know that substantive changes will be required to win the backing of more of his medical colleagues as well as health charities and other stakeholders.
And David Cameron and Nick Clegg will need there to be meaningful changes too. It was fascinating at the listening event to hear the prime minister speak of “tweaks” and his deputy of “tweaks or changes”. That may say as much as anything about their respective expectations of the exercise. But it does show that at the end of the pause, they both expect to be able to point to changes which have been made as a result of their listening.
The changes won’t be fundamental ones, as the review’s terms of reference make clear. The NHS commissioning board and GP consortia are coming, whatever people argue today. Competition too will play a major role in the new health service, although the debate will continue over whether this is an evolution from Tony Blair’s reforms or a break with them.
Instead, changes will occur in details of the bill. The health select committee has already weighed in with its proposed changes. Health charities will spend the next two months adding their own ideas. The result may be a bill with less of a gap between the principles behind change and the reality of their implementation. But the heat is far from certain to cool in the public debate. And all the lessons are that it won’t be easy for the health secretary to take the politics out of the NHS.
Neil Churchill is chief executive of Asthma UK.
The opinions in politics.co.uk’s Speakers Corner are those of the author and are no reflection of the views of the website or its owners.
