Society North

Doctors against the marketisation of the NHS are planning to stand candidates for Parliament against coalition supporters of the Health and Social Care Bill. Locally we may well see consultant oncologist and stalwart NHS campaigner Dr Clive Peedell facing off against Lib Dem MP Ian Swales in Redcar. While there are undoubted benefits to the plan, not least the publicity keeping the NHS campaign in the public eye, there are also dangers. So is this something that will help secure the future of the NHS, a new risk or a distraction?

Pros
Some of the prospective candidates would make very good MPs with a great deal of integrity. MPs with a good sounding in science, a passion for healthcare and a professional life outside politics are good for Parliament, the NHS and the country.


Docs running for Parliament will keep the NHS centre-stage in constituencies around the country, and the media love them!
With sufficient candidates they may qualify for a party election broadcast.


Some may manage to take seats from coalition supporters of a marketised NHS (although so far the like of Dr Richard Taylor or Martin Bell had the benefit of at least one party standing aside).


If the docs can take more votes from coalition parties (who would not consider voting for an alternative party) than they take from pro-NHS opposition parties, it could cost coalition MPs their seats.



Cons

There is a risk that the docs may take more votes from pro-NHS parties like Labour or Greens than from coalition parties. This could actually see coalition MPs hold seats they would otherwise have lost. This is particularly true in Conservative marginals – Conservative supporters are far less likely to be opposed to the marketisation of the NHS than Labour or LibDem supporters. The intervention of the anti-EU Referendum Party in 1997 contributed to Tory losses to pro-EU Lib Dems. Ross Perot and Ralph Nader both intervened in US Presidential elections and helped politicians diametrically opposed to their philosophies over the finish line.


Mainstream political parties and their commitment to the NHS would really benefit from more medical / nursing / other health involvement. Medical input into the Socialist Health Association helped deliver the NHS and will be crucial in ensuring that Labour have the right health policies going into the next election and a real commitment.


The NHS is not a ‘single issue. Better health needs to bring together housing, transport, planning, jobs and the environment quite apart from the NHS bricks and mortar of ‘Save Our Hospital’. We need sufficient MPs (as a government) to deliver on all these social determinants if we are not just to ‘save the NHS’ but improve health inequality and ultimately stop people dying before their time.

For all their failings, all the main parties have a solid base in local government that provides an understanding of and ability to deliver local action.

A few thoughts…
In many places docs, nurses or anyone commited to the NHS should join the political party they support, get involved in policy, in campaigning and in candidate selection (particularly with all the boundary changes)


Choose the right seats to contest – even commission opinion polls to work out whether intervention would hurt or help the coalition. Richmond or Scarborough would be a better bet than Redcar, as far high profile coalition MPs in safe seats.


Find out who the other main candidates are before deciding to stand – these may well change significantly because of extensive boundary changes. It would be counter-productive to campaign against Evan Harris or Charles West, but not in those same seats if they are replaced by candidates who haven’t stood up for the NHS

The NHS campaign has involved tens of thousands of people in active health campaigning. Even without standing candidates there is a massive potential to sway political discourse and election results. ind out

As usual, please note any views are my own, not those of my employer, party, council, trade union etc. Any examples used here are specifically not taken from my professional life unless specifically identified.

Why I believe in clinical commissioning
Effective clinical commissioning is vital to delivering the best healthcare. Clinicians on the ground have knowledge, experience and a perspective that office-based policy makers, managers or administrators can’t. The same could be said of non-clinical support staff on the ground. Clinicians have been integral to almost all the main improvements delivering better health care, and many of the biggest cock-ups (such as NPfIT) have come when service improvements are driven forward that don’t have the effect on the ground the DH or McKinsey would expect. Good commissioning needs effective clinical involvement (as recognised by World Class Commissioning) and good provision needs effective clinical leadership (as immediately obvious on a high-performing ward or top-class GP practice). Good commissioning and effective services also demand effective managers, administrators, support services and technical people. Partly because were clinicians to manage the NHS they would have to spend less time with patients, and thus reduce the unique benefit they bring to leading health care, but because management, finance, system design, public involvement or analysis are skills that are both necessary and specialist, things that can take years to learn how to do properly – not something that can be learnt in the necessary depth in a short training course or an NAPC briefing. The third leg of our tripod of developing effective health care is patient and carer involvement, in which the NHS as a whole has a very mixed record. Look through the Health Service Journal, Nursing Times, GP or Pulse at the examples of best practice, the newly commissioned services or redesigns. Those wonderful services that get highlighted are almost always there because committed clinicians are working hand-in-hand with those derided as managers and pen-pushers, combining vision, drive, capacity and know-how, and in doing so improve patient outcomes and experience.

Why the Health and Social Care Bill scares me
Much of the Health and Social Care Bill can be summed up in two ideological prongs – structural reform to abolish PCTs and SHAs under the guise of clinical commission, and the consolidation of the market within the NHS under the guise of patient choice. As legislation and guidance has been brought forward the DH and the Listening Exercise have whittled away many of the most exciting things about GP-led commissioning – the local focus and innovation. At the same time, the particular form of clinical commissioning proposed has worrying issues around conflict of interest and political accountability. The Government seems to have stumbled into a clinical commissioning approach that doesn’t address the barriers to successful GP led commissioning I outlined in May:

• Centralised powers
• Finance
• Competition rather than co-operation
• Bureaucracy
• Lack of management resource
• A political ‘blame game’

GPs and other primary care clinicians are the logical people to provide clinical leadership for a whole patient approach. Specialists have the clear expertise to develop services and pathways for particular conditions – but it is the GP, practice nurse and the patient themselves that can understand the needs and the health system for patients with more than one condition at a time.

Yes – I’m a passionate believer in effective clinical leadership of commissioning, and I believe Mr Lansley needs to drop the Bill to save it.

Why does clinical commissioning need saving?
Of the Bill’s two main strands the Government has seemed more willing to sacrifice key elements of clinical commissioning in order to protect the second prong of promoting marketisation of the NHS. This marketisation may or may not be ‘the thin end of the wedge’ with regards to privatisation, but it will make massive changes to the way health is delivered and potentially disrupt our trust in our clinicians. For some there is an ideological opposition to making profit out of the provision of health care (although there are tens of thousands of suppliers to the NHS that make profit – and have been for decades). Others are worried about the destabilising effect of competition on local health services, particularly the knock on consequences of stripping services from hospitals, others on the risk competition poses to integration of care, or those who see the ‘devil in the detail’ of the actual methods used to effect competition. In practical terms there are powerful arguments that markets in health are potentially damaging. While patients (and carers) do want more choice the NHS is popular the public do have a devotion to the NHS and are skeptical of changes that could undermine it, or their local hospital.

A combination of concern over marketisation (particularly from the Royal Colleges and BMA) and worry over the unresolved issues around conflict of interest and the political accountability of CCGs leaves the Bill at risk from Lord Owens proposals that the House of Lords should give the Bill thorough scrutiny such radical changes deserve, even if that disrupts the timetables needed to pass it. If the Bill doesn’t reach the statute books there will be utter confusion in the management of the health service, a continuing ‘brain drain’ from commissioning and a lot of hacked off clinicians. If the Bill passes as-is the NHS embarks on some of its riskiest reforms ever, a continuing ‘brain drain’ from commissioning and even more hacked off clinicians. On top of that with such fundamental reforms rammed through without Labour support, or a full degree of scrutiny, why wouldn’t any new Labour Government bring in a whole load of new structural changes?

How can effective clincial commissioning be saved?
Andy Burnham, the shadow health secretary has offered Andrew Lansley a deal. It is an offer that has attracted criticism from some in the Labour party. Burnham has offered that if the Government drop the Bill, Labour will offer support to make sure that an enduring framework for delivering clinically-led commissioning within the existing legislation can be agreed and put into effect quickly.

If Mr Lansley takes Labour at its word and decides delivering enduring clinically led commissioning is more important than trying to push through marketisation, there is a chance to develop consensus and create systems that will be given the time to work, and without the delays potentially falling out of Lords votes.

Summary – Ditch the Bill to build good commissioning
I love the NHS – I rely on it for my healthcare, so does my family, and without the specialist neurosurgery unit and ICU at Hull my mum would have died when I was just 21. I know if I’m ill I’m not going to have to re-mortgage my house to pay the bills (even re-mortgaging wouldn’t have paid for my mum’s surgery). I know that if my GP says I need to be referred to hospital, or a consultant that I need a CT scan, it is because that is their best belief. When I go to the vets there is always a (tiny) suspicion that my cat ends up with particular drugs because that’s what pays the vet. I don’t want an NHS where I have even the tiniest suspicion that I’m getting care I don’t need, or denied care I do because of money.

I chose to work in the NHS because I believe in it – just like hundreds of thousands of clinicians, managers, support staff and volunteers. There is something special that makes it more than just a big pot of money and a little blue logo. The NHS has an ethos and is stronger because of a history of co-operation. If I see good practice somewhere else I will ask how to replicate it and will happily share my good practice with other NHS colleagues – it is in the interest of patient and taxpayer. A few years down the line, those people could be competitors, not part of the NHS family. It would still be in the patients and the taxpayers interest to co-operate, but working with competitors could cost contracts and jobs. I chose to work in the NHS because it was an incredibly complex organisation dedicated to improving things for patients, not having to rely on getting one over on competitors.

I love the NHS. So does Mr Lansley. And Mr Burnham. Labour’s offer gives a way out. Take it. Please. Get clinical commissioning sorted now, bring back your proposals for marketisation next year with time for proper scrutiny. Give the NHS the direction and stability it needs to concentrate on meeting the £20bn QIPP challenge, rather than risk paralysis through uncertainty.

Andrew Lansley – it is now the time to be an unusual politician and do something amazing as Health Secretary – put off your marketisation proposals for just a single year to establish a form of clinical commissioning that will work, and that will last. Recognise that clinical leadership will save more lives this year than an NHS market would. Perhaps the politics are all wrong – but the NHS is a matter of life-and-death.

Six health related articles worth reading…

Health Foundation
Getting out of Hospital
The NHS is placing a lot of hope for improving quality and delivering the £20bn QIPP savings it needs to make on moving care out of hospital. The Health Foundation’s review finds very little hard evidence that moving care out of hospital is saving money, particularly as the new services are bolted on to what was already there, rather than switching funding out of hospitals into the community. There are some areas, e.g. supporting early discharge with a great potential.

Kings Fund
Can competition and integration co-exist in a reformed NHS?
How the integration agenda can be taken forward even in an environment of multiple, competitive providers.

Left Foot Forward
The NHS needs reform and accountability – not the opening up of the market
Debbie Abrahams MP talks through her (Labour) view on the Health Bill’s amendments. In association with South Tees Dr Clive Peedell & Lucy Reynolds.

Roy Lilley
More to learn?
Roy Lilley on responding to complaints – comparing the NHS to Rupert Murdoch

Health Service Journal
Lansley heralds change in size and role of acutes subscription only. Andrew Lansley on acute reconfiguration: “It’s impossible for us to achieve the changes we are talking about without there being changes in the capacity of acute hospitals and the configuration of acute hospitals. Whether there are fewer in total is a moot point”

and finally the best of them all…
Private Eye
NHS Whistleblower Special
No link – fantastic expose of how some very brave people risked their career to protect patients. Makes me both at once proud and ashamed to be part of the NHS.

When Tsz-hia became governor of Ku-Fu, and consulted him [Confucius] about governent he answered, “do not wish for speedy results. Do not look at trivial advantages. If you wish for speedy results they will not be far; and if you regard trivial advantages you will not successfully deal with important affairs.”

Analects of Confucius, c. 3rd-5th century BCE

Contrast Confucius’ words from at least 2,200 years ago with the actions of Birmingham City Council with their decision to outsource 100 IT and HR roles to India by the end of the year (and make the staff they are going to make redundant help train them). This will presumably save money for Birmingham City Council, but will take money out of Birmingham (the effect of staff salaries in the local economy after the ‘multiplier’ effect), cut income tax receipts, increase benefits payments and health spending. Ultimately it is the taxpayer who will make savings on the council’s payroll, and the taxpayer that has to pay out (a potentially larger amount) to make up for the higher costs and lost income elsewhere in the public sector.

For this outsourcing to make sense in purely financial terms either:
a) there is sufficient unmet demand for labour that current employees can find new jobs without displacing other job seekers; or,
b) The money paid to Capita for delivering services from India together with all the higher costs and lost income from elsewhere in the taxpayer-funded public sector is less than that currently paid by the taxpayer for the services of these Birmingham council staff.

Are either of these likely in the current economic climate?

That’s even before considering quality or the political and moral arguments as to whether our tax payments should be supporting jobs in the UK or abroad when delivering public services.

It isn’t just Birmingham City Council that are taking short-term decisions or seeking trivial advantages, with the public sector cutting back services that prevent greater costs in future, or shunting costs (e.g. health to social care and vice-versa) to make savings in one part of the public sector while creating greater costs elsewhere to be funded from the public purse.

It seems such a shame that there is an endemic weakness running through UK public finance and public services that was identified by students of government at least 22 centuries ago. Perhaps we’ll have started looking the big picture in government and public services by 4200 AD? If they still exist that is.

Working together for a stronger NHS, the Government’s ‘listening document’ proclaims:

Too often people feel that while they can take control over most of the decisions in their lives – the things they buy, the entertainment they watch, the holidays they take – when it comes to public services, they have to take what they’re given. But we understand that choice is absolutely crucial to driving improvements in the NHS.

It’s hard to find anything not to agree with there, but for the Government choice seems to only be the very narrow choice of choice between providers offering almost exactly the same thing, while its policies undermine real choice. As time goes by I’m being given a choice over the little things, a facade of choice, but having to take what I’m given even more than under the previous Government (which itself had a long way to go). Competition can be a means to deliver choice, but if it is taken as an end in itself it can reduce choice. These policies damaging patient choice fall into several main areas, some related directly the the Government’s proposed health reforms, even more related to decisions taken over NHS funding and the gutting of local government budgets.

Commissioners not funding treatments or delaying them

In response to funding pressures, particularly the need to balance short-term spending, PCTs have been limiting or delaying treatments previously available to patients. Some of these decisions have been taken in a rational, evidence based way – if there is limited funding, identify the least cost-effective procedures and make any cuts there first – others not. Many PCTs are not providing treatments that NICE, the official body that assesses the cost-effectiveness of treatments has signed off as being cost effective, for example limiting IVF treatment. Elsewhere in the UK PCTs have been delaying referrals to secondary care, limiting drugs, or trying to push for a lengthening waiting list to push activity out of the current year. So I have to take what I’m given, even though I can choose between the providers I can’t receive IVF at or choose which provider waiting list I’m languishing on. Some choice!

Paying for choice

With lengthening waiting lists and procedures not funded by the NHS, I have choice, if I have enough money to go private. The boss of the UK’s largest private healthcare provider has just told the Health Service Journal that he is ‘more excited than ever’ by the NHS reforms and the spending squeeze. “Healthcare in the UK must see either an increase in private provision and funding, or accept unsatisfied demand… what better marketplace could you be in as a healthcare provider?”. Of course, if you don’t have the cash, its not much of a choice and you have to take what you’re given.

Competition’s real cost

Uncontrolled competition will mean currently viable hospitals are unable to cover their costs as they lose the simpler work to the private sector. Much of a hospital’s costs are fairly well fixed, especially if it is a PFI hospital – it will be paying for a room whether or not it uses it. On a lesser scale, specific departments in currently viable hospitals will be closed. At the moment I have four consultant-led maternity units, and two midwife-led units within half an hour’s drive (traffic permitting). Both those midwife-led units used to be full maternity units, but were ‘downgraded’ because of a clinical need to concentrate consultant-led care on fewer sites. The next closures could well be because of cost as the independent sector takes away many of the simpler gynae work that pays the consultants. See also Why markets in health rarely make sense (in a few simple steps). Similarly elective procedures in other specialties may be available at fewer hospitals if those hospitals cannot afford to keep the key emergency services in place in case of complications.

Mental health and learning disabilities

Mental health and learning disabilities are two areas where real choice could be offered as there are very different philosophies of treatment and potentially a multitude of providers (without the costs of expensive equipment, and only very specific need to maintain spare capacity for round-the-clock emergency cover). (Concentrating on mental health as that’s an area I know more about) there are a huge number of non-medical services designed to promote recovery and rehabilitation. Choice isn’t just between whether you see a surgeon at your local NHS hospital, or see the same surgeon at the local private one, but a real choice between differing treatment approaches. Medically-led care can be fantastic for some people, for others not much of a help at all. Unfortunately cuts to the NHS, local government and Supporting People are hitting some of the very services that give people with mental health problems any choice. On top of that impoverishing disabled people on benefits will make it even harder for people to access the services that are there. And the poorest will be hardest hit.

Health promotion

When the Government came in it took an ideological decision to cut public health promotion campaigns. I deliberately say ideological as they pulled some TV spots that had already been paid for. A direct result has been fewer people making use of services to help people give up smoking, find out about substance misuse or improving their lifestyle. I am glad that in the face of overwhelming evidence, Mr Lansley has been willing to change tack on these specific parts of health promotion, but it is still demonstrates a mindset against many of the health promotion / public health measures of the prior Government. Sometimes people do need a bit of help to get to the point they can make a choice.

Competition can be a really useful means to an end, if used properly. There are things that the NHS currently does, that it does worse than similar services in the voluntary or private sector (e.g. group weight loss sessions). Similarly real choice empowers patients – we know our specific circumstances better than a doctor or a nurse, however skilled and experienced they are. The Government is going wrong by pursuing damaging policies that promote very narrow competition while undermining choice. And once again, it will the the poorest who will bear the brunt of the damage.

Please note that all views expressed here are my own and not necessarily shared by any past, present or future employers, colleagues or associates. Any observations are general (i.e. not relating to any specific person or locality) unless otherwise specified.

I am not an instinctive supporter of anything proposed by the Tories, but I was pleased when Andrew Lansley was appointed as Secretary of State for Health with his experience as a shadow minister, his stated commitment to increased clinical leadership and his promise for no more top-down reorganisations of the NHS. However when I first saw the Health White Paper last year I was amazed at how the Government had managed to take so good broad principles (clinical leadership, choice, quality, localism) and still retained the worst of Labour’s central controls, while destabilising the health service by making hospitals unviable as competition salami-slices their revenues. “No top down reorganisation” had gone out of the window – “revolution” rather than “evolution” was the new watchword.

A year on, Lansley’s plans are getting a rough ride. They aren’t popular with the public, most of the medical profession, nurses, health service staff unions and the Liberal Democrat Spring Conference. The great and the good of the health service (at least those who haven’t already come out against the changes) have been sent forth with a mission – to listen – to the views of all those who’s submissions to the White Paper consultation were ignored. What next? Who knows? Probably even Mr Lansley doesn’t. On the off-chance anyone is listening, I’ll make one final plea to reform, rather than ditch, proposals for GP-led commissioning. Why?

Mrs Smith is 72, a long-term smoker, with hypertension, arrythmia, a history of several TIAs and is developing vascular dementia on top of COPD. She will regularly see a specialist heart nurse, is admitted to hospital with respiratory problems several times a year and under the care of the community mental health for older people team. There are only three people who link the various strands of health care Mrs Smith receives – Mrs Smith, her husband, and her GP. It is people like Mrs Smith that the NHS is really struggling with – patients with multiple morbidities spanning several commissioning pathways. GPs see patients like Mrs Smith day-in, day-out. They know which services are working for their patients, which are poor quality, and where the gaps are. GPs are the best placed professionals if you want clinical leadership of the whole system. Of course your cardiac pathway needs to draw on the latest research, on cardiologists and specialist nurses, but if you want your pathways to fit around actual patients it’s GPs you need.

These health reforms ostensibly take GP-led commissioning to their heart. It is one of the central planks of the reforms, for much the same reasons as outlined in the paragraph above. I however am skeptical on how well these will be delivered. Key barriers to genuine GP led commissioning that will still be in place with the current proposals:

• Centralised powers – while talking of localism, the NHS Commissioning Board will be created with vast powers over commissioning consortia. With local branches looking suspiciously like Strategic Health Authorities with many of the same personnel, are consortia really going to be given the freedom that PCTs weren’t?


• Finances – the state of finances and the need to meet David Nicholson’s QIPP challenge will mean GPs with a huge number of ideas of how to make changes to local health services in a way that will improve quality and save money in the long run just won’t have the finance up-front to implement it.
• Competition rather than co-operation – the sort of whole patient service that GP-led commissioning promotes relies on collaboration with other parts of health and social care. A variety of providers can strengthen that, especially those that offer services that the NHS doesn’t. However unplanned fragmentation, particularly with poor information systems will make it harder to ‘join up’ patient care. From an economic viewpoint, competition over outpatient appointments, simple surgery and the like can leave GP consortia with few choices in emergency care when it leads to the local hospital going belly-up. On top of this the changes in procurement law mean that commissioning can not be Fundholding Plus.


• Bureaucracy – goes hand in hand with the centralisation. No doubt the Commissioning Board is going to demand a host of returns. FoI requests will come in from journalists, the public and health businesses. The authorisation process is likely to be big on evidence collection followed by invasive investigations, interviews, demand for more evidence etc. Evidencing World Class Commissioning took up a huge amount of PCT resource, despite having known the criteria in advance and indexed evidence throughout the year. Quite how the new consortia will take to another (unnecessarily) bureaucratic process is yet to be seen.
• Management support – as GP led commissioning gets more established, GPs will better know what sort of management support they need to to actually do commissioning under GP leadership. At the moment, GP consortia will be trying to commission with a lower management resource at just the time that effective management support is needed to deliver unprecedented savings. As the Kings Fund has reported and the FT has confirmed the NHS is undermanaged and overadministrated d . Of course management support will have to evolve from the way PCTs have been managed, but buying-in all core commissioning support won’t be an effective in the short-term as they lack the local contacts, organisational knowledge. In my own discipline local knowledge of how different providers report activity and the reliability of specific data is vital in providing effective information for commissioning. Management cost cuts will undermine the ability of GPs to get on top of commissioning.
• The blame game – at the moment if something goes badly wrong or an unpopular decision has to be made it is ultimately the Government that fronts it. Now GPs will be in the firing line (at just the time there will be a lot of unpopular decisions). Government MPs criticising health cuts, Government ministers seeking to deflect anger, and their spindoctors will point the finger of blame at GPs. Whatever the legislation, it will still be the Secretary of State for Health on the Today programme being asked what he will do about the latest Mid-Staffs. We can’t expect the Secretary of State to hold back, except when wanting to pass the blame. Remember that Paxman interview with Michael Howard after the escape of IRA prisoners from HMP Parkhurst, where the Home Secretary repeatedly tried to stitch up the head of the Prisons Agency and absolve himself of blame for an ‘operational matter’. We’ll see the same a few years down the line (although I’d bet that the Secretary of State isn’t Mr Lansley).

What happens next in Parliament is anyone’s guess. The Secretary of State has opened a new ‘listening process’ under Prof. Steve Field, which will obviously come up with answers from clinicians, managers and patients very different from those in the White Paper consultation. They’ll produce a very nice document no doubt which they will send to Messrs Lansley, Cameron and Clegg. Meanwhile the said Lansley, Cameron, Clegg plus Mr Osborne and probably some whips and party apparatchiks hole up in a room and do some good old fashioned political sausage making, and then pop up citing every line of the report that backs up what they’ve decided to do. How the competing pressures of iffy polls, pro-competition Tory backbenchers, the LibDems desperate to show how they’ve made a difference, and a skeptical House of Lords. Despite the Tories efforts to ‘detoxify’ themselves with regards to the NHS, they still wouldn’t want to end up going to country over these reforms, or having to use to Parliament Act to overturn a House of Lords with some very vocal medics and surgeons in it. It’s still Cameron’s view that matters here, but he is not entirely unconstrained.

Quite what will emerge, I’m not honestly sure. To me there are three worst case scenarios specifically for GP-led commissioning as the Bill wends its way through Parliament .

1. GP-led commissioning is dropped in its entirety, causing engaged GP commissioners to drop out, and seeming to send a signal to PCT Chief Executives that they can ‘roll back’ on the sort GP engagement in commissioning that is happening under current legislation. Thankfully not likely.
2. GP-led commissioning is fudged so that it’s not clear who is accountable, and there is not sufficient coherence within the board to deliver necessary service re-design.
3. The Bill goes through as is and GPs officially take over, but are stifled by NHS Commissioning Board, financial crisis, a lack of management support and a ‘World Class Commissioning’ style authorisation process. GPs get the blame, and the headaches, without ever being given the tools to make a real difference for their patients.

A few suggestions:

• Retain PCTs (or equivalents) as Statutory Bodies appointed by the Secretary of State with the majority GPs and other primary care clinicians nominated by their peers, including a Director of Public Health from the local authority/Public Health England, patient & local authority representation and the minimum of Executive Directors on the board (Chief Exec & Director of Finance?).
• Boards can consider (as they do now) whether they want to buy-in support services or provide them in-house and do this at their own pace, without the ‘fact’ that all PCT employees are going to cease to be so in 2013 forcing the timetable.
• The Government do not seek to re-organise, merge or otherwise interfere structurally until the changes have had a chance to bed down and be objectively assessed.
• Boards be allowed to look at the whole health care system in the round, using the private and not-for-profit sector where it can be shown to deliver better quality than NHS providers. Competition should be embraced where it is a tool for better services, but limited where it would destabilise those NHS acute hospital providers undermines their abilities to provide emergency care. Big decisions should be made by the NHS, not by the unintended consequences of the market.
• Assess Boards on how they meet their public health objectives, improve quality and patient experience and deliver good value in the medium and long term. Too many decisions that are bad for patients and bad for taxpayers are made because PCTs and their predecessors are judged on short term factors. Many services that will save a fortune in the long run will cost when first introduced e.g. screening programmes).
• Minimize bureaucracy in commissioning and the wider health service – judge commissioners on outcomes not process, stop the endless ‘re-freshes’ of policy documents unless there is something worth changing, and collect the information that is needed to manage the NHS effectively (“do it once, do it right”).

Grahame Morris, MP for Easington and a member of the House of Commons Health Select Committee raised the future of public health observatories in an adjournment debate 17th May.

Public Health Observatories (PHOs), based in each English region produce high quality intelligence about health of their local population, and each also leads nationally on specific issues. If you want to know how many undiagnosed diabetics there are in the country or where has the worst diet, it’s PHOs that will tell you. Without this sort of information it is impossible to identify the health needs of the population and where NHS spending is not focussed where the problem is, it will be wasted.

North East Public Health Observatory (NEPHO), based at Stockton, hosted as part of Durham University is saluted in the ministerial reply for its excellent work and its close links with academia, and for its role in leading mental health research. Well done. However I’m none the wiser after the minister’s reply in the debate whether we should expect a North East Public Health Observatory a few years down the line. The regional level is ideal – concentrated enough to have the expertise but local enough to understand local issues, impact on regional policy and improve understanding amongst local clinicians and commissioners of population health. This has been particularly noticeable in the North East where the co-terminosity of the SHA, Government Office and much of civil society has meant that NEPHO and public health generally have been able to make a greater impact than if all the UK’s epidemiologists were holed up in Birmingham or London.

The plight of public health observatories in the NHS reforms gets far less attention than competition, privatisation and redundancies (not entirely surprising that), but they do make a real contribution to improving the health of the millions of people who have never even heard of them. The Government needs to tread carefully – if it ain’t broke don’t fix it!

The Health Service Journal has used the Freedom of Information Act to obtain a copy of research done for the Department of Health on hospital efficiency of inpatient care. The research, done by the highly-regarded Centre for Health Economics at York University examined efficiencies in admitted patient care in England’s 163 acute hospital trusts/foundation trusts.

The North East’s hospitals hit the national rankings thus (out of 163):

25 – County Durham and Darlington NHS Foundation Trust
74 – North Tees and Hartlepool NHS Foundation Trust
83 – Northumbria Healthcare NHS Foundation Trust
93 – Gateshead Health NHS Foundation Trust
96 – The Newcastle Upon Tyne Hospitals NHS Foundation Trust
106 – South Tyneside NHS Foundation Trust
127 – South Tees Hospitals NHS Trust
140 – City Hospitals Sunderland NHS Foundation Trust

Obviously there’s bound to be a lot to say about the methodology, and it is also worth noting that tertiary and particularly specialist hospitals seem to be judge less efficient. It would be very interesting to set that against effectiveness.

The full article (and national figures) can be found here.

From Public Finance magazine:

The Co-operative Group has launched a ‘one-stop shop’ to help local government set up mutuals to run services.

Public Service Mutuals, launched today, is aimed at directors of services in local government and public sector bodies. It will offer practical assistance and examine the potential for mutualised services in six stages.

The move follows theModernising commissioning green paper, published last year, which attempted to provide a level playing field for charities, voluntary groups and social enterprises bidding for public service contracts.

The Co-op, the UK’s biggest mutual organisation, will run the service in conjunction with law firm Cobbetts and consultancy Westminster Bridge.

Peter Marks, chief executive of the Co-operative Group, said: ‘We have heard a great deal from all the mainstream political parties about the co-operative model delivering public sector services but up until now we’ve lacked a one-stop shop where people can get the advice and assistance necessary to turn great ideas into practical solutions. Public Service Mutuals fills that gap

‘We have a purpose beyond profit, with a vision of creating a better society and we believe this new venture will enable us to help communities across the UK deliver important services in an alternative way.’

Earlier this year, Cabinet Office minister Francis Maude told Public Finance that he would like to see 1 million – one in six – public sector workers employed in mutuals by 2015.

The move comes a fortnight after a review commissioned by Co-operatives UK concluded that the UK was not yet equipped for large scale public service mutuals. The review, Time to get serious: International lessons for developing public service mutuals by Jonathan Bland highlights the success public service mutuals have had in those countries that supported their development through provision of suitable legal forms, business advice, tax incentives and/or supportive public procurement.

Co-operatives UK provides a wealth of information for public sector staff interested in setting up their own mutual (particularly useful for smaller mutuals who need a helping hand to get going but don’t have significant resources).

NHS reform is probably the best change that the Lib Dems have to force through changes in any major legislation that demonstrate a Lib Dem difference, offering coherent and effective opposition to the Tories whilst within Government.

As a whole the Lib Dem party is opposed to (as demonstrated by their conference vote) grand swathes of Andrew Lansley’s NHS reforms, with a particular strain of thought against private sector competition and in favour of integration of (control of?) health by local government.

The Lib Dems have suffered so badly in the polls (both opinion polls and at the ballot box) that decimation would have looked much better. The party lost significant support to the Labour Party as it was punished for their coalition with the Tories. Lb Dems are now promising a more ‘muscular’ role within a ‘business-like’ coalition. Health is one of the, if not the only, area that the Lib Dems could afford to properly oppose policy being taken forward by their Government.

If the Lib Dems volte face and turn against something they reluctantly allowed to be explicitly included in the coalition agreement then they face justifiable charges of bad faith and weak will. Those supporters who have stuck with the Lib Dems are those with the most positive, or at least the least negative, view of coalition, and would see an early departure from the coalition agreement as a betrayl. Major planks of Lansley’s reforms are not only not in the coalition agreement, but seem to actually contradict it. If the Lib Dems have come to believe the legislation is wrong for the country, there would be nothing here to bind them not to push for amendment or even go for the ‘nuclear option’ of voting down the bill.

If the Lib Dems got to the point of combining with Labour and the smaller parties to vote down a major piece of Government legislation, there would be an election. The Tories would quite fancy their chances of snatching an overall majority in a snap election with the electoral system delivering Tory gains on the back of a Lib Dem to Labour making any Lib Dem threats to bring down the Government on almost all issues implausible. There is however one issue that the Tories would really dread fighting an election on, the NHS, combining toxic’ NHS reforms and the growning number of service cuts and longer waits. An election in that circumstance would not lead to a Lib Dem landslide, but it might help shore up some Lib Dem support, but more importantly it would hurt the Tories. David Cameron, Andrew Lansley and the National Association of Primary Care lined up against Labour, Lib Dems, Greens, Unison, RCN, RCM, RCGP, BMA – which has more public appeal?

The Lib Dems can afford to be robust in opposing the existing proposals for NHS reform as it goes well beyond the coalition. The Tories can’t afford to get so irritated by Lib Dem sniping on health that Cameron himself calls a snap-election because of the electoral toxicity of the subject. Equally, and for similar reasons, the Tories can’t afford to be so obstinate that the Lib Dems vote en-masse against the Bill such that the Government loses. Nick Clegg has power to demand serious concessions, and it is this rather than a PR driven ‘listening exercise’ (the original consultation with pretty much identical responses was mostly ignored) that will decide the future of the Bill.

Prof Steve Field, the listener-in-chief on Andrew Lansley’s behalf can think what he wants about whether the reforms are unworkable – the decision on how far the Bill will be gutted will be down to the ‘sausage factory’ negotiations and muscle-flexing between Clegg and Cameron (backed up by the input from backbenchers, Andrew Lansley and Paul Burstow).