Extraordinary change requires extraordinary justification backed up by extraordinary evidence.
There has been, or very soon will be, extraordinary change, but there hasn’t been justification or evidence. There has been a lot of rhetoric and hot air, with repeated claims that ‘everybody accepts that the NHS has to change… is bloated… hasn’t improved in spite of all the extra money… is woefully inefficient…’ etc. Without a shred of supporting evidence.
Not only has there been a desperate lack of evidence to support the claim that the NHS was broke and needed Lansley to fix it, there is an even less excusable lack of evidence to support his proposed changes (opening the NHS up to any willing provider, GP commissioning etc.) many of which were well under-way before the bill came to Parliament on Wednesday.
What needs changing in the NHS and could it have been achieved without converting a public service into a market?
I can agree with the Lansley on 3 things,
- Increased clinical involvement with managing and planning services is necessary
- Many hospital services can be provided more efficiently, effectively and safely in the community
- The NHS needs to be more responsive to patient needs
The risks are
- that medical professionals will spend more time in meetings and less with patients, undermining efficiency gains
- Hospitals will have to find ways of remaining financially viable once services are provided in the community, or they will have to downsize, close or merge with other hospitals.
- There will have to be greater patient participation at every level, more open and democratic processes, and better accountability at every level.
These changes could be achieved without converting the NHS into a market.
Clinical involvement is welcome, but it needs to be multi disciplinary, involving specialists as well as generalists. There is no reason to exclude hospital specialists, nurses and community services all of whom have important perspectives on the provision of care. This could have been achieved by altering the PCT structure. The GP-purchaser, hospital- provider split is costly and obstructive -the financial incentives obscure clinical decision making.
Clinical services do need to move out of hospitals to save money, improve access and safety, but this must be done in ways that does not force the financial collapse of the remaining hospital services. It has to be done in ways that ensure that essential services are protected and that health care is provided according to clinical need. Converting the NHS to a market risks private providers cherry picking the most profitable services, undercutting the local hospital and causing financial ruin and collapse of complex/ high risk services. One effect of converting the NHS into a market is that the government can wash it’s hands of responsibility once hospitals close, saying GPs chose to commission services elsewhere and so it was up to them. The alternative, careful planned closure would be politically very unpopular, however careful. Unplanned closures, due to the whim of markets will cause total chaos.
Greater responsiveness to patients can be achieved at a practice level by funding the creation of Patient Participation Groups (PPGs) and ensuring every practice has one. Representatives could then form PCT wide PPGs which could have representatives on the PCT board and on the Health Scrutiny Committees. Our local PCT is being demolished to make way for a commissioning consortia that includes 3 PCTs so it will be far more remote from patients. There is nothing in the white paper to reassure patients that they will be better represented.
I think that change is due, and what is more agree with the government about three important areas in which it should happen. These changes could be achieved without privatisation which is unnecessary, unaffordable and harmful.
BMJ editorial: Lansley’s Monster
Independent: Shock therapy for the NHS
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These do exist in varying formats, stronger in some specialisms (eg mental health) than others. However successive Govts have tried to artificially engineer patient/user concerns down certain channels, and have always restructured and reconfigured user/carer/patient participation and involvement (from Community health councils which kinda worked, to PPI forums, to LINks and onwards to HealthWatches) each time it became apparent that users/carers/patients mightn’t be happy with neo-liberalism,back-door privatisation, turbo-charged marketisation, and the chimera of choice, and so might buck what the DH was pushing. The patient experience and involvement is essential for clinical effectiveness, but as far as the DH is concerned is a damn pain for the effectiveness of their ideological drive.
I appreciate your views differ a little from mine, but I see the problem essentially one of structuring the tariffs correctly. If these are set at the right level then there would be a way for the currently financially burdensome services such as a 24 hour Emergency dept to remain financially viable, even if other services move out to polyclinics. I have just finished a post on this.
Thanks for your comment Dr Phil. I see the problem as having to set up tarifs in the first place. Your ‘if’ is a ‘big if’ The health economy is extraordinarily complex. A mistake in one part can cause another to fall apart. The rug of available funding has just been shrunk by 20%, pull it a little in one direction and the service on the other side topples over. This week a private company from Kent sent us a brochure for their ecg interpretation service. On the same day I faxed an ecg to our local cardiology registrar and he phoned my back with the advice I needed. Before long he will have to set up a formal service and undergo a tendering process. The NHS depends on informal sharing of advice, opinions, resources etc. Before 1990 when the internal market was introduced I could refer my patients to any consultant withing the NHS. Contracts ended that. The cost of subjecting everything to formal contracts will divert an unacceptable amount of resources away from patient care.