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.’