Fishburn Hedges

26.07.2011

Last week saw the start of summer recess. It also saw draw to a close what have been a turbulent few months for the Government’s health reforms.
 
We took a moment to reflect on where we’ve come from and where we’re going with the reforms. Our roundtable event last Thursday drew together opinions from across the public, private and voluntary sectors on what the changes to the Health and Social Care Bill really mean.

The keynote speaker was Dr Michael Dixon OBE, Chair of the NHS Alliance and a practicing GP.

The key points covered during the discussion were:

- Many of the changes to, and discussion around, the Health and Social Care Bill has been little more than ‘political cant’
- Getting the role of the National Commissioning Board right will be key in making the reforms work. It cannot afford to be out of touch with commissioners on the ground
- The most promising aspect of the reforms is the alignment of fiscal accountability with clinical decision making
- We are likely to see the concept of – and dividing line between – ‘public’ and ‘private’ provider fade away over time

The listening exercise

There was general agreement that the Government’s changes to the Bill following the ‘pause’ were purely a political exercise.

Overall, and putting aside the cynicism that lingers around the Bill, the conclusion was that change to the NHS has to be better than clinging onto the existing system, particularly if it can foster a sense of ownership and accountability among clinicians.

One note of caution though: the host of new bodies being created could very easily increase rather than reduce the amount of red tape that already exists.

The role of the clinical commissioning groups (CCGs)

The discussion was framed by research out on the morning of the event from the Royal College of General Practitioners, which stated, among other things, that 85% of GPs have not been reassured by the Government’s revisions to the Health and Social Care Bill and 60% don’t want to be involved on a commissioning board.

However, Dr Dixon was not concerned by these rather stark statistics. In his view, GPs are easily persuadable and will get on board if time is taken to explain the real opportunity to them.

In his view, there are two questions that need to be answered:

- Will CCGs be allowed to do anything? The answer to this question lies in how the National Commissioning Board will function when up and running, and the extent to which it supports (rather than suffocates) local innovation and integration. Local commissioner representation on the National Board will be key.

- Will CCGs be able to get their own people on board? It is vital that the groups have real autonomy to shape themselves as they see fit (compromises such as mandating inclusion of hospital doctors on CCG boards are seen as little more than politicking.)

CCGs must seize power – it will not be handed to them.

Clearly it will never be possible to convince every GP to take an active role in the new commissioning structure, and there is a job to do with all GPs to broaden their focus out beyond the consulting room. However, with just 500 ‘leaders’, Andrew Lansley’s vision can become a reality – if the considerable resourcing challenge can be overcome. 

Public v private

The concept of ‘public’ and ‘private’ is changing. Back in Alan Milburn’s day, he talked about the NHS becoming a ‘system’ rather than a ‘structure’. This is a change that, in Dr Dixon’s view, is already happening.

The Health and Social Care Bill provides a punctuation mark between the past and the future.

We’re heading into an era where the concept of a public entity will fade, as we see the creation of a system where commissioners are free to simply choose the service that’s best for their patients.

After all, the idea of a purely public sector health service is a wonderful fable, but doesn’t really exist.

National v local

The role of the Secretary of State, who will remain politically accountable, was questioned. How do you prevent top-down interference?

For the NHS Alliance, the concern should not be about the role of the Health Secretary, but the National Commissioning Board. The organisation is actively pushing for the Department of Health to keep hold of powers to intervene, so that the National Board cannot dominate.

Involving the public

Greater public involvement in the new NHS is vital.

However we must acknowledge that the public’s relationship with the NHS is often an emotional rather than a rational one. As a patient, there may well be concern about the increased role of clinicians in commissioning impacting on the face time they get with their GP.

The key, in Dr Dixon’s view, is to create a sense of ‘corporate ownership’ of a practice, where patients are as involved in decision making as clinicians.

There is a communications job to do, to help patients and the public understand what the changes really mean for them; how services are integrated into the community; and what ‘choice’ really means.

Accountability

The question in the back of everyone’s mind is: how do you stop CCGs from becoming just like Primary Care Trusts (PCTs)?

The key is peer pressure. Clinicians talking to clinicians and holding each other to account. In the past it was seen as the PCT’s problem if targets were missed. In the new structure clinicians are truly accountable.

Of course penalties need to also be in place, but if a common objective (and threat) exists, you can get everyone to point in the same direction.

The inevitable question was asked about the ‘postcode lottery’, and whether increased localism will create more variation in the services available. Dr Dixon’s response was a simple and optimistic one: the differences may increase, but hopefully the overall quality will rise.