David Cameron has chosen health as a key issue on which to attack Gordon Brown at recent Prime Ministers Questions.
Following the Healthcare Commission’s Annual Health Check, he mocked the Prime Minister’s statement that he would listen to people. “He should listen to people in working in the NHS. The Healthcare Commission quotes a senior manager saying, "if anyone says the priorities are not finance and targets then they are lying".
Cameron continued, "The nurse of the year has today resigned and says she is leaving because of bureaucracy and paperwork.
Cameron then moved onto hospital acquired infections. “Deaths from c.difficile have trebled. If we are going to deal with hospital acquired infections then he has got to listen to the views of those working in the NHS.”
Gordon Brown responded by saying, "it is precisely because I have been listening to the British people that we have made £100 million available to tackle MRSA and c.difficile".
There are some common themes to the Conservatives criticisms of government social policy and one is a tendency to centralism. Cameron is presenting the Conservatives as champions of localism and Brown as fundamentally a centrist.
"On October the 24th, Cameron asked “when is the Prime Minister going to give up his mania for state control and start trusting teachers?"
To what extend should choice be the main driver of reform and what does Gordon Brown mean when he says he wants to "personalise" public services?
The number of patients who recalled being offered a choice of hospital for outpatient services has fallen, according to the DoH patient choice survey. The latest MORI poll of 75,000 people was carried out in May this year and shows just 44 per cent recall being offered choice.
For Nicholas Timmins, writing in the FT, the figures are ‘further evidence that the government's "choice" policy is struggling as a means of driving reform in the National Health Service.’
And according to Fraser Nelson, writing in the Spectator, there is a battle within the Labour Party over the approach to public service reform.
‘For some time now we have been waiting for Gordon Brown’s “vision” – the image of the future so compelling that he claims he had to cancel an early election to better explain it to us’. He says Labour MPs are growing impatient.
“I suspect Gordon is bluffing”, he reports one MP saying. ”There is no alternative Labour vision of the future other than the Blair one. His vision seems to involve turning the clock back ten years to top-down state control. And if he does that, the election is as good as lost”.
Nelson claims ‘the Prime Minister’s Strategy Unit has been ordered to drop the words ‘choice’ or ‘contestability’. This supports Nelson’s view that there is a clear policy difference between Blair and Brown. ‘Blair always trusted the invisible hand of the market. Brown, despite his occasionally protestations to the contrary, always preferred the clunking fist of the state’.
However, even if this analysis is correct, Brown may not be able to change the approach. A former Blair strategist told Nelson, ‘the genie is out of the bottle. ‘Once NHS users are given a choice of public or private hospitals they will not allow that choice to be withdrawn. “Gordon may have to rebadge the Blarite agenda, perhaps under his title of “personalization”. “But it’s out there now. It’s popular. It’s too late to go back on it.”
Speaking on November the 1st – a day that was widely touted for a general election – David Cameron told activists in his Oxfordshire constituency that Labour was “stumbling around looking for a vision”.
Cameron said the only way public services would be improved was by setting them free of state control. His view is that people must vote Conservative to achieve this. "This Prime Minister is never going to change, he is never going to give up the top-down targets and central control. It's in his nature, it's his philosophy. But unfortunately for him, it's history."
The Economist says ‘Mr Brown needs to convey a sense of how he intends to finish the main tasks—reforming the public services; reshaping the constitution—that Mr Blair botched. ‘That was this newspaper's plea when he took office. It has not been answered. It is worrying that, despite his pledge of yet more cash for the health service, he has said little about how to spend it more effectively. It is worrying too that his views on choice in schools are opaque. He says he wants the public sector to offer “personalised” services. But it is not clear what (beyond “better”) that means, or how it is to be achieved.’
The same divide that Fraser Nelson describes within the Labour party is also apparent within the Lib Dems, as they discuss the person and the ideas they want to shape their party.
In an article for the Telegraph, Chris Huhne took a swipe at his rival for the leadership, Nick Clegg. Huhne says there is "no gap in the market" for a third party "parroting" David Cameron by promising choice and competition in public services.
Are the government getting tougher with NHS management?
The health secretary, Alan Johnson, apologised for the "truly scandalous" outbreak of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust, which claimed up to 90 lives.
The Conservatives tried to turn the story into a reflection of the government’s approach, that managers were too focused on external targets rather than on the basics. But while there may be some sympathy for this view, reducing MRSA is itself a national target, albeit a new one.
Alan Johnson has reportedly ‘asked David Nicholson, the NHS chief executive, to call in the chiefs of the four trusts that received bottom marks from the Healthcare Commission for the second year running to explain what action they are taking to solve their problems.’
Mr Johnson said: "If this is not satisfactory we will consider more radical action. Stringent assessments would need to be made regarding the most appropriate [solution], but one of the options could be takeovers by well-performing trusts."
In the HSJ, Nigel Edwards bemoaned the culture around the reward and punishment regime for chief executives.
Many managers step up to become chief executive in a “failing” trust. If they face an impossible situation, far from “being promising future chief executives they become ex-chief executives and inevitably suffer damage to their reputation, self esteem and confidence - damage that is avoidable and generally undeserved.”
Has the NHS got a handle on its financial strategy?
The Audit Commission’s report on the use of finance in the NHS found that a third of NHS trusts in England are failing to provide adequate value for money.
The Health Servive Journal reported that many NHS trusts ended the last financial year in dispute with the PCT over sums owed for treating patients.
‘The Audit Commission raised the issue in its Review of the NHS Financial Year 2006-07. It described a 'growing problem with disputed balances' but could not quantify them. The Department of Health was also unable to give a figure but claimed it was 'certainly not significant'.’
‘However, HSJ has examined the audits at seven NHS organisations chosen at random from across England. In those seven, external auditors identified a total of £26m in contested bills - just over 1 per cent of the total £2.6bn turnover. If replicated across the entire NHS, the total disputed debt would be £869m.’
There are even bigger problems on the horizon for the NHS, according to widely reported analysis from the Foresight programme, commissioned by the government’s chief scientific advisor, Sir David King. If its projections of increases in the incidence of obesity are correct we will see a huge strain on public services.
Increasing numbers would face the prospect of limb amputations, as stressed joints struggled to cope with excess weight. Rates of heart disease, diabetes and breast and bowel cancer would also rise sharply.
Tam Fry, from the charity the National Obesity Forum, said: "People thought we would never reach this point, but we are now looking at a catastrophe for current as well as future generations."
The irony is that financial pressures in the NHS last year meant that PCTs raided £100m from public health funds in various measures to escape financial crisis.
A survey of PCTs by the Association of Directors of Public Health showed that half of their 103 respondents ‘axed almost all the projects promised by the government in the Choosing Health white paper from 2004. ‘Less than 103 of PCTs used the full public health allocation for the intended purpose’.
Tim Crayford, the association's president, said: "Three years after the white paper, funding intended to tackle preventative health problems is still being used to pay for financial deficits in some parts of the NHS." Instead of preventing the dangers, the health service was spending a fortune on treating the medical consequences. "With funding [available] at grassroots level, the government should make sure it is ring-fenced so that it can be used for its intended purpose."
Why are GP earnings back in the headlines?
After a few weeks respite, GP earnings came back into the headlines with the publication of a report on their income from The Information centre. The press headlines focused on the number of GPs earning more than a quarter of a million pounds (now up to around 300).
Matthew Elliott, of the Taxpayers' Alliance, added: "This is an astonishing amount to pay GPs when the service received by patients has improved so little. Katherine Murphy, of the Patients Association, said: "GPs are 10 per cent better off but their patients are not. “Patients have to pay more than ever for their NHS and are entitled to expect a better service.
In an opinion piece for the Independent, GPC chairman Laurence Buckman argued that ‘the government propaganda that GPs are monsters who have stolen money from the NHS is very wearing.’ He pointed out that the DDRB did not give a pay rise to GPs and that increases in pay were directly correlated to increases in performance. “Now they are unable to say that we are rubbish because the quality and outcomes have proven we are not, so they go and call us thieves instead.”
Jeremy Laurance asked, ‘have patients benefited from the largesse handed out to doctors practices? The answer is: up to a point. The chief reason for GPs' large pay rise since 2004 is that their new contract set a number of targets, with payments attached, designed to incentivise specific areas of care, such as treating blood pressure and helping smokers give up.’
However, Laurance also argues that GPs have chosen to pay themselves more rather than invest in practices. ‘The report from the NHS Information Centre reveals that, during 2005-06, they spent less on their practices and kept a larger profit for themselves – for the second year running. Over the two years, the extra they have pocketed amounts to £10,000 per doctor’
Laurance says, ‘ministers got us into this mess and ministers must now get us out of it. Gordon Brown pledged on the eve of becoming Prime Minister last June to improve access to GPs. Alan Johnson, the Health Secretary, has demanded more flexibility with opening times and more Saturday surgeries and threatened to make GPs' lives a little less secure by bringing in competition from private companies.’
‘In short, the Government wants a bigger bang for the extra bucks it has invested in general practice – and so do patients.’
As The Guardian’s John Carvel noted, ‘Opposition politicians were careful not to antagonise the medical profession by suggesting doctors are earning too much. But the Conservatives and Liberal Democrats called on GPs to do more to earn their salaries by improving the quality of service to patients.’
But then on November 2nd the Conservatives published what would have been their first piece of legislation had the Conservatives been elected, “the NHS autonomy and accountability bill”.
The Conservatives are keen supporters of GP-led commissioning and wish to see more clinicians take responsibility for the system. But with power comes responsibility and the Conservatives say they would financially punish practices that ‘do not come up to scratch on waiting times and clinical standards’.
This stance may not endear GPs to Conservative policy because – as commissioners – they will not see themselves as having ultimate control on waiting times across the system nor of the clinical standards of other providers.
Why does the Darzi review vex doctors so?
There were further reports criticising out of hours care and critical of GPs in particular.
Giving evidence to the Health Select Committee Lord Darzi estimated that there would be a 77% increase in GP consultations in London over the next ten years. For this reason, he said Polyclinics were needed.
When pressed by the Health Select Committee Lord Darzi conceded that the idea of polyclinics was ‘a vision statement, not a business model’.
A BMA-GPC survey found that three-quarters of GPs do not think spending money on extending GP opening hours would be the best use of resources.
A survey of European GPs by the French general practice magazine, Le Generaliste, found that British GPs are in an unusual position. While they are the happiest with their pay they are the second most worried about the future of their profession.
4 in 10 doctors believe the Darzi review is 'nothing more than a political tool'
A poll by Doctors.net found that 41% consider the Darzi review to be 'nothing more than a political tool'.
Andrew Lansley: "As a clinician he is held in high regard but I am unconvinced that Lord Darzi is in a position to speak on behalf of doctors' views".
A third - 29% - felt more positively about the review and felt it would achieve its aim of increasing access to family doctors.
As Nigel Hawkes wrote in the Times, If Gordon Brown thought that having a distinguished clinician as a minister would mend fences with the medical profession, this will be a sharp awakening.
Hawkes declared himself unsurprised by doctors' view. 'Small wonder, as these were little more than recycled ideas snatched from the in-basket of the Department of Health and thrown into a document that Mr Brown expected to form part of his election platform.'
'The best we can hope for now is that from now on Lord Darzi is allowed to conduct his review and produce his conclusions with less political interference.'
The Times’ Camilla Cavendish sees the report as fundamentally political.
‘His interim report was little more than an advert for the Government’s two populist priorities: extending GP opening hours and tackling MRSA. Until then, the greatest worry about the Darzi review had been that it might delay progress towards much needed reforms. No one had dreamt that he would be co-opted into a propaganda exercise’
Lord Darzi replied by letter.
‘She claims that my interim report, published last week, is an advert for populist priorities. I make no apologies for addressing two areas which patients and staff have told me need to be urgently tackled, but the review goes far beyond that. It is an ambitious vision to create an NHS that is fair, effective, safe and tailored to the needs of each individual. It is about improving the quality of care for everyone to ensure that every aspect of our health service matches the best.’
Cavendish also questioned the support Darzi has for reforming the NHS. Lord Darzi says this view is wrong.
‘Nothing could be further from the truth. I made absolutely clear in my report that my review is not about slowing down on reform. It is because of the reforms the Government has undertaken that the NHS has been able to deliver radical improvements in care for patients as evidenced by reductions in cardiac and cancer mortality over recent years.’
Is the Darzi review about empowering local change or driving change from the centre?
In his HSJ column (11 October), Michael White notes that 'experts are sounding sceptical about Lord Darzi's interim report. He says there are 'themes common to left and right'.
Reform say that the Darzi review smacks of centralism. They say it marks a 'retreat' to the central direction and spending of the Blair years. Unison are concerned that the Health Innovation Council is a new version of a 'failed centralised model' for service change.
The King's Fund has warned ministers to 'resist the temptation to issue central directives' in favour of 'practical and effective' local change.
As well as health, Reform is also very critical the government’s stance on education. They are similarly critical of the Gordon Brown’s latest speech on education, saying the Prime Minister is turning away from reform and from promises of localism.
Not all agree, however. As The Times’ Peter Riddell points out, “critics, such as the Reform think-tank, eager to show how the Brown Government is retreating from Blairite policies, claimed that the speech represented a significant extension in central government powers, moving away from choice and competition. This point is exaggerated as, for instance, the city academy programme is still expanding rapidly”.
A role for the private sector in increasing capacity within general practice?
HSJ editor. Richard Vize, says the message of the Darzi review is clear, ‘reform faster’. He believes that in speeding reform, the Darzi interim report ‘clears the way for private sector providers to break the logjam over GP access.' He says the private sector is attractive to government because it can introduce changes quickly.
Niall Dickson, writing in the Telegraph, argued for a radical approach toward general practice. To break their monopoly he suggested, ‘we should be thinking about giving surgeries five-year contracts which would only be renewed if agreed standards were met.’
In the Health Service Journal (11 October) Victoria Vaughan and Jennifer Trueland reported that Alliance Boots said they could provide the capacity for all 150 high street walk in centres that Lord Darzi’s interim review recommended.
The head of public affairs for Alliance Boots said that their stores had space. "It would essentially work as a landlord's deal - we can let the space and they can use it".
Alan Maynard of York university is a bit cynical about the deal. "The government lost out-of-hours in the new contract and is having to spend a large lump of money to improve access - it seems rather clumsy".
Uncertainty about use of the FESC framework
It is not clear how quickly the FESC framework will take off in England. This is the arrangement by which private firms can be contracted to provide data analysis and contract management eservices to PCTs.
The HSJ polled 74 PCTs – ‘including more than half of those in the North East, South Central, South East Coast, West Midlands and Yorkshire and the Humber strategic health authorities’,. It ‘shows that among sometimes strongly differing opinions between chief executives and commissioning directors, there is at least uniform uncertainty in whether they will be using FESC.’
‘The views of the 40 chief executive respondents were generally more positive about the framework than those of the 38 commissioning directors. The chief executives showed more belief in FESC, higher levels of clarity on how the expertise of private sector companies could help improve commissioning, less demand for other support and higher expectations of success.’
Clinical engagement to become a key target for PCTs
According to Healthcare Republic, ‘Continuous engagement with clinicians will become a key competency for which PCTs will be held accountable under the DoH’s new vision of world-class commissioning. ‘Clinical engagement will join 13 other competencies that PCTs are expected to develop as one of the three building blocks of the DoH’s redesign of primary care.’
Presumably, one of the way in which this will be gauged is the extent to which practice based commissioning is developed in local areas.
Healthcare Republic reported that a third of practices still don’t have an indicative budget. More fundamentally, half of the 1000 practices surveyed by IPSOS MORI (for the DH) were critical of their PCTs approach for the initiative.
Despite a lack of progress, 57% of those surveyed were supportive of the scheme. Only 8% were ‘strongly opposed’.
Public Finance magazine noted that ‘Almost a third, 31%, said PBC had not improved patient care, while a further 37% said it was too early to tell.’
Dr Laurence Buckman, chair of the British Medical Association’s GP committee, said he was not surprised by the results.
Most PCTs had simply been too slow in getting the policy put in place, he said. ‘PCTs just were not geared up for it and the amount of money available for them to do it is very small.’
The NHS Alliance, which represents PCTs and GPs, said there was a ‘worrying gap’ between manager and doctor perceptions, as PCTs claim to have given ‘virtually all’ practices an indicative budget.
Spokesman Dr David Jenner said: ‘If [managers] continue to maintain the mistaken belief that all is well, PBC will fall apart.
Doctors are also worried about polyclinics.
Reports of an ‘emergency meeting’ at the BMA said London doctors believe the Darzi review ‘sets out answers and asks questions about how to achieve them rather than looking at problems with a blank sheet’.
A Pulse report reinforced their fears, saying that they are prepared to withdraw funding from GP practices to fund the polyclinic model.
Dr Chaand Nagpaul, GPC negotiator and a GP in Stanmore, Middlesex, told the meeting: ‘PCTs are not behaving as if it’s a consultation, and are acting as if they have to implement it.’
RCP president says that doctors should be given more senior positions in organisations
Professor Ian Gilmore told the Health Service Journal that doctors need more clear leadership, which ‘isn’t about standing on a soapbox and shouting at government that they have got it wrong.
It is, however, difficult for clinicians to take on top management roles in the NHS. “It's cliquey at the top of trusts and it's not easy for doctors to come forward. Career managers who have been brought up together have a certain ethos and it's not easy to step up and leapfrog them to a chief executive position.’
Gilmore called for trusts to be headed jointly by a clinician and a manager, with the clinician taking on a much bigger external role than currently expected of medical directors.
Local staff need to be empowered to take ownership of the quality agenda
In the Chief Medical Officer’s 2005 Annual Report on the state of the public health, Liam Donaldson drew attention to the variation in clinical practice that patients receive. He said that while some of this may be appropriate variation, it may also be the case that patients receive treatments which are not very effective. He said patients have the right to receive the same high standard of care wherever they access NHS services.
In response Ministers asked the CMO to set up a High Level Group to report to him on the scope for improving clinical effectiveness in the NHS and to make recommendations for future action.
The group was chaired by Sir John Tooke and reported on October 23rd.
Their report said much work already being undertaken by a range of organisations but that there is no ‘single bullet’ to address the issue of clinical effectiveness, which is ‘a complex issue’.
It argues that staff in the NHS need to be empowered locally to take ownership of the agenda and promote clinically effective practice.
The report makes a number of recommendations: aligning national activities, promote local ownership, ensure clinical engagement, harness the capacities of academia and the research agenda.
The CMO has accepted the recommendations and will take these forward in conjunction with the new Health Innovation Council, headed by Lord Darzi. Donaldson also announced a call for proposals to pilot ‘Academic Health Centres of the Future’, ‘bringing together academia and the NHS across the health community’.
