Towards greater local accountability in health

A move towards greater localism in the NHS will raise two critical debates. One relates to the level of local variation and the extent to which national standards and guidance can and should bind together a common service. The second is how to better hold local decision makers to account.

Enhancing patient and public involvement

A report from the Picker Institute – Is the NHS becoming more patient centred? – argued that patient involvement in their care is not improving. Their report says that the proportion of patients who said they were closely involved in their care has only fluctuated by 1% since 2002.

Monitoring regional variations

The European Index, cited earlier, is critical of the UK for having ‘regional variations in supply of healthcare’ . There is growing concern that localism could lead to greater variation. At the beginning of October a survey for ITV’s Tonight programme suggested that 16 of the 152 PCTs ‘have policies that refuse non-emergency surgery to smokers or those classified as obese’.

The IPPR published Great Expectations: achieving a sustainable health system in September . Its central argument is that unreasonable public expectations threaten the survival of the NHS. ‘The report rejects the concept of a list of core NHS treatments as part of possible NHS constitution’. Instead, ‘a transparent and robust resource decision-making process is necessary, alongside fair and democratic means of taking decisions about health priorities’.

To create this level of agreement and transparency the report calls for the Darzi review to ‘propose the establishment of Foundation PCTs’. The best would be given local freedoms and citizen membership of these bodies would provide greater legitimacy to local populations.

Publishing information on specialist outcomes

Another IPPR report – Public services at the crossroads – was published in early October and made some interesting comparisons between the information parents have to choose schools with what patients have to choose hospitals.

In the education sector ‘parents can access raw test results and contextualised, ‘value added’ scores’. While in healthcare, ‘there are currently no statistics published on treatment outcomes at the provider level in the NHS’.

The report says this makes it difficult for people to make informed choices. As a result ‘the public judge hospital services in terms of the dignity and respect with which patients are treated, the visible cleanliness of wards, the quality of food and the availability of parking’. The report argues that while these are important aspects of treatment quality, they miss out even more important factors, like risk adjusted success rates for treatment.

There are moves to correct this.

At the end of August the Guardian reported ‘a radical overhaul of NHS strategy which will give patients a right to know the success rates of every specialist unit in every hospital’

For the first time, patients will be allowed to compare the quality of the clinical care provided in each NHS department. People with a particular medical condition will be able to assess the quality of the relevant specialist teams at rival NHS hospitals before choosing where to go for treatment. In some specialties, results for individual surgeons may be available.’ ‘David Nicholson is understood to ‘regard measurement of medical outcomes as the key driver of local improvement in the health service when the government moves away from setting central targets’ ‘The plan builds on a pioneering initiative by heart surgeons, who published results earlier this month showing the survival rates of patients undergoing coronary artery bypass grafts and aortic valve replacements at 38 specialist centres across Britain.

Sir Bruce Keogh, president of the Society for Cardiothoracic Surgery, said: "It is time for other specialties to take the bull by the horns and focus hard on defining what outcomes they feel can be used to tell whether their service is delivering good quality ... Without measurements, any declarations on quality are just empty rhetoric." He said, ‘in some high-risk specialties, the relevant outcome might be the survival rates of patients. In others, quality was more likely to be measured by assessing improvements in patients' condition. Identifying the right outcome was complex. "But we will all have to do it," he added.’

The IPPR report says that until information can be made available, the choice and markets in healthcare should be switched from the acute secondary sector to the management of long term conditions, where information problems can be more easily overcome .

Engaging the public in service change

Research in August suggested reasons to be concerned about service reconfiguration. It suggested that ‘people who were taken in an ambulance because of breathing difficulties were much more likely to die than others. Their chances of dying were 13% if they were between 10 and 20km from a hospital but 20% if they were more than 20km away. The findings held true even after the researchers accounted for age, sex and the severity of the illnesses patients had’.

Even though the research was based on data from 2001 - and things have changed - the research will raise questions about the capacity for new urgent care centres to cope with all patients and the optimum distance between A&E centres.

The authors of the report don’t pull punches. They say Government policy-making "may be driven by anecdote or supposition" rather than based on evidence of what is best for patients.

Michael Summer from the Patient’s Association summed up the quandary when speaking to The Guardian. "District hospitals will close and people will be travelling further. That time is critical for the most ill people. But the super-hospitals the government is proposing will mean when you get to hospital you'll receive the best attention."

A bigger blow to the government’s plans came from the outgoing patient tzar, Harry Cayton, talking to Laura Donnelly in the Sunday Telegraph. ‘Mr Cayton revealed that he resisted pressure from ministers to produce a report supporting plans to reorganise and close hospitals because he could find no evidence that the proposals were driven by the needs of the public.’

LINKs

Quiet but important progression of the Local Improvement Networks (LINks) has taken place this summer. LINks will replace patient forums and hold local health services to account. They will have the power to inspect premises, to request information (via the Freedom of Information Act) and to receive a response to its recommendations within 20 days. LINks will be able to refer issues to the local authority Overview and Scrutiny Committee.

Local authorities have each received £10,000 to begin setting up the process. Local government will tender for a ‘host’ organisation to manage the local LINk.

Patient and public involvement will have a structural link between the NHS and local authority bodies.

The aim is to improve local accountability. In the context of the centre ‘letting go’ and devolving more decisions, all political parties believe this move should be countered with greater local accountability.

Developing local accountability

There are a variety of debates about how best to strengthen local accountability.
The IPPR’s suggestion of foundation PCTs is one of several options being discussed.

Back at the beginning of September Gordon Brown began talking about ‘a new kind of politics’. He said he wanted to see citizen’s juries and to get people involved in the political process. Polly Toynbee was not convinced.

‘Labour will try to re-engage people with politics, locally, nationally, through citizens' juries examining the evidence on thorny policy questions. Locally, people will influence their beat policing, their local NHS, the help carers get and what schools offer. A citizens' summit will help draw up a "British statement of values". These promises are tricky. Will each participant protest when not all their views are acted on? Promising people power opens a Pandora's box’.

Options for the future seem genuinely open.

Minister Ben Bradshaw has called for a debate on how PCTs can be subject to more local accountability from local people. He said, “the degree to which PCTs involve public and the patients fluctuates, with far too few examples of it being embedded in culture and practice. Without being prescriptive about how, he said, “the growing culture of patient empowerment must extend to the governance of primary care” . This was in large part because “they will be responsible for spending vast sums of money and commissioning services don’t have any direct democratic accountability”.

Michael Dixon from the NHS Alliance believes that the issue of directly elected boards is “up for debate”

The Liberal Democrats have the most radical stance. Health spokesperson Norman Lamb says the NHS is ‘hopelessly overcentralised’ . The logical of reform is local devolution with the possibility of health eventually becoming the responsibility of local authorities.

The new political season sees a resurgent opposition and a tense political period for the government. In this context, discussions about service development and change will be tense and politicised. The coming months are a crucial time to see the extent to which the health service can begin to make sense of strategic priorities locally and take the opportunity to strengthen and improve local care systems.

Changing central and local relations

A key question for the NHS is the extent to which the government are prepared to allow policy to develop locally or whether – given the politicised nature of health policy – they will want to keep hold of the decision making process.

Gordon Brown’s announcement during his leader's speech at the Labour Party conference, for example, stated that the NHS would double the number of matrons to 5000 will concern those that believed central politicians were backing away from operational decisions in the NHS.

Politicians’ announcements are not always what the service needs. On October 1st, Independent Nurse announced that John Reid’s target to recruit 3000 community nurses by this year has been scrapped. A DH spokesperson explained this ‘This followed a call for ‘greater flexibility’ from PCTs and SHAs, and a belief that it was sometimes appropriate ‘to hire a social worker as a case manager’ instead .

In the HSJ, Richard Vize noted that ‘while Mr Johnson ostensibly banged the localist drum in his conference speech there was an undercurrent of central control, with heavy emphasis on how Ofcare will have new powers to inspect, investigate and intervene’. His view is that ‘if ministers fail to make this shift in thinking they will undermine the drive for a more patient centred, locally responsive NHS’.

The Darzi review points to locally driven change

Alan Johnson told the Labour conference that the Darzi review is an ‘unprecedented opportunity to shape an NHS which as clinically led, locally driven and focused on personalised services for patients’.

A new partnership with health professionals in developing reform was a key theme of the report.

"This interim report is the result of my discussions and sets out a vision for the next phase of the NHS. This vision for the future should not be just mine – or the Government’s – but a vision for the future of health and healthcare in England that is developed and owned by patients, staff and public together. At the end of the next phase of the review, I shall outline how we plan to make this vision a reality, in spring next year.

"This is not about imposing more change from the centre. Effective change needs to be led locally, driven by clinicians and others working in partnership across the service.”

These goals are supported widely though there is uncertainty about what they will look like. BMA chairman, Hamish Meldrum, said his association had longed call for this and hoped the government is sincere about this aim.

Gill Morgan noted the importance of developing a local view of reform. “To date, staff and the public have not had a compelling story setting out the need for change and this resulted in their increasing level of disengagement”. She said the review should leave a “lasting legacy” rather than be “a one-off exercise”. This would depend on “how widely local people are engaged and whether the process is sensitive to situations – there can be no national blueprint directing things in the background”.

The Darzi review envisages local consultations run by clinical champions appointed in each region. Eight doctors each working leading reviews of different services in the nine SHAs outside London. There will be 72 doctors leading reviews nationally.

The Darzi review will lead to widespread debate and some local political discussion of the various proposals being discussed.

One of the first opportunities was at the Royal College of GPs annual conference where representatives of the four UK CMO offices offered different views on whether extended opening hours will benefit patients. England’s deputy CMO Dr Bill Kirkup argued that sufficient evidence existed to justify an ‘experiment’ and that such a move could help to reduce health inequalities. However Scotland’s CMO Dr Harry Burns was less convinced and contended that the tackling of health inequalities would require a population-based approach. Northern Ireland CMO Dr Michael McBride concurred with this perspective. Deputy Welsh CMO Professor Mike Harmer stressed the need to consider the structure of service provision and expressed concern that drop-in centres could be subject to inappropriate use.

GP delegates voiced concerns that widening access would harm recruitment and retention, possibly impact on continuity of care, and they questioned whether the NHS had the resources to implement wider access.

London GP Dr Claire Gerada said the DoH should address the accessibility to acute trust services, such as X-rays and the ability to use Choose and Book outside office hours, rather than ‘fiddling’ with primary care.

Towards an NHS Constitution

The Darzi review says quite a lot about the balance between central and local direction of health policy and uses an interesting phrase to describe a change in approach: ‘supporting local change from the centre’.
The review states, ‘in time for the 60th anniversary of the founding of the NHS, establishing a vision for the next decade of the health service which is based less on central direction and more on patient control, choice and local accountability.
Lord Darzi says he has asked David Nicholson to put together a national group to explore the idea of an NHS Constitution.

The future for independent providers in the changing NHS

David Nicholson told HSJ that the days of centrally driven private procurement are over. Together with other reports of uncertainty, there have been questions about the government’s commitment to plurality.

In September the head of Nuffield Hospitals said they were uncertain about the direction of reform and the role of the independent sector. They said the role of independent providers under Gordon Brown is one of the most opaque areas of health policy. “Mr Johnson needs to come clean on the government’s thinking”.
Private health sector analyst, Laing and Buisson reported modest growth in the market by 2%. This is a slower rate of growth than in recent years and lower than that expected by many independent hospitals. The 2% growth rate ‘compares with the 10-year average of a 6 per cent increase and almost a 10 per cent rise in 2005’ .

But not all private providers are so gloomy about their prospects. Centres for Clinical Excellence (which took over Nations Healthcare in June) said that will announce sites for five ‘mini polyclinics’ within two months. According to HSJ, ‘CCE is pushing ahead with expansion plans despite other private companies’ concerns about the government’s commitment to involving the independent sector in healthcare’. They expect to attract some private patients and NHS work under the extended choice scheme. ‘The five mini clinics will be the first of 50, carrying out diagnostic work and procedures that do not need overnight stays’. Managing partner, Ali Parsa told HSJ: “We have not heard anything from the government which says they are going to curtail people’s choice. I am pretty confident that our investment is the right thing to do’.

Up until now central government has played a key role in the procurement of private sector support. Rather than a turn away from plurality from the centre it seems more accurate that the centre is retreating from being the driving force in procuring independent capacity.

The question of how far private provision will grow will depend upon local appetite to involve new providers. As Nicholas Timmins says,

‘How big a role all that will mean for the private sector will depend on patient choice; on how far primary care trusts take advantage of the new commissioning contract; and on how energetically they seek out private providers to challenge existing GP services. But after months of uncertainty there appears to be at least greater clarity on the independent sector’s role, even if Gordon Brown and Mr Johnson avoided any public reference to it in their launch of Lord Darzi’s report.’

The Darzi report was described by the FT as giving ‘the clearest indication’ that the government remained committed to ‘at least a degree’ of choice and competition. ‘After months of mixed signals to both the private sector and the NHS itself, the health secretary said the independent sector would have a role in providing 150 new health centres and 100 new GP practices that were announced’.

The announcement of the new framework to help PCTs commission gave the green light to 14 private firms who can be contracted to perform monitoring or analytical functions. The press release announcing the initiative said that approval of the firms would save local trusts procurement costs.

Hillingdon PCT has confirmed it wishes to work with BUPA. BUPA will be employed to help validate activity data supplied by the trusts it commissions from. The PCT hopes that it can begin to work with BUPA from November.

A few months ago, Hillingdon indicated that they would wish to outsource all of its commissioning. An important change over the last few months is that scope of activity for private firms involved in FESC is more limited that previously suggested. It is not now suggested that private firms could take over a whole area of commissioning.

The FT reported that UnitedHealth is advising ‘a couple of dozen PCTs but largely on a consultancy basis rather than taking over commissioning work itself’. Dr Rebecca Rosen, Humana Europe’s medical director, said that while she thought there would be “lots of PCTs who will seek a bit of help” with data analysis and moves to reduce the demand on health services, it would take time before “a small number of PCTs” might move on to “a much more integrated approach” in which the private sector undertook much of the commissioning on their behalf.

BMA chairman Dr Hamish Meldrum said the framework could help PCTs in the short term by providing expertise they might be lacking, but a cautious approach is needed to identify any negative impact on the provision of local healthcare.

Mark Britnell says focus on long-term conditions will be re-energised
Speaking at an event on commissioning for long-term conditions, Mark Britnell said that private firms could add value by helping the NHS to intelligently segment populations and better understand their needs.

He said that the plan last year to move care closer to home and concentrate more on long-term conditions had been “the right idea at the wrong time” as managers were being asked to save a lot of money. He said this was now being reenergised. This will be achieved he said by a concerted effort on access, a focus on inequalities and through the forthcoming framework for world-class commissioning.

He said the work of Lord Darzi should be seen though three prisms”: inequalities, access and the quality of services.

Britnell said that commissioning would be performance managed by Strategic Health Authorities and assessed by the Healthcare Commission/Ofcare. He said that PCTs would face “ten to fifteen key outcomes”. These would include their demonstrating improvement in the management of long-term conditions and in involving local people.

David Nicholson says he wants to see greater devolution

Talking to the Health Service Journal, David Nicholson talked about some of the things he has heard while touring the country with Lord Darzi.

“People say to me: no organisational change and no national blueprint.”

He says of the Darzi review, “each region will be in a place where they will set out what their vision is for their part of the NHS”.

Insisting he is a genuine supporter of devolution and promising to push for it, the NHS chief executive said: “My next phase of this change is to start to be much clearer about what the relationship between the centre is and the rest of the NHS.”

Managers and doctors shaping healthcare locally?

Nicholson thinks there is a lot of potential for doctors and managers to work together.

“What you find through the work that’s been done is that often clinicians and managers can be quite suspicious about what motivations each have. “But when you go underneath it they are all driven by the same kind of values.”

He said Payment by Results and practice based commissioning are enormously important tools in engaging doctors with change.

In his own interview with the Health Service Journal, Hamish Meldrum said something similar, that ‘we need a culture change to achieve a position of trust between doctors and managers’. He said better data was needed to support practice based commissioning.

Outlining a clinical vision of a reformed NHS

On October 3rd the NHS Confederation and the Joint Medical Consultative Council (formerly JCC) published a joint paper outlining ‘a clinical vision of a reformed NHS’.

At the start of the event Nigel Edwards explained that the report drew out some common ‘design principles’ for developing services. JMCC chair, Bill Dunlop, said it was essential that doctors were at the forefront at change, supported by managers

The report draws on interviews with doctors, from a wide range of specialisms, who have changed services. It shows that doctors and managers talk about changing services in very different ways. Doctors tend not to talk about plurality, choice and process redesign. Doctors put a lot of onus on the NHS as a system, underpinned by shared values. Clinicains see their role as working as part of a system which links colleagues and other services. ‘In this context, the division between primary and secondary care is increasingly redundant’.

All of the doctors interviewed had set up their own systems for collecting data to monitor and improve services. The report says ‘the NHS needs to make sure that the correct data is measured so that a truly focused service is created’.

The joint work outlines a set of principles to guide the design of services. It aims to ensure support for clinicians to lead services.

Professor Bill Dunlop, chair of the Joint Consultative Medical Council and co-author of the report said, “Doctors often complain that NHS reforms have resulted in incoherent health policies which have not led to improvements in patient care that the Government envisaged. Too often reforms have appeared to be imposed from the centre and without local consultation’.

Debating the future shape of care

The Darzi review is not going to rid the NHS of internal division on how to improve access in primary care, but it does provide a process for open discussion of service development. It will inevitably prove a political process. There will be a range of ideas put forward. If people feel they were not listened to they will provide little support for the adopted approach.

Some early signs of this are evident.

Pulse reported that two of the GPs advising the Darzi review said that GPs working for longer hours was not necessarily the answer. They also reported complaints that only a handful of the 72 clinical chairs leading the review in local areas are GPs.
Beyond the BMA, there is a feeling that GPs are being seen as part of the problem rather than the solution. Pulse reports that Gloria Middleton, a managing partner in a Sunderland practice and chair of the Institute of Healthcare Management’s primary care sector challenged Lord Darzi in a web chat held as part of the consultation process.

‘It is the belief of general practice that they are not being consulted and their views sought. It is very much from the patient’s point of view and the trust’s point of view with the exclusion of the people who are at the forefront of patient care.’

As part of the Dazi review, Sam Everington (member of BMA council and east London GP) will lead on access.

A federated model of GP practices

In September the RCGP published ‘The Future Direction of General Practice: A roadmap’. It sets out to tackle the problem of how general practice should respond to a changing context. It calls for a ‘federated model of primary care delivery. This would involve practices remaining their current size but collaborating in a federation of providers. This would include social care and reduce fragmentation .

The report calls for the new care models to be built around the primary care health team, linked to practices, rather than to the PCT.

In some ways the model might aim to deliver a virtual polyclinic as patients would be access ‘expert generalists’ through a local network of provision, expanding access to diagnostics, for example.

The report calls for equivalent access to diagnostics for GPs as specialists have with the promise of reducing referrals to hospitals. The report also aims to strengthen GP relationships with hospital based specialists, allowing them to consult for advice without the patient visiting hospital.

The report argues that only very specialist care needs to be delivered outside of primary care. The authors say the strength of their vision is in providing a critical mass for the development of care pathways, practice based commissioning, teaching and research and improving the management of long-term conditions.

Pauline Brimblecombe feels that the proposals “will help GPs drive changes in healthcare”. The model received some support form the BMA. Its chairman of council told BMA News the report “describes a clear direction of travel in an increasingly confusing and contradictory health environment”.

The nurse perspective

Healthcare Republic has been gathering the views of key figures on the Darzi review. Rosemary Cook, director of the Queen’s Nursing Institute, said that she was worried that the review was too focused on GPs.

“The focus of the resources is on GPs, GP practices and GP-led health centres. But more of the same in GP services is not going to deliver the changes needed.” She urged nurses on the advisory board to Lord Darzi’s review to ‘ensure the future vision of the NHS makes the most of the potential of community-based nurses’.

Some nurses will find the RCGP approach too GP-centric, with the concept of the primary care health team seen as a euphemism for GPs directing the activity of nurses. Some may see opportunities in winning contracts from commissioners to lead in the care of certain patients, a more attractive proposition than being under the control of practices.

A difference in emphasis from specialists?

There is a different view again from the specialists.

The President of the Royal College of Physicians, Ian Gilmore, wrote a piece for the HSJ about whether this is the end for DGHs. He suggests that ‘there will have to be an understanding of how to provide access to primary care in an unscheduled way and over a wider range of hours than has been delivered to date’.

Rather than propose ‘expert generalists’ as the RCGP report does, Gilmore says ‘we believe the direction of travel should no longer be for GPs to develop more specialist interests, but for more specialists to move into the community, working across the primary care/secondary care divide, for which general clinical engagement is essential’.

‘In creating a more community orientated service we must be careful we do not end up creating an expensive replica of DGH functions while destabilising local hospitals’.
‘Market levers should facilitate clinical networks not hinder them’.

The Academy of Medical Royal Colleges also published a report outlining their view of how service change should be approached. It said that while there is no evidence for the centralisation of non-complex and high volume cases, evidence does exist to support centralisation of complex and high volume care. The report proposes that community hospitals and urgent care centres can provide focus for people with less serious injuries and illnesses, plus access to x-rays.

The report is aimed at local decision makers, chief executives, and is designed to help them. The report says that Payment by Results is a barrier to change and that competition can undermine a collaborative approach between providers and sectors.
Polyclinics

The Telegraph report of the Darzi review was the only one to place emphasis on consultants. They reported that their creation would provide a new setting for consultants and specialists to provide outpatient clinics .

One of the ideas behind polyclinics and working across the divide is that consultants would move and work in community settings. So a report in the HSJ that specialists employed by PCTs feel professionally isolated is a cause for concern.

Michael Dixon of the NHS Alliance said this was an important issue to explore. “Too often their difficulties have been viewed as ‘a problem of their own creation’ or ‘problems faced by a small number of doctors who should have stuck around in hospitals.”

The report calls for more integrated approaches to providing care across the primary/secondary care divide.

GPs, however, are concerned about being herded together. To support their case they will point to data from the Improving Practice Questionnaire which shows that ‘small practices outperform larger models on opening hours, telephone access and waiting times’. Healthcare Republic says they ‘undermine the case for policy clinics’

The clinical director at the firm of analysts who drew the data together said results lent weight to the federated model, put forward as an alternative by the Royal College of General Practitioners.

Shaping future services locally

One of the difficulties in the NHS is that the idea of managers and doctors coming together to shape services together is easier said than done. There are very mechanisms, for example, to allow primary and secondary care clinicians to talk to one another.

The main mechanism was thought to be practice based commissioning. But this concept has substantially weakened over the summer and yet for a few years it has been seen as an indispensable part of the reform programme.

At the end of August, The Times’ Nigel Hawkes wrote ‘practice based commissioning is in trouble’ and said only a minority of GPs were truly committed to the scheme.

In early October the former chairman of the commercial advisory board (see story above about their voluntary disbanding) told GP magazine that he felt PCT management was obstructing the development of practice based commissioning because ‘it is easier to do nothing’ than ‘have to take a risk’.

It’s the financial climate that is to blame. “They are operating within the most draconian climate due to money. That’s not conducive to people taking risks”. He continued, ‘‘I have heard it from right across the country. Groups of GPs are getting together and they can’t get anyone to make a decision.’

He urged GP consortiums to push their problems further up the NHS, to SHAs. “If you are not getting the right kind of relationship with your PCT, go straight to the SHA and get it to step in. It has no option but to do something because it’s it responsibility to make all this happen”.

There is a view amongst GPs that there is little interest in practice based commissioning and that PCTs will seek to shape changes by working with private companies under the FESC agreement.

As part of the Darzi review, the chair of the NHS Alliance, Dr Michael Dixon, will lead on practice-based commissioning. Some of his insights can be gleaned from the mid-September NHS Alliance report on PBC – Early wins, early lessons.

It talked about ‘in-house clinics and participation in a PCT-led GPSI scheme’ that have allowed Whitstable Medical Practice in Kent to save £380,000 while treating patients faster. The practice is now planning new premises which will include a six-GP surgery and a community pharmacy alongside a brand new Polyclinic.

‘The North Peak Collaborative has commissioned its own out of hours service with the support of Derbyshire PCT. Of 200 patients surveyed, 182 describe it as “excellent” with the rest saying it is “good”. ‘GPSI urologist Dr Ashok Deshpande provides a telemedicine service for the diagnosis of prostatic hyperplasia. Now available across the whole of Havering PCT’s area, it saves £31,000 for every 100 patients seen. If that were replicated across the whole country, the NHS could save around £150 million’.

There are many more achievements like these. However, PBC has yet to be universally implemented.

Michael Dixon says that what is needed is the will from PCTs to devolve commissioning to the frontline, and the will from GP practices to grasp the opportunities that brings. Equally important are the basic essential tools: accurate, timely data - still not available to all practices – and management support, whether provided by the PCT or bought in by the PBC group.

Key issues arising from the new political season

At the start of the Conservative conference, David Cameron was under a lot of pressure. He started his “fightback” by stating that the NHS is his “number one priority” and announced his party’s intention to ‘renegotiate the GP contract’ . A report proposed individual budgets for people with stable long-term conditions and a new number for non-emergency unscheduled care – 116116 .

At the Labour conference, Gordon Brown said the NHS was his priority too. Like Brown, Cameron was described as at his most passionate when he talked about his personal experience of the NHS . Both leaders promised substantial change in primary care, especially on access to GP care.

Conservatives and Labour are battling over who is most competent to manage the health service.

Who is most competent to manage reform?
Speaking at the opening day of the Conservative conference William Hague said Gordon Brown is not a conviction politician. “He is a calculation politician. He calculates that people will forget who caused the current crises in our health service…He calculates that he can pretend to be a new government. But he is the old government and, after ten years of failure and disappointment, he cannot be the change the country needs.’

The Economist is also annoyed by Gordon Brown’s ‘year zero fallacy’ – the idea he is head of a new government.

‘In recent weeks Brown’s government has taken small but telling steps to rein in reforms in education and health, and Mr Brown’s conference speech left its hearers little the wiser as to where he might be heading. Change and more change are on the cards, it seems, based on listening to and learning from the British public. Mr Brown does not support analysing and learning from his own ten years in power. For that, honestly undertaken, would mean admitting mistake, and Mr Brown has little taste for it. Yet there are important lessons to be drawn. The first is that throwing money at a problem before nailing down the reforms needed to secure commensurate improvements is not enough.

The Conservative’s strategy is to directly blame Gordon Brown for problems in health policy in three ways: (a) when Chancellor his Treasury targets let to today’s problems, (b) his funding increases and then cuts have created a policy mess, (c) since Brown became Prime Minister the Tories say he has retreated from reform.

In his leaders speech David Cameron said: “Ten years on from a government that said “24 hours to save the NHS”, billions spent and yet morale is so low, some hospitals still threatened with closure, departments shutting down, productivity so poor in the NHS, what’s gone wrong?.”

Is the Brown government retreating from reform?
The think tank Reform released a paper after Gordon Brown had been prime minister for only 4 weeks, saying he was backing away from reform. They specifically cited th Darzi review. “Such reviews have in the past been an excuse for delaying reforms.

The Economist was also worried about signs of a change in direction.

“Public services cannot be improved by central diktat and performance measurement. Better by far to set up market mechanisms to allow individuals to do this. Hints that Mr Brown is undercutting reforms to increase choice and competition in public services, for example, support a view that this lesson has passed him by’.

NHS staff representatives were very pleased to hear a different language at the Labour conference. Dave Prentis, general secretary of Unison, the biggest health service union, said: "We were really pleased that Alan made no mention of markets, competition and choice in improving our health service."

It is clear that the government is seeking to talk about health in a different way, focusing on inequalities, for example. In his first speech as heath secretary, Alan Johnson said, “as we move on to the next phase of our transformation of public services, we must ensure that these improvements reach everyone, using our unprecedented investment combined with increased efficiency, to promote fairness, equality and social justice; closing the gap between rich and poor.”

Peter Riddell said that the government is right to talk about making public services accessible. ‘But that requires diversity of supply and patient choice, which he is reluctant to mention’. These ideas would challenge the workforce, ‘but keeping UNISON content is not the route to a personal health service’. A leader in the times talked about ‘Brown beginning an ill-conceived journey away from Blairism’.

By contrast, a week later Peter Riddell was pleased to hear Andrew Lansley talking about ‘increasing diversity of provision and extending patient choice. “These go much farther than Labour’s plans, at the same time as there are now doubts about the direction and pace of reform under the Brown Government”.

In the midst of a debate about the government’s commitment to reform, health minister Ben Bradshaw declared himself ‘puzzled’. He did not detect an ideological shift. It was more accurate to say that the ministerial team had “taken a step back to catch our breath and see what is going on”.

On the 11th and 12th October two announcements saw the government send clear signals that they saw a role for further developing plurality and competition. Asked about the role of the private sector at the launch of the Darzi review, Alan Johnson said: “Yes, there is a role for the private sector here, and there is a role for it in the rest of the NHS. But it is about patient care first.” The following day saw an announcement of 14 firms to support PCT commissioning.

While the government has stepped back from itself driving plurality but has established the means for local commissioners to employ the independent sector to provide care and support commissioning. The focus is on overcoming inequalities and in areas where access to general practice is poor the government has sponsored the use of new providers where local GPs are unable to meet need.

Changing relationships with professionals
The starting point for the new ministerial team was to change relationships with professionals. Lord Darzi’s appointment was widely reported as a step in that direction .

Recent weeks, however, have seen an interesting twist on clinical engagement: reassuring nurses and challenging doctors.

Alan Johnson’s conference speech noticeably praised nurses and midwives. Labour’s conference promised more matrons and more midwives. He said people who assaulted NHS staff would face jail. He promised spending on alarms fitted with satellite tracking technology, for staff working on their own .

At the end of Alan Johnson’s speech, Gail Cartmail of Unite's health workers' section congratulated Mr Johnson for a promise to recruit more specialist nurses, health visitors and midwives. "Thank you for changing the whole atmosphere of debate" .

When husting to become deputy leader of the Labour Party, Alan Johnson said he felt that the [Blair] government had listened too much to organisations like the BMA and not enough to others, like the RCN. Hamish Meldrum, the BMA Chairman of Council, seems not to feel so reassured by Johnson’s approach as other health professions. This summer he has complained that “ministers shout at GPs through the media”.
The BBC’s Nick Triggle speculated that the government are ready to push GPs in a piece entitled, is the PM gearing up for GP fight?. He argues that the Department of Health believe the threat of private sector encroachment into primary care ‘will force GPs to the negotiating table’.

Reinforcing this view, John Hutton told the Telegraph that what set Labour aside from the Tories on health was its willingness to challenge doctors and really drive reform. He described the Conservative public service policy report and its stance of leaving health to the professionals as "being where we were about ten years ago".
The Conservatives review was co-chaired by former health secretary, Stephen Dorrell. He argues that successive governments have systematically undermined a professional sense of ownership. He says that 30 years ago professionals were not sufficiently challenged. To fill the gap of consumer pressure, managers inserted themselves as proxy consumers, and they have gone too far.

This stance was not shared by all Conservatives. (It is important to remember that just at the end of September the leadership stance on policy was widely criticised within the Conservative Party). The Spectator’s political editor, Fraser Nelson, wrote on the 22nd September that Conservative health policy ‘is throwing in the towel’. ‘It’s all about saying: “we’ll do whatever the nurses and doctors want. Of course it’s important to take doctors and nurses with you in the reform process. But in public service you have to be on the side of the people’.

At the Conservative Party conference the Conservatives launched a pamphlet – The patient will see you now, doctor – which adopted a more challenging stance toward GPs. It seemed to suggest a change in approach. The document states an intention to give GPs the responsibility for providing out-of-hours care. It does not aim to revert to the old contract – as some commentators implied - the intention is to give GPs a commissioning budget for out-of-hours care.

The Daily Mail portrayed the line as a “U-turn for Mr Cameron’, but although the language is strident the policy is in line with the Conservatives support for practice based commissioning . What is interesting, however, is that the Conservatives are sending different signals to different groups? At the same time as grabbing headlines suggesting they will be strong on reform there are lots of reassuring words for professionals.

Writing in the Times on the penultimate day of the Conservative conference, David Cameron accused Labour of creating ‘a generation of demoralised public servants’ and called for a culture change. ‘What needs to happen? First, politicians need to give the professionals freedom to fulfil their vocation. ‘In return, professionals need to recognise that any move to realise them from the constraints under which they work now must be accompanied by stronger structures to enforce accountablity’. This includes ‘linking GPs’ pay directly to the service they provide’.

When speculation over a November election was at its height, David Cameron wrote to the prime minister to ask him to facilitate meetings between his team and the civil service, to prepare for a possible change of government. His first priority was to introduce ‘an NHS Independence Bill to make doctors more accountable to patients‘ .

The politics of service change
One of the most volatile political issues in coming months will be service change. The Conservatives will make the future of the DGH a key issue in the run up to the next election, with a particular interest in marginal constituencies.

On the 20th August David Cameron told the BBC’s Today Programme, "The basic point here is we believe the district general hospital is an absolutely key part of the NHS," . In his leaders’ speech to the Conservative conference, he was critical of the Lord Darzi’s plans for service change and its implications for local communities.
The Darzi review opens with the following sentence, addressed to the prime minister, the chancellor and the secretary of state for health. ‘As you know, I am a doctor not a politician’. Lord Darzi said he accepted his new role because of the need for a non-political view of health policy.

Cameron immediately politicised the report.

“The latest fad comes straight from the new Health Minister and he says of District General Hospitals, that their days are over. Well I think he’s wrong. People in this country, towns and villages and cities really care about their District General Hospital, they want it to be there when they’re ill, they want their children to be born in it and they want an accident and emergency unit open 24 hours that they don’t have to drive hours to get to.

“So if this government goes ahead with the plans to say the District General Hospital is over we will fight them every step of the way between now and the General Election.”

In the Times, Cammilla Cavendish said Darzi’s interim report ‘was little more than an advert for the Government’s two populist priorities: extending GP opening hours and tackling MRSA’ .

Even the timing of the report was immediately politicised. It was suggested the review was brought forward ‘as Mr Brown cleared the decks for a possible election announcement’. The Financial Times described it as the centrepiece of a ‘fightback’ by the government ‘in the face of the Conservative’s determination to put the NHS at the centre of any forthcoming general election’.

Conservative health spokesperson, Andrew Lansley said: "This is hypocrisy gone mad. Bringing forward Lord Darzi's findings so soon is yet another example of this government using our NHS as a political football. “How can NHS professionals feel confident, and how can patients feel safe, when they know that this report must have been cobbled together without consideration for clinical evidence?"

Lord Darzi himself, speaking on GMTV, denied the launch of the report had been rushed out for political reasons. “I had this report ready on October 1. "The launch is today because I am meeting 72 clinical leaders across the country who will be leading this review until June of next year." He said the interim report was always due to be published this month, before the Treasury's comprehensive spending review.

Addressing problems in primary care
The centrepiece of the Darzi report is its framework for addressing problems in primary care. Lord Darzi says it is ‘the issue that has been raised with me most frequently during the first part of this review’.

‘Sadly, it turns out that our current GP system has actually led to a larger inequality in the distribution of GPs across the country even as the overall numbers have increased. ‘We therefore need to open up the supplying of GP services in deprived communities to a wider range of providers’.
For the last three months a series of stories have created an appetite for radical change in primary care.

There were concerns about out of hours care, for example. In defending the decision to opt out, GPC chairman Laurence Buckman said that it was uncommon for professionals to work weekends. A vicar wrote to the Times the next day to say he was quite busy of a Sunday; a vetinary surgeon suggested ‘the suicide rate among vets is the highest of any profession because the hours we work mean we cannot get an appointment with our GP to pick up our anti-depressants’.

There was a sense that public sympathy was not fully with GPs.

A leader in The Times said, with respect to out of hours, ‘both sides have legitimate grievances. The retreat of GPs from out of hours ‘has made them look more like salaried bureaucrats than the self-employed professionals they claim to be’. On the other hand, ‘the BMA is on strong ground if asserting that young people will be put of medicine if they though governments could tear up contracts at will’.

Back at the end of August, The Times’ Nigel Hawkes wrote an article weighing up the
government’s options of working with GPs or taking them on. ‘Picking a fight with family doctors is a high-risk strategy’ as doctors are more trusted than ministers. The GP contract can hardly now be rewritten. ‘It could be torn up, but the precedent goes back to the days of the Conservatives when Keneth Clarke was in charge, so is unlikely to appeal to Gordon Brown’. ‘The alternative, if the government wants to square up to GPs, is to make their lives a little less secure by the threat of competition’.

In a parallel article, Hawkes explained that ‘primary care services offered by GPs have until now been largely exempt from competition. But things are changing. A survey last year by Doctor indicated that 40 GP practices are managed by private companies’.

GPs were under pressure and on September 4th the head of the Royal College of GPs wrote in the Times, ‘hardly a day goes by without GPs featuring in the headlines and usually not in a positive light’. Yet ‘recent surveys on GP workload and access showed positive results family doctors spending 40 per cent longer on each patient consultation and an 86 per cent satisfaction rating’. Mayur Lakhani is ‘concerned that GPs seem to have become the whipping boys for everything that is found to be wrong with the NHS. This obsession with GP pay is wearing thin. It is exaggerated, unfair – and must be brought to an end.’

It didn’t stop though and the debate was reignited by new figures showing the GP contract had cost £1.8bn more than ministers expected.

Then the CBI issued a report calling for a rewrite of the GP contract ‘to give patients more convenient access to GPs and to make it easier for the private sector to provide alternatives to existing primary care services’. The CBI think patients should be able to register with more than one GP. The minimum income guarantee that GP practices received, and which made it harder for private providers to enter the NHS market, should be "reviewed".

A Health Service Journal editorial described the recommendations as ‘modest principals’. A bullish editorial said that whatever the doctors’ trade union said the outcome would be the same, ‘alternative provides will move in to deliver better services’.

The NHS Confederation’s PCT Network chair, David Stout, said he welcomed the report but pointed out that “local solutions will depend on the local issue”. He noted “wide variations for satisfaction rates for GP services, depending on various factors. “For areas where opening hours are an issue for patients one local solution may be for PCTs to extended hours from selected practices.” He also suggested that people might register with practices near their work.

As part of its Darzi review process, the government has been talking the public about the future of health care. ‘The juries around the country were asked questions themed throughout the day’. These included: what are you main concerns for healthcare in the future? And, what are the current barriers to accessing health services? One of the participants ‘challenged the NHS to think outside the box to ensure better access. ‘Do you have to have GPs as gatekeepers to all NHS services? Another said there should be the option to bypass GPs and go directly to a specialist if the patient wanted to’.

The Darzi’s review is supportive of the registered list system and proposes 100 new practices as well as 150 GP-led health centres. The aim is to increase capacity for care in community settings. Lord Darzi writes, ‘where existing GPs do not start to offer these extended services, PCTs will be able to use the funding we will make available to commission new services’.

The review further proposes that GP income will be linked to their success in attracting patients. Patients’ right to choose practices will be reinforced and there will be more information published on NHS Choices to help them choose.
Healthcare Republic reported that ‘each practice will have its own ‘MySpace-type’ page’ on the NHS Choices website from the end of October. Practice managers will be able to edit and update their own webpages. This initiative is part of supporting patient choice in primary care and improving information for registered patients.
‘In the middle of this month, practices will be sent a template to allow them to begin online editing of their own web pages. It will provide patients with the most up-to-date details about surgery opening times, access for new patients, available services, appointments and biographies of staff. Practice managers can also upload their own patient satisfaction surveys. Quality framework details and the national patient survey will be uploaded centrally. As with MySpace, practices will be able to upload photos and videos onto their own page and will have the opportunity to explain to patients and potential patients, the strengths and aims of their services.’

Patient choice will be ineffective if there is no capacity for them to move to a new service and a discussion has begun on the best way to ensure this.

Back in June, in his HSJ column, Simon Stevens argued that the government had three options for delivering better access to primary care: through compulsion, capitation or competition.

In the months since there has been discussion around all three. A climate of discussion had built up that sought to compel GPs to respond. Ideas have been put forward for GPs to lose some income if their patients use other services. There are also clear signals in the Darzi review that competition will be used to increase supply.

The CBI report proposed dual registration in general practice, but this has been rejected by Labour and Conservatives as too expensive.

Writing in the Health Service Journal, David Stout, director of the PCT Network said, ‘another approach would be to recognise that patients are in many cases already voting with their feet by choosing to use alternative providers such as A&E departments as their main source of primary care.’

‘Rather than assuming the patients are wrong and trying to find ways of dissuading them from ‘misusing’ A&E, maybe we should turn this on its head and see this as an example of patient choice? The problem as it stands is that PCTs end up paying twice for the same service, as we continue to pay practices for patient registration through the Global Sum in the GMS contract and then in addition pay trusts for each A&E attendance. Instead, we could give patients the right to register with walk-in centres, urgent care centres and A&E departments for their primary care services as an alternative to a general practice”.’

An alternative incentive for GPs to increase access was reported by GP magazine in mid October. The plan is ‘to take 60 points from the clinical areas of QOF and make them available for improving access. For the average practice, 60 QOF points are worth £7,476 a year. GPs who had previously earned these points for their clinical care would lose them, unless they won them back by opening on Saturdays or in the evening’ .

The Comprehensive Spending Review
Alistair Darling’s Comprehensive Spending Review that a higher than expected settlement for health will finance Lord Darzi’s plans. Resources were announced for over 100 new GP practices in the 25 per cent of PCTs with the poorest provision, 150 new health centres.

Not all were impressed by the increase. Andrew Haldenby, director of Reform, said: “If the problems of the NHS and state schools were to be solved by an extra £2 billion, they would have been solved many years ago.”

The Chancellor also announced that he expects at least £8.2bn in value for money savings to be made by the NHS, which equates to a goal of 3 per cent in efficiency gains. The 2007 CSR states that it will be for individual NHS bodies to decide the best measures for their local circumstances to achieve these savings, but proposals include:

Improving community-based services to help those with long-term conditions avoid traumatic and expensive emergency readmissions.

Reducing variations in productivity across the NHS by spreading new technologies and best practice across the NHS.

Improving procurement practices.

The King’s Fund’s Niall Dickson said the CSR settlement “does leave the service short of the real terms increases of 4.4 per cent over the next five years that Sir Derek Wanless recommended in his 2002 review. “While the NHS is in better financial shape than in recent years, there remains a considerable challenge facing the service from poor productivity and slower than expected progress in tackling unhealthy lifestyles.” “As Sir Derek recently recommended in his report for the King’s Fund, the service must focus on improving productivity, tackling variations in performance and setting the right incentives for both staff and institutions.”

Derek Wanless evaluates policy development and financial management over the last five years
The King’s Fund published Derek Wanless’ appraisal of progress against his long-term plan.

Despite being critical, Wanless offered advice to the government about how to develop policy form here.

 Don’t draw back on payment by results or practice based commissioning
 Policymakers need to think about how the whole system of care fits together
 There is a need for a much stronger focus on public health

The Financial Times said the conclusion the government should draw from Sir Derek's review is that it needs more of the current reform, not less. ‘Labour's more market-like reforms are currently at about the stage that the Tories had reached in 1992 when they took fright at the implications and backed off full implementation. If Labour does the same now, it will be guilty not of five, but of 15 wasted years.’

Health policy and economic management emerge from the party conferences as political battle lines that will run until the next election

The 2007 conference season proved the old adage, ‘a week is a long time in politics’.

On Saturday the 29th September an election seemed certain. Gordon Brown told the Sunday Times that he would make health policy the central issue. “We will show we are the only party with the strength and vision to deliver change against a Conservative Party which refuses to back our reforms and cannot match our investment".

But by Saturday October 6th the prime minister told the BBC there would not be a November election. He wanted time to set out his vision for the country. In the intervening 7 days the Conservatives bounced back in the polls. They claimed the NHS as Conservative ground and accused the prime minister of playing politics with the timing of Darzi review – releasing it at the end of the Conservative conference and ahead of parliament reconvening.

A result of the conference season has been to make health policy and economic management the central themes of a reinvigorated and intensified political debate - two issues that are closely tied together in the Darzi review. The review will be the prism through which political issues are debated, raising issues such as reconfiguration, reform in primary care and ways to improve public accountability. It will also reveal different ideas within healthcare about how to develop reform, raising important issues about organisational and professional power.

This following draws upon a wide range of media reports, new research, discussion at seminars and the publication of guidance and policy to try and make sense of the complex context. It is divided into three parts. The first sets out emerging issues likely to dominate the new political season. The second explores how policy is likely to develop in this context. The final part focuses on what may become the biggest area of debate, how the NHS can be made more locally accountable.