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… .