How should general practice be changed? Is there a future for practice-based commissioning and how large a role should the private sector play in its provision? Is it possible to work in partnership with the doctors in reforming the NHS? Is an NHS Constitution the answer to the problems of how to square the economic and quality aspects of regulation and achieve the right balance between collaboration and competition? Just how local is the local decision-making that is promised from the centre? What will happen after the Darzi review reports? Will the Constitution set out rights and responsibilities for patients? Will local hospitals begin to close? Just how will politicians deliver on their promise of greater local accountability for communities?
Health policy continues to be a key battleground between the major political parties. As the Economist noted, ‘no sooner had the new year begun than the parties grabbed scalpels and started scrapping for advantage in the operating theatre’. The Economist believes the political battle results from a vacuum in politics and public worries about the health of the public services. In this context the Darzi review is crucial to the government, says the Economist. It serves two political purposes: first, it allows Brown to set out his vision, and second, is an opportunity to build a bridge with the medical profession.
How will health policy fare in a more ‘fluid, yo-yoing 21st century politics’?The Economist’s Bagehot believes that we have entered a new phase of politics, which are more volatile than at any point in the last decade.
The Conservatives are portraying the prime minister as a failed central planner. His misty view of reform is preventing change. His centralism is blocking the locally led change that is needed.
At the end of January, a comment piece in the FT by Philip Stevens summed up how David Cameron hopes to contrast himself with the prime minister. ‘What he is offering instead is a break-up of monolithic provision of public services. Mr Cameron's pitch is for competition, choice and private and voluntary sector engagement in education, health and welfare. He wants a big shift from central direction to local accountability.’
‘The Tory leader calls this the coming post-bureaucratic age. It is not the catchiest of catch-phrases. I doubt it resonates with voters.
‘If some of this sounds familiar, that is because it is. Mr Cameron has picked up the baton from Tony Blair. Pluralism, decentralisation and competition were a big part of the agenda pursued by the former prime minister during his last years in office. He got only so far, largely because of resistance in his own party. Most of what the Tory leader is talking about is a logical progression.’
While Gordon Brown was content to cede Mr Cameron the Blairite policy ground last summer this is no longer the case. While Brown was never an enthusiast for his predecessor's reforms ‘to his mind, market mechanisms were advancing too deeply into the health service - ‘things have changed’. ‘In the description of one cabinet colleague, the tribulations of late 2007 proved a "seriously cold bath" for the prime minister. Mr Brown realised that running as the I'm-not-Tony-Blair candidate was getting him nowhere.
What kind of reformer is Gordon Brown?One of the key accusations against Gordon Brown and Alan Johnson is that their approach to reform has not been clear. Attacks from the left that they was continuing to pursue Blairite reforms hit their mark as did suggestions from the right that they were pulling back from it. Both left and right could cite quotations to make their case.
As the Guardian’s John Carvel put it, ‘during six months at the helm, [Alan] Johnson has avoided confirming or denying that he is setting a different course. He shunned interviews that might have teased out the character of the new regime’.
2008 has seen a new approach.
In a January interview, John Carvel said the Health Secretary opened up to him. ‘Far from abandoning use of the private sector, he says he is extending it into primary care – where he has plans for 250 new GP-led health centres. He quotes Johnson: “Lots of them will be run by the private sector…We will bring in GPs employed by private organisations”.
Gordon Brown had already said something similar to the Common Liaison Committee, in the House of Commons, back in December. When one member challenged him on the role of ISTCs, Brown said that private involvement would continue to grow. “The role of the private sector in this area is expanding and will continue to expand and will be a lot bigger in the next few years than it is now.” “The extension of it to the GP sector and social care sector is going to be increasingly important in the years to come.”On January the 7th, Gordon Brown delivered his first speech on the NHS as Prime Minister
Gordon Brown’s first speech on health as prime minister was on January 7th and was widely reported. He was keen to emphasise the need for change and said “it would be a failure of leadership to impose a moratorium on reform”. The recently critical HSJ was positive. It said the speech was ‘a crucial moment in [Gordon Brown’s] bid to relaunch his premiership’. ‘For the first time, his vision for the NHS is clear. And the cornerstones are prevention and early diagnosis’. The FT’s Nicholas Timmins said it promised ‘more choice for patients’ and more local autonomy’. ‘Mr Brown repeatedly underlined his determination to stick by the Blairite programme of competition, choice and use of the private sector’. In his HSJ column, Simon Stevens agreed that before the speech Brown had been ‘painfully quiet on where he thought the NHS should be headed’. He declared himself pleased that Brown ‘finally showed some leg’. Stevens says the proof of the pudding will be in the eating. He believes that ‘the first real test case of Mr Brown’s commitment to reform is likely to turn on primary care. This is because the prime minister rightly insisted…that primary care needs to become “more open and convenient with new providers and more weekend and evening access”.
How will the government change general practice? GPs are feeling under pressure from the government and some that they are under attack. The government is determined to increase access to GPs and at the end of 2007 talks were broken off.
The DH gave notice that it intends to impose a new contract if agreement cannot be reached.
The HSJ noted that an ‘increasingly acrimonious row took a new turn when BMA GPs committee chairman Laurence Buckman wrote to 32,000 GP members updating them on the ongoing General Medical Services contract negotiations. Buckman said that the government had terminated discussions in favour of imposing its preferred solution, despite having agreed improvements such as an extension to screening in general practice. His letter suggested that the government was solely concentrated on increasing opening times in order to meet a political target.
Amid an escalating row, at the end of January Alan Johnson sent a briefing to all Labour MPs. He complained that the BMA were giving a distorted picture of plans to reform care. Mr Johnson wrote: "The proposals put to the BMA before Christmas were based on practices opening for an extra period, based on the number of patients registered with that practice. This would typically see an average practice opening for three hours each week, either on a Saturday morning or on one or more weekday evenings." The longer hours would be funded by using the £150m currently set aside for incentive schemes to improve patient access. Under the plans, evening or weekend appointments would be offered in addition to daytime services. "There would be no adverse impact, as the BMA has claimed, on the majority of people who [use] services during the daytime".
Johnson urged MPs to explain these plans to their constituents, including the findings of a survey which showed that nearly 6.5 million patients were dissatisfied with the opening hours of their GP’s surgery.
The BMA has been getting its message out to the regions. The Basingstoke Gazette reported that ‘doctors at the Overton and Oakley Partnership have sent a letter to the prime minister objecting to the proposal’. One of the doctors, Richard Coppin, said: "We felt the need to send a letter because we believe we're being forced by the Government to take actions that will harm the most needy. "I've spoken with many GPs locally and they have all said the same thing. The Government's number one priority should be patient care, but it seems this proposal is just to win votes. "They aren't taking a long-term view of the medical profession and are tinkering around the edges and causing harm. We feel very strongly about this and hope it can be resolved." In modern media, readers very often post comments at the end of an article. Sarah from Hythe made it very clear how she felt.
‘What a crock. Partners at a surgery can easily pull in a six figure salary yet appear to think that people only fall ill between the hours of 9-5. 30 mins per thousand patients means a Saturday morning or an evening a week for most practices. Perhaps this would give healthcare access to the taxpayers who actually pay their wages and don’t want to see a triage nurse at a walk-in centre or bung up their local casualty. I imagine most GPs will have shock when they discover there is more to their job then signing sick notes for Jeremy Kyle fans.’There does seem to be a sense that the public want GP surgeries to be more accessible to them. The pressure is not purely political.
Managers seem quite keen to push the case too.
The HSJ reported a plan by Heart of Birmingham PCT to set up large scale primary care centres and ask GPs to work in them. An editorial showed little patience for GPs opposing the scheme. “People with chronic conditions and poor care should not be expected to wheeze and hobble for a few more years, waiting respectively until those with nothing more useful to contribute than labelling a plan “a lunatic design” to come up with a better idea”.
An editorial suggested that larger centres would improve care and access to it. The Times said that the DH saw the plan as a future model.
The BMA will ballot its members next month over how to oppose the government’s imposed plan and is threatening to mobilise public support through a campaign in surgeries.
In a pre-emptive strike, Mr Johnson told Labour MPs the "BMA is out of touch with the concerns of patients on this issue". He quoted one BMA leader comparing family doctors to accountants who refused to work weekends. GPs have also been criticised for resisting longer opening while their salaries have risen by 55 per cent since 2002, to an average of £110,000 a year.
To understand the GP side, it has to be borne in mind that GPs believe the introduction of initiatives like Polyclinics – to which the government is committed, is building and commissioning – will spend the end of traditional family practice. According to a poll by the National Association of Primary Care, three quarters of GPs feel this way.
On the 4th February the secretary of state decided to bypass the BMA as he wrote directly to GPs. The health minister, Ben Bradshaw, told the Today Programme that the leadership of the BMA don’t really speak for the profession at large. A BMA spokesperson told the HSJ, “GPs are very concerned about the whole direction that the service is going”. ‘Asked if the BMA had gone to war with the government, she said: “Yes, very definitely”.’
Private sector involvement in primary care
Lots of analogies with dentistry have been made by GPs. What are they getting at? On the one hand, it is a reference to the exodus of dentists from the NHS. On the other it is a reference to the potential influence of the private sector in general practice.
We may see a return to the fraught arguments over the involvement of the private sector in healthcare.
Dr Buckman’s letter to GPs included an A4 poster for GPs to display in surgeries. It said, “Your general practice and the family doctor service in general is under threat. “The government is taking steps which doctors believe will harm patients. It is encouraging commercial companies to set up and provide GP services, but many doctors are concerned that if this happens, company profits will come before your needs.”
The letter was written a couple of weeks before United Health won the contract for three practices in Camden. The award of a fourth practice in east London prompted a protest at which local campaigner Dr Jackie Turner said: "Services will be provided for profit by a company whose staff may come and go, instead of committed family GPs and nurses who know the East End and local patients.".
In each case local GPs tendered losing bids.
Simon Stevens says there is no need for anyone to resist. Since UnitedHealth won a contract to deliver services in Derby city centre, the number of GPs has doubled, the range of services has expanded, the QoF score has jumped from poor to reasonable and surgery hours have been extended until 8 in the evening. ‘And, the ultimate validation – patients have voted with their feet in favour of United’s new GP services: the list size is up 33%.’
Stevens says ‘if this is a “threat” to old-style corner shop general practice, then we need more of it’.
GPs themselves are responding to opportunities to provide care in different ways. At the end of January, groups of GPs beat competition from the private sector to run four practices in Kent. GP magazine, in fact, reported that there is a 70 per cent success rate in GPs winning tendered contracts.
Virgin announced their first foray into primary health in mid-January. Their plan is not to compete with GPs but to work with them to provide premises and additional services. Virgin has no plans to bid for alternative provider contracts from primary care trusts.
Mark Adams, the ceo of Virgin Healthcare said his company was “there to help GPs rather than to threaten them”.
The FT explained that ‘under the business model, GPs would retain their existing contracts but Virgin would manage funds the doctors receive for staff costs and rental. Virgin would then offer a range of additional NHS and private services to visiting patients, including dentistry, screening, a pharmacy “and a range of conventional and complementary therapies”.’
How do the DH commercial directorate see private involvement developing?
Chan Wheeler, a former board member of UnitedHealth, is now the Commercial Director for the Department of Health.
He’s had a difficult press of late.
The Daily Mirror reported that he is getting his £2100 a week rent paid for by taxpayers.
‘Fat cat Chan Wheeler, 55, pockets a £185,000 salary but NHS bigwigs threw in the perk - equivalent to the wages of five nurses' - to lure him from his native US.’
Frank Dobson’s parliamentary questions that revealed the deal. He described it as “a bit much when everybody else in the health service is being subjected to pay restraint”.
The negative publicity continued in the Health Service Journal, which said he had donated thousands of dollars to the Republican Party.
The much written about Chan Wheeler was interviewed in the FT. He has ‘largely completed his review of central government contracts for extra treatment centres negotiated by his predecessor, binning those judged no longer to be value for money’.
Previously, the decision to cut back the ISTCs had been interpreted as a retreat on reform but this analysis suggested that the private sector’s role has been rethought.
Chan Wheeler says, ‘the projections for the capacity needed, made two years earlier, had been “severely miscalculated”, given improved performance by NHS-run institutions in the meantime.’
The market available to the private sector will be smaller than once imagined, as many reported. However, as the FT pointed out, “against that marked shrinkage, the government has announced a programme worth £1.25bn over five years for new GP surgeries and health centres that the private sector will be able to run, bidding for them against existing GPs and others. That – and free choice of a public or private hospital for routine operations from April 2008 – still adds up to enough to provide a dynamic NHS market for the private sector.’
When John Reid was secretary of state he predicted that one day the private sector might account for 15% of the total activity.
The current figure, Mr Wheeler told the Financial Times in an interview, was “less than 5 per cent”. And while he could not predict what the numbers might be in two years’ time, it certainly “won’t be 15 per cent”.
The important thing is that these deals will be done locally ‘with the commercial directorate’s role changing from negotiating centralised contracts to supporting primary care trusts in commissioning care from the private sector’.
A major fear amongst GPs is that practice based commissioning – the concept of clinically led service change – will be jettisoned in favour of working with private sector firms who have been awarded contracts to fulfill some commissioning functions.
BMA News said GP leaders were encouraging GPs to ‘stay involved’ in practice based commissioning to stave off competition with the private sector.
Healthcare Republic reported that only a third of PBC groups that have put forward plans have had them accepted by their PCT. The survey was carried out for the DH by Ipsos MORI.
The survey also found that 59% of all PCTs had yet to commission any services at all from PBC groups.
Can the government work with the professions?
In his regular column for BMA news, Hamish Meldrum, BMA chairman of Council, wrote, ‘at the risk of being accused of massive understatement, I would have to say that the prospects for 2008 don’t look too good. Many of the problems are ongoing and solutions will not be easy.’
The government might say that it is typical of the BMA to complain about being isolated, but there is a wider sense that doctors feel they are not being listened to.
As well as the BMA the Royal College of General Practice complained that its members feel excluded from the Darzi review process.
In January a Lancet editorial attacked the government for subjecting the health service to a series of evidence-free initiatives, such as the ‘deep clean’ for each hospital. In a separate piece, the editor Richard Horton described Mr Brown's vision for the NHS as a "dismal collection of patronising homilies, ill-thought out policies, and feeble rhetoric".
Is the government working with the professions?
Representatives of the royal colleges speaking at an MMC inquiry hosted by the Commons Health Select Committee said that a medical “vacuum” is being created at the heart of the Department of Health.
They claim medical professionals are being excluded from key decision making.
Former head of the Royal College of Surgeons, Mr Ribeiro told HSJ: “Before 1997, there was a proper avenue for medical views in critical areas. Now there is no way for medics to have access to the chief medical officer except on an individual basis”.
“There’s a distinction between the profession and the hierarchy of the DH as a result”.
‘Mr Ribeiro also said that hospitals needed more clinicians in management positions, calling the lack of chief executives with a medical background a “disgrace”.
Jon Restell, who is the chief executive of Managers in Partnership (the managers trade union) says there has been a decline in partnership working. “Certainly, the NHS in England gives the appearance of lots of partnership working at all levels. But it feels superficial – although the quality of engagement between the partners does often get better the closer to the ground you go’.
He says he went to two recent meetings – one was a manager audience and the other a union meeting. ‘The first group saw mostly opportunities; the second group mostly threats. ‘The only thing both groups clocked was the growing importance and likelihood of an NHS Constitution’.
The government seems to have an uneasy truce with nurse groups. Their staged pay settlement for last year seems to have been accepted. But they have warned that they will not accept any government interference with pay review body recommendations made this year.
The case for local pay settlements
They examine the effect of labour markets on the quality of care. It finds that in northern labour markets it is easier to retain nurses as pay and status are
relatively good. But in the south wages are relatively lower making it difficult to recruit. This means hospitals more reliant on agency staff. The authors show a correlation between quality of care and local labour markets.
For the Economist the problem is the rigidity of uniform pay systems in the NHS.
The FT agreed and said ‘centralised pay settlements are killing patients because hospitals cannot recruit sufficient skilled staff’.
What is meant by local control?
As the NHS debates its future, it is clear that the Darzi review and a possible Constitution are seen as incredibly important. There may be a danger, however, that too much stock is put in them. As one (anonymous) commentator put it, ‘the Darzi review is being talked about as the Second Coming’ while ‘the Constitution is seen as providing the ten commandments’.
But is talk about local delivery genuine? Is it a euphemism for greater local responsiveness to central policy? Is it possible that any document, even an NHS Constitution, could resolve the tensions that exist around the future of the NHS?
Alan Johnson: 'Our Goat is tethered'
In his interview with the Guardian, Alan Johnson was keen to say that Lord Darzi is not in total control of the future NHS.“This work has not been subcontracted to Ara. He is not producing an independent report that will be left on a shelf gathering dust. He is doing this as part of a team. He guards his independence, but he develops his proposals in discussion with us, and recognising our settlement in the comprehensive spending review”.
Darzi is one of the people brought in under the drive to have a “Government Of All the Talents (GOAT).
Johnson ends his comments by pointing out that, “our goat is tethered”.
Are we really going to see more local control?
The editorials of the HSJ have been angry at times in recent weeks. One example was headed, ‘just what do you mean by local control?’
Just before Christmas the government released the operating framework. It prompted the HSJ editor to ask whether the chief executive would be eating his previous advice to managers, that they should ‘stop Kremlin watching’.
It said, ‘the rhetoric of the last six months does not match the reality of the operating framework’.
‘David Nicholson and health secretary Alan Johnson have made considerable strides in renewing trust between the DH and NHS staff. But if they want to build on this they need to work harder on delivering their promise of a locally driven service’.
Not long later, HSJ editor Richard Vize returned to the theme.
‘Don’t be taken in by ministerial hot air on their belief in local decision-making. The latest move after the Clostridium difficile deaths…demonstrates that soundbites, press releases and the irresistible urge to be seen to be doing something still take precedence over sensible government.’
‘Just like Gordon Brown’s nationwide deep clean, it shows that when the going in the media gets tough, this government quickly defaults to a position of central interference’.
It called on the NHS chief executive, David Nicholson ‘to take a tougher line on ministerial meddling’.
Can policymakers change relationships in the NHS?
‘ A polyclinic is to be built just two miles from the hospital which will replicate a lot of what the hospital does from minor surgery to diagnostics. The argument that this is "care in the community" makes no sense to me. Surely the hospital is in the community, in fact at the heart of the community. ‘When the centre is up-and-running it is likely to deprive the hospital of valuable patients and therefore funds that it needs to keep operating. There just doesn't seem to be any overall planning. It is being done on the hoof.’
In his interview with the health secretary, John Carvel asked Alan John how he intended to overcome the ‘tricky part’ of moving work out of hospitals. ‘Hospitals need a share of the income for care provided off their premises because otherwise they would have no incentive to surrender the patients’.
Johnson says this could be achieved by “unbundling the tariff”. This is work that is in progress.
In mid-January the NHS Alliance added their voice to the debate. They said primary and secondary care organisations must work together rather than working in ‘adversarial competition’. Integrated healthcare services: the future of commissioning and provision of out-of-hospital healthcare in the NHS proposes ‘integrated provider organisations which will be based around one or more PBS commissioning groups, depending on population size.
Finding incentives for intergration
He expounded on his view in subsequent days – the former head of strategy at the Department of Health, believes the NHS is using the wrong sort of competition to improve services. The FT reported his view that instead of institutions competing over individual operations, the NHS should instead be building clinical networks to treat patients with chronic disease. One these are developed, patients could have a choice about which network they wanted to join.
At the end of 2007, the Nuffield Trust published a report by Chris Ham on clinically integrated systems. It says that resources should be given to specialists and generalists to manage, with incentives to maintain people in good health rather than treat sickness. Ham says we need to see hospitals as cost centres, in an integrated system, rather than as units encouraged to suck in resources, and as profit centres.
Ham told the FT, the type of competition that the NHS was adopting “risks fragmenting services for patients”. It could be suitable, he said, for relatively young and fit patients needing one procedure. “But, increasingly, older patients have multiple or complex conditions that require treatment by integrated teams of specialists, not treatment as a series of discrete, fragmented, problems.
“If you look at the evidence from the US, the highest quality care is delivered by integrated organisations that bring together commissioning and provision – for example Kaiser and the Veterans Administration [which provides for US ex-service personnel and their families]. “Integrated organisations may then compete against each other for patients, but once the patient chooses they get integrated, not fragmented, care.” That allowed specialists to lead the drive for service improvement, he said, and the NHS should be commissioning such clinical networks.’ “In the longer term, ministers could then explore how patients might choose between integrated systems, rather than just choose isolated elements of their care.” That would retain the benefits of competition, but with patients receiving a much more seamless service.
The worry, however, is that the NHS will not work together because of different sectors competing.
It is not that the secondary care sector should not provide outpatient services, it is that there is now real conflict in view over whether care delivered outside of hospitals should be led by the primary or secondary sector.
In his January speech, Gordon Brown said that he would permit Foundation Trusts to deliver primary care services. For some this worsens the divide within the health system as different sectors compete to provide care.
The NHS Alliance expressed concerns about Foundation Trusts providing primary care services. Michael Dixon said they would have a ‘vested interest’ in referring patients to their own hospitals. He says the motivation would be profit and actions would ‘feed the beast of secondary care’.
Sir Robert Naylor, the chief executive of University Hospital London NHS Foundation Trust, said that as a result of the announcement the trust would consider whether it would provide the primate care services in its planned poliyclinic itself, rather than invite a group of GPs.’
Arguments over the future of regulation
Sir Ian Kennedy, the chair of the Healthcare Commission told the MPs that are scrutinizing the bill – the Care Quality Commission – was neither necessary nor desirable.
The Guardian reported that ‘in an outspoken memorandum released last night, he told the cross-party committee scrutinising the health and social care bill that work to improve standards of care and hygiene would lose momentum if inspectors were distracted by at least two years of unnecessary upheaval. The merger would cost £140m and the rationale was unclear.’
The FT agreed. The changes in the Bill are important but none necessitate the winding up of the Healthcare Commission and Commission for Social Care Inspection. The forming of the Care Quality Commission would cost £140m that could be saved.
Too much change could also threaten progress. ‘If this goes ahead as planned in 2009, the two sectors and all their providers will have been subjected to three different regulatory systems from three different regulators within five years. That is a crazy way to try to improve services.’
There remains a lack of clarity over the roles and responsibilities of different bodies, such as Monitor and the new Care Quality Commission.
As a leader in the HSJ put it, ‘Monitor has warned ‘there is a risk of duplication of its own powers and a consequent lack of accountability’. The HSJ thinks that ‘warnings over accountability should be heeded’. It reports a leaked letter from the Sir Ian Kennedy to health secretary, Alan Johnson, which warns ‘it needs to be clear whose job it is to do what’.
Monitor says it is happy for the new Care Quality Commission to identify any failings on the part of foundation trusts, but it wants to retain sole responsibility for intervention.
There is an uncomfortable gap opening between the economic and quality aspects of regulation.
In his interview with the FT, Chan Wheeler – the head of the DH commercial directorate – promised a new code for the NHS, setting out some rules of engagement in a more competitive environment. It will allow all hospitals to market themselves to NHS patients and include ‘measures to stop primary care trusts obfusicating patients’ right to go to a private hospital at NHS expense’.
A report from the King’s Fund argues that a lot of these difficult issues could be resolved via the resolved NHS constitution.
The King’s Fund report favours a constitution over the idea of an independent board, which they call “misguided”. The report, Governing the NHS: alternatives to an independent board, argues for a constitution that would ‘enshrine the principle of subsidiarity – meaning actions should be taken locally whenever this would lead to better outcomes’.
Co-author Anna Dixon, who is deputy policy director of the King’s Fund told HSJ that “a constitution could spell out the roles of the Healthcare Commission and the Department of Health”, for example. The constitution should clarify roles and relationships.
It should not, however, seek to clarify boundaries on areas such as private sector involvement in the NHS – as the BMA suggested in its Rational Way Forward.
Will a constitution settle the NHS?
The Constitution has an important political dimension and is not just about setting out the roles of various agencies. It is an opportunity to forge a new relationship between individuals and the state.
Alan Johnson told the Guardian that “We are not 100% certain we are going ahead with a constitution, but we are examining the case for it”.
Interesting, Johnson says he does not want the NHS Constitution to be enshirined in legislation because that would give patients rights they might seek to uphold in court. “I don’t want the constitution to give lots of work for the lawyers so that the NHS spends more time in court and less on treating people”.
Why is there so much interest now in the idea of an NHS constitution? Former advisor to Patricia Hewitt, Liz Kendall, says it is closely linked to ‘tensions between central and local control and between politicians, clinicians and (more latterly) managers, which have bedevilled the NHS since its inception’.
There is great interest now because ‘these tensions have been brought into sharper focus in recent years. Many staff are disillusioned and disempowered by the top-down target driven approach that has dominated much of the last decade of health policy. Patients and the public are deeply concerned about proposed changes to local services yet feel powerless to influence decisions. And ministers feel frustrated that they are still being hauled in front of Parliament and the medial over local NHS ‘crises’.
At this time, it is an idea that attracts a lot of people.
As Kendall notes, however, the precise content and form of the constitution is yet to be determined. She thinks it should ‘find a way of enshrining the fundamental principles of the NHS’. ‘The second challenge is to increase the accountability of local services to patients and the public. ‘This raises the thorny issue of whether local government should have a bigger role’. While many in the NHS will recoil in horror, ‘increasing accountability over the commissioning of NHS services will be crucial’.
Kendall recognises the challenges of forging a constitution but if it can achieve ‘a batter resolution of the inevitable tension between central and local control, so that the NHS looks out to patients and the public rather than up to patients, it will be the best present the NHS receives’ in its anniversary year.
Will a constitution set out rights and responsibilities for the public?
In Gordon Brown’s new year message to NHS staff he suggested patients would be given responsibilities as well as rights. He said his offer to renew the NHS will be enshrined in the Constitution. “The Constitution will set out what you can expect to get from the NHS and what we expect to give you in return”.
Many interpreted this as meaning that treatment may be denied to people who led unhealthy lifestyles. Indeed, the BMA’s Rational Way Forward argued that a constitution should explicitly set out what patients were and were not entitled to.
Johnson says, “this will not be about denying healthcare to anybody”.
Members of the public will hold Johnson to his word, particularly amid reports that doctors themselves would be pretty hawkish about applying limits to treatment. The Telegraph saw a ‘new’ and ‘disturbing willingness to deprive people of medical treatment because of the way they have chosen to live’.
‘Many are starting to divide patients into those who "deserve" to be treated, and those who do not. 94 per cent of the doctors surveyed by Doctor magazine, for instance, insist that an alcoholic who refuses to stop drinking should be denied a liver transplant. Half believe that patients who smoke should be refused a heart bypass operation; a third think that many old people should not be offered any surgery at all; and a quarter maintain that anyone who is obese should not qualify for a hip replacement on the NHS.
Focusing the NHS on prevention?
‘Focusing the NHS on prevention’ is talked of as a magic bullet for resolving the ills of the NHS.The Times likened the government’s Obesity Strategy to the typical British body: ‘The framework is sound enough but its potential is buried beneath layers of blubber’.
There are signs that the government is looking to innovate in terms of ‘responsibilities’.
Financial incentives will be used, schemes that have been successful for medical insurance companies across the world such as offering discounts for people who go to the gym regularly.
The strategy said: "We will look at using financial incentives, such as payments, vouchers and other rewards, to encourage individuals to lose weight and sustain that weight loss, to eat more healthily, or to be consistently more physically active."
‘Employers will be encouraged to set up competitions with money, vouchers and other rewards for people who give up junk food in favour of healthy eating and living. Those losing the most weight would earn the biggest prizes.’
The Telegraph said having failed with ‘reasoning’, failed with ‘frightening’ people is now looking for a new idea: ‘fighting greed with greed’.
Lib Dem call for elected health boards
In his early weeks he has twice talked about the NHS ahead of detailed proposals due at the party’s spring conference.
First he paralleled David Cameron’s call for greater choice, albeit parading Denmark as the model above the Conservative’s favored Swedish model. On the second occasion he joined in with the traditional Labour sense that the NHS is a public service unlike any other and must be central to society. “I want the NHS to become a people’s health service”.
In an article for the Daily Telegraph, Nick Clegg said, ‘On top of daily control of their care, people must have input into the local management and decisions of our health service. Campaigns against local hospital closures show that people care passionately, yet feel they have no voice.’
‘Decisions should no longer be taken in Whitehall, shrouded in secrecy. Instead, directly elected local Health Boards would put people in charge. Via the ballot box, communities could choose to focus resources where they're needed - based on their own understanding of local needs. They could choose to have the council commissioning services, too, if they preferred. In time, I envisage us going further and raising some of our NHS money locally.’
Can effective local accountability be brought into the NHS?
The Scottish government is asking people whether they want the introduction of direct elections to local health boards. The SNP was committed to direct elections in its manifesto. The consultation document questions whether a move to elections could lead to special interest groups conspiring to get elected and then skewing local priorities.The NHS Confederation has consulted its members on a number of options for increasing local accountability – including local elections and creating new bodies to sit between the NHS and local government to commission services.
The HSJ report that about a third of PCTs responded to the online survey. More than 8- per cent wanted the current system to be given a chance to develop before any further changes. Nearly 60% were against having a single prescribed model. They want PTs and partners to be able to respond according to local circumstances. ‘Nearly 40 per cent of PCTs would support foundation trust-style membership while about a quarter supported appointing council representatives such as lead cabinet members or representatives of the main political parties to PCT boards’.
Can the NHS deliver information to inform patient choice?
According to the HSJ, the operating framework requires trusts to collect information on the success of
treatments ’in a move that could pave the way for more public information about individual clinicians’.
From April 2009, hospitals must gather data on patient-reported outcome measures (PROMs).
The King’s Fund chief economist, John Appleby, said the move was ‘unbelievably fantastic’. He said it would help the NHS assess productivity, which it has previously struggled to measure.
