This tangled mess: a junior doctor unpacks the NHS reforms

by Rudrajoy Chakraborty

The NHS, like any service, can always improve and it cannot live in isolation in an ever changing world. If financial management needs to be on the national agenda, it needs also to be on the NHS agenda. Healthcare provision and the way it is delivered are not set in stone, but I think it’s fair to say none of us knows definitively the best way of running a health service in the UK. However, without doubt is a service which needs to be excellent in the present as well as the future.

Whatever the health and social care bill actually brings to the table, it is rivalling Eastenders for being what everyone is talking about. I don’t have the intellectual capacity to entirely appreciate the ramifications of the NHS reforms. I struggled to list the main features of the government’s bill three minutes after reading it, despite extensive notation. Judging from my conversations with patients, reception and security staff, domestic cleaners, doctors, nurses and that dodgy cat who hovers around outside the old Queen Elizabeth Hospital Birmingham main entrance, my lack of comprehension makes me perfectly representative to discuss this bill. I’m too disengaged with the political manipulation of healthcare services in my 15 years of vague political awareness to tackle it all at once, so let’s tackle it only in part today, ladies and gentleman (and cat).

Commissioners and providers. That’s one of the ways you can categorise the work of the NHS. Commissioners give money to providers to deliver to you all that wonderful NHS care you love. Geographically we have strategic health authorities (SHAs) that oversee department of health plans in their areas through the various segments they manage, such as primary care trusts (PCTs), hospital trusts and mental health trusts. PCTs control much of the NHS budget at their local level and are the main commissioners at present. Hospitals (whether they be foundation or NHS trusts), GP practices, private hospitals (yes, I said it) and others are the providers who negotiate with the commissioners to get the contracts (i.e. money) to do what the commissioners feel is necessary for that area.

Let’s say we have the Narnia PCT. They’ve done their research, and they realise their area needs more angiograms as quite a few of their lions are dying of coronary artery disease. They then negotiate with various providers to see who can deliver this service to the standards the PCT wants. Narnia Hospital may tell Narnia PCT, “Hey, PCT, we have a cracking angiogram suite with a  big stone table, lots of handsome cardiology and radiology doctors and all the gear to do for you 10,000 angiograms this year”. Narnia PCT will discuss how much they are willing to pay for such services and how they will monitor this and, with the addition of some performance-related contracts now in the works, this is my simplistic conception of commissioning and providing.

I had the fortune of spending one of my clinical placements with folk at Wolverhampton PCT in my penultimate year of medical training. Once I’d overcome my egoistic sense of injustice at seeing non-medical people making decisions on key healthcare issues and spending, I accepted these people recognised and respected their role. Unfortunately, I also witnessed a few meetings where the slick provider negotiators ushered out more than the PCT should in all honesty have provided, as their slightly less well-dressed team didn’t seem to have much of an understanding of driving a hard bargain to get their money’s worth. GP consortiums seemed equally good at getting as much money out of the PCT as they could, and I realised the NHS isn’t all one Barcelona-esque team in the sense I had naively presumed it was.

We are going to replace our primary care trusts (PCTs) and strategic health authorities (SHAs) with clinical commissioning groups (CCGs). These new groups will include local general practitioners (GPs) hence the forwarded notion that we are supporting “our local doctors in governing our care, rather than some bureaucrats in PCT offices”. We have a few issues here; GPs being part of these new commissioning groups, competition being increased within the NHS, and increased private involvement.

We have an NHS budget, which regardless of how spectacularly cost saving plans work, is going to be effectively reduced despite it’s supposed protection, and much of this will be in the hands of these new commissioning groups. Will GPs and the CCGs they are a part of be better equipped to commission? Well, first they’ll need to recognise what the problems they need to tackle are. Medical people may have clinical experience and knowledge to interpret healthcare needs, and maybe they’ll apply this to studying the vast swathes of data they would need to in order to fully appreciate the healthcare demands of their region. I am not as big a hater of non-medically-trained individuals being involved in healthcare decision-making as some. Interpreting data on healthcare needs is something I wouldn’t trust to most of the people I studied with for 6 years, and certainly not many of the ones I imagine are going into general practice (perhaps hideously unfair, but the truth nonetheless) and I genuinely hope these CCGs have lots of cracking individuals who aren’t GPs to help with this aspect.

As for striking a good deal with providers? GP practices are essentially private money-making entities (I am told) and therefore their business acumen and ability to strike a good deal with the NHS budget may be better than their counterparts. The reforms are likely to mean there can be more private bids for these services, with Monitor, a group currently involved predominantly with foundation trusts, ensuring GPs are in their eyes rightfully promoting competition for the provision of services. This is going to put a lot of responsibility and pressure on the shoulders of these CCGs.

Competition drives up standards. This is a key concept. Seb Coe was quicker because Steve Cram was after him. Birmingham Heartlands Hospital has to make it’s chest X-ray unit more efficient to ensure not all patients are sent off to the new Queen Elizabeth Hospital. Seb Coe had to run quicker. How Heartlands improves it’s appeal is more complicated. Research is already being done since the provider base widened to include private and other public sector bodies for services that were traditionally just handed over to the local GP practice or hospital.  Patient choice for where they receive their operation has driven up quality in surgical practice already – though it should be noted this is through competition between public sector hospitals rather than private firms. Fears over private practice skimming low-cost services and not improving standards are evident in early research into recent provision adjustments.

There is also a fear that too many providers will cause fragmentation in service provision and therefore introduce bureaucracy and unnecessary divides in care which should ideally be centralised and united. If I need a benign skin growth removed and suddenly there are concerns over the nature of the growth, I’d like to be able to go across to the complex dermatology clinic in the room next door, rather than wait for an appointment at my local hospital for the less cost-efficient, more complex management path I may now head down having initially been at a private clinic for this quick growth removal. A shift towards centralisation of specialised and even primary care with fewer but bigger GP practices and specialised centres is generally thought to improve care, or at least in specialised service provision. However, research is difficult to come by when one is comparing improved quality of medical knowledge base and material resources, as would come with 25 GPs in the same building, against easy and consistent access to your local practice doctor or nurse that would come with more local practices.

At times, private involvement seems to be more an issue of political stance than of evidence. Clearly it sits uncomfortably with people that something as vital as the NHS is exposed to the market, to the motivations of bodies who are essentially viewed as money making bodies above all else. We will have to extra vigilant to their advances if their room for potential involvement increases as clearly investment into lobbying commissioning groups will grow when they can get a bigger pot of the money the CCGs have. Therefore, understanding the private sector will be vital. I don’t. I’ve never worked in it and I imagine it’s not a homogenous group of evil, money-making, people-hating bastards. One would think the growing sector of social enterprise would love a bit of NHS involvement.

I will delve into the murky waters of treatment of private and NHS patients in hospitals and healthcare worker pay reforms another day, and I imagine the upcoming BMA forums will help cast more insight into the minds of my colleagues in the West Midlands. I think the notion of QALYs and it’s impact upon the economic mindset of NHS care would also be interesting to touch upon in future.

However, as regards the issues I have stumbled through, I think it’s fair to say I do not know what these changes will bring. Commissioning groups have tough times ahead with less money and growing service demands. They need to have support in terms of research to know the needs it is required to wean out of the plethora of providers, and they need to have the time, energy and ability to negotiate well with providers on these services, to get good prices and effective ways of monitoring them. I am not sure GPs will be better at this job than non-clinical people, and I would imagine excellent management staff would trump GPs in negotiations any day of the week.

However, perhaps this new role for GPs will entice a new group of people with a fresh way of thinking into the career, rather than being often the home for those who don’t want to be regularly called into hospital at 4am to reperfuse somebody’s dying heart. It will take a special type of person to make for an excellent commissioner, and I wish them good luck! As regards competition and private involvement: I am not sure competition itself is the problem, even if it does tie in with an obsession with league tables and manipulating statistics. Incentives are an important part of the society we live in, and competition and pay related to it recognises that. I have an inbuilt bias against private companies striding into healthcare, and it is difficult to assess neutrally or find sources that search for the evidence-based truth above the desire to make the NHS fit one’s own moral vision. My exposure to the pharmaceutical industry makes me somewhat skeptical of private companies having patient care alongside their search growing profits in the field of healthcare, and early research does not encourage me as to how this will change when they start offering more of the direct clinical services.

I have opposed the bill on the basis that I don’t feel such a sweeping change made in this fashion, for an NHS which isn’t as broken as some would believe, is being done in the best interests of patient care. Babak Moussavi touched on the government’s poor selling of this bill to the public and healthcare staff, which will undoubtedly also affect how these changes are implemented and practiced and therefore it’s overall performance. The lack of acknowledgement of the strong opposition despite some bill adjustments strikes of arrogance, foolishness and general indifference towards the actual outcome.

The NHS was many things, including a political creation, and if I seek to defend, protect and improve it today, I must equally acknowledge that politicians can be a force for good in the field of life or death. I am just not sure where Andrew Lansley stands on that political pedestal I have in my mind… .

  1. We also see this kind of social welfare reworking in America on a regular basis. And I always have to wonder how many times we can restructure failure in the name of progress before we are forced to recognize failure. The negotiating you mentioned is always the problem with any government system because government bureaucrats are always spending other people’s money. A few dollars under the table here and there and all of a sudden your a business mastermind. Play it straight and you might not fare as well. Free enterprise with open markets and charities for those in need is the best way.

    • The context in the case of the UK is very different to that of the US. In the UK there already is a public healthcare provider that is free at the point of delivery. In the US, the pre-Obama system relied on private insurance, with the result that millions were (are) not covered. From your comment, and your blog, I would infer that you were ideologically opposed to Obama’s reforms, despite the improved efficiency that they would give to the system, by rectifying grotesque market failures that come through adverse selection on the part of private insurers (see Fareed Zakaria’s article in Time this week for a conservative defence of the individual mandate). But presumably, if you are indeed a proponent of “free enterprise with open markets” in the field of healthcare, you would support these reforms by the British government?

      • A third party payer system, especially government, is not insurance it is fraud because it is sold as something for nothing which is impossible. An entitlement means something you have a right to, we are entitled to be free, we are entitled to justice, and we are entitled to the truth we probably are not entitled to high tech medical care paid for by someone else. If insurance company X sells a medical policy with co-pays and deductibles they are really selling entry to an entitlement. Pay us 800 dollars per month and you will be entitled to healthcare. The false promise is that the customer is getting anything at all from the insurance company or government as the case may be.
        The customer was always entitled to buy medical services at negotiated rates, to arrange for barter or financing probably not entitled to be given medical services.
        It is informative to ask what does the insurance company provide in terms of services. When I say insurance I mean government also. My answer would be nothing. Some would say that insurance companies are able to negotiate lower rates. But if you look at historical consumer rates for healthcare during the last 100 years, you soon realize that nothing could be farther from the truth. Some would say that insurance companies streamline the process and make access more efficient. If you have dealt with any insurance paperwork, denied claims, or if you tried to file a claim lately that argument quickly looses weight. So the question remains what do insurance companies, including Medicare and Medicaid really provide. What function do they serve?
        I would submit to you that they serve the function of transferring wealth from the healthcare system, the providers and patients to large corporations and stockholders. Government systems serve the function of transferring power and wealth from the population to government. The fraudulent effect of insurance on the healthcare system is to siphon revenue from the providers by way of forcing their prices down and narrowing their margins and from the patients by driving their insurance rates up. This is not conjecture look back 100 years and the only people involved in healthcare to get richer are insurance companies. That is a simple fact not hard to verify.
        Another overlooked effect of health insurance is to drive up prices by increased provider and consumer bureaucracy, by eliminating the provider’s incentive to be efficient and by eliminating consumer’s incentive to consume services frugally.
        Insurance per se is not harmful or deceptive the theory is to spread the risk of catastrophe (a very rare event) over a large population thus minimizing the effect of the catastrophe on any one person. This would be a healthy system even for healthcare if we bought insurance for cancer, injuries, and life-threatening diseases. The premiums would be very low and most would never use the policies.
        Most would not consider buying car insurance for oil changes or flat tires because we can all see that this would dramatically increase the cost of flat tires and oil changes. Why then would we think health insurance for runny noses and checkups would make any more sense.
        Compounding the problem currently is the unholy alliance between government and insurance companies where government force is used to protect insurance company monopolies while criminalizing cooperation between physicians.
        Why not return to free markets where patients and groups of patients can negotiate for better deals. Where doctors can run hospitals and offer services to patients at the best possible price.
        The criminalization of profit is a giant step towards Socialism we should all be vigilant against this type of thinking. Were it not for the profit earned by the capitalist the socialist could not afford to exist.
        I am a doctor in the US and I see these systems operate in parallel every day there is no question that the cash system operates at about 30% the cost of the commercial or government systems.
        I used to be a socialist of sorts though that is a dirty word in the US but I began to study history and economics and have since become a libertarian, not by choice, but by sheer force of facts.
        Thanks for the opportunity to discuss these issues.

  2. And those charities marshall the equivalent resources of the NHS how, precisely?

    It’s all very well arguing that healthcare should be provided by private providers and charities. However, private provision results in exorbitantly expensive services – and not everyone can afford this. Look at the USA (where I think you’re from): millions of people, without health insurance, cannot access the health services that Europeans and the wealthy in America take for granted. And charities evidently rely on individual donors for their success. This results in a huge number of problems. Not only are those charities dependent on people actually coughing up the same amount as the government would otherwise raise through taxation to provide an equivalent standard of care, but there are no economies of scale. The NHS, for example, commands a lot of market power: after all, it is the lion’s share of the health market. It therefore is in a much stronger negotiating position than would be hundreds of isolated, charitable/private hospitals. Further, there are evident savings on administration and so on when running a single, large organisation than by running many, much smaller organisations that have similar needs.

    Please then explain to me: what is the advantage of having hundreds of private/charitable hospitals, for which people would ultimately end up paying for through donations, insurance payments or ‘purchases’ of treatment, and for which (due to the profit motive and a lack of economies of scale) they would probably end up paying more, over state provision of healthcare?

  3. Rudge said:

    So let me get this right.
    1. Insurance systems in the USA haven’t brought down prices.
    2. They give money and power to insurance companies / government.
    3. We don’t have an entitlement to high end medical care.
    4. If patients and patient groups came together, they’d get lower prices, providers would get more money and there’d be less bureaucracy (also meaning less unnecessary cost).
    5. Governments protecting insurance company interests – a bad alliance.
    6. Free markets would be better along with charity groups for those who can’t get in on the private action.

    1. Private insurance misses out on lots of people.
    2. Charities would not be able to help these people, or at least in not as cost efficient and clinically effective a way, especially in light of fragmentation meaning no power of economies of scale.

    Those the key points?

    Out of interest, I’d love to see some links to reading for the evidence behind all of this, and I will read that article in Time before I comment here.

    In America, are healthcare providers driven by profits in the same way other private sector companies (putting them all in the same basket lazily) are? Does “Washington Hospital” or whatever have the same desire to make as much money as possible as Shell?

    I’ll return later with something actually useful. There is a doctor’s union meeting today in Brum which I will hopefully go to (i.e. I’ll end up at work 5 hours beyond my end time and miss it as usual).

  4. katalog said:

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    at this and understand this side of the story. I was surprised you are not more popular since you certainly have the gift.

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