Memorandum by Keep Our NHS Public (KONP)
(COM 112)
COMMISSIONING
WHO WE
ARE
Keep Our NHS Public (KONP) was launched on 24 September
2005 by the National Health Service Consultants Association
(NHSCA), The National Health Service Support Federation (NHSSF)
and Health Emergency (HE). These groups felt that a campaign concentrating
on drawing attention to the marketization and privatization of
the National Health Service was needed. We are a non-party political
organisation.
OUR AIMS
ARE:
— To inform the public and the media what
is happening as a result of the Government's "reform"
programme.
— To build a broadly based non-party political
campaign to prevent further fragmentation and privatisation of
the NHS.
— To keep our NHS Public. This means funded
from taxation, free at the point of use, and provided as a public
service by people employed in the NHS and accountable to the public
and Parliament.
— To call for a public debate about the
future of the NHS and to halt the further use of the private sector
until such a debate has taken place.
We are a campaigning body working in the public
interest and are not a charity.
MEMBERSHIP
Over 5,000 people have signed the launch
statement on our website and over 1000 have joined. Thirty-three
KONP groups have been established (28 still active in 2009)
and have been active locally in fighting hospital cuts and closures.
Seventy-two other groups, many of them pensioners groups or those
fighting cuts locally, and ninety unions or union branches have
affiliated.
INFORMATION ABOUT
US AND
OUR POLICIES
The KONP website www.keepournhspublic.com
has policy documents and analyses of the government initiatives
and a round-up of national news stories about the NHS. It is a
valuable resource for campaigners and academics. People can join
on line and their names are added to the supporters list if they
wish. In 2007 we started a bi-monthly e-newsletter to keep
members of KONP and NHSSF updated.
We believe that the founding principles of the
NHS, "medical care free at the point of need, available to
all and funded from general taxation" are still relevant
today. In addition we think that this service is best delivered
by the NHS, not outsourced to private companies and corporations
whose primary duty is to make a profit for their shareholders.
The essence of the NHS since its inception has been a culture
of co-operation between its branches: hospital, community and
public health. There is no evidence that introducing competition
is necessary or helpful in improving the service.
There is evidence that when the public are presented
with a fait accompli (as recently in Camden or in 2007 in
Derbyshire), then the majority are against using corporate providers.
EXECUTIVE SUMMARY
1. "World-Class Commissioning":
what does this initiative tell us about how effective commissioning
by PCTs is?
1.1 Nothing.
1.2 Whilst there is a wealth of documents
and high aspirations there are virtually no hard data. The few
examples of change that have occurred which are given in the Department
of Health's submission to this committee might well have happened
without this initiative. Some process measures have been monitored
but we have found no systematic data about the outcomes of commissioning.
2. The rationale behind commissioning: has
the purchaser/provider split been a success and is it needed?
2.1 We do not believe the purchaser/provider
split has been a success, nor that it is needed in a state-funded,
co-operative NHS.
2.2 The only specialty where services were
improved in the 1990s, after the introduction of the purchaser/provider
split, was in the provision of termination of pregnancy. Legal
abortion is a discrete area where doctors may exercise their statutory
right of conscientious objection. This led to unacceptable variation
in provision. There was already a well established charitable
sector.
2.3 None of the 27 Keep Our NHS Public
groups reported any improvements in services as a result of commissioning.
2.4 What the split does facilitate is the
introduction of private health care companies into a market. Evidence
from the USA suggests this will drive up costs and may lead to
reduced services.
3. Commissioning and "system reform":
how does commissioning fit with Practice-based Commissioning,
"contestability" and the quasi-market, and Payment by
Results?
3.1 Firstly we must correct the use of "quasi-market"
in this section. There is no doubt that since the creation of
the Commercial Directorate in 2003 the DH has been engaged
in creating a real market. The private sector are in no doubt
about this nor is the head of the Foundation Trusts Network. The
establishment of the Co-operation and Competition Panel consolidates
the fact of this market.
3.2 Contestability is thought to improve
services and efficiency by competition or the threat of it but
there is little evidence to support this idea.
3.3 It is not clear exactly what is meant
by practice based commissioning. If it means that GP practices
are commissioning care for their patients we do not think this
is a good idea. GPs are not trained for this task, have a heavy
and increasing workload and there is a possibility for conflicts
of interest to occur. If however it means working with PCTs to
advise about improving services this seems eminently sensible.
It does not need World Class Commissioning to do this.
3.4 Payment by Results is a misnomer—it
is Payment by Treatment (or completed consultant episodes) not
by outcomes. It facilitates the market by making treatments into
commodities which is necessary if there is to be competition in
a market. It incurs great transactional costs and the Audit Commission
warned that it can cause financial instability in the NHS. It
is necessary in a market but not in a planned, co-operative tax
funded NHS.
4. Specialist commissioning
Planning of specialist services needs to be
done at SHA level with considerable input from senior clinicians
as even at PCT level the numbers involved will be small.
5. Commissioning for the quality and safety
of services.
5.1 Providing a good safe service is a professional
responsibility and should not require a huge bureaucracy to commission
this.
5.2 There is already the Care Quality Commission
overseeing services and monitoring by PCTs of adverse events,
which are often a reflection of system failures as reported by
the independent organization Dr Foster this week. The President
of the Royal College of Surgeons is quoted as saying "Too
many hospitals are too concerned with meeting NHS-imposed financial
targets at the expense of clinical standards." (29.11.09 The
Observer).
5.3 The failure by the Department of Health
to monitor the standards of the Independent Sector Treatment Centres
has led to some preventable deaths (Panorama 2009) with a private
company spokeswoman defending the lack of blood in a surgical
unit—something that would not be accepted in the NHS. A
government minister stated that the lack of monitoring was "to
reduce bureaucracy". This is not the way to ensure there
is a culture dedicated to safety.
5.4 We do not see the need for this initiative
which will spawn more bureaucracy at considerable cost.
0. Background to the topic.
0.1 For the first 40 years of the NHS
medical care was provided by hospitals and GPs without specific
commissioning of services. Regional Health Authorities were responsible
for planning and allocated funds to Area and then District Health
Authorities (DHAs), who using block contracts with hospitals ensured
that the necessary services were provided.
0.2 The major problem for the NHS was the
persistent underfunding which led to the UK having fewer doctors
per head of population than almost all the other OECD countries.
This in turn meant that there were long waiting lists for surgery
and outpatient appointments and short consultation times with
GPs
0.3 However negotiation between the District
Health Authorities (DHAs), created in 1974, and hospital clinicians
and managers meant that services were provided for the local population.
As the DHA had representation from the local council as well as
professional staff there was greater democracy than in the current
system where PCT board members are appointed not elected.
0.4 Despite a completely new managerial
structure, consensus management, being imposed on the NHS in 1974,
this system worked satisfactorily and with minimal administrative
costs for the NHS of about 5% (Webster 1998). Certain fields were
not as well served as they should have been, eg mental illness
and care of the elderly (and with all too typical spin these were
labeled priority services but it made little difference to the
share of the budget that they received). Major innovations in
care were primarily pioneered by doctors usually facilitated by
forward looking administrators.
0.5 The advent of general management in
1984 increased the administrative costs as more managerial
staff were employed with no discernable difference in the scope
or quality of the services provided. In 1988 a pilot study
of resource management was started which involved clinicians in
attempts to improve services in a cost effective way. This promising
initiative was swept away by the reforms introduced by Kenneth
Clark in 1990 which included an internal market, the purchaser
provider split and GP fundholding. This increased the administrative
costs to 12% (Dobson 2006))
0.6 Although the idea that GP fundholders
would be able to address the power imbalance that was seen as
a problem in services provided by hospitals, with a few exceptions,
little changed. Some fundholders behaved unethically, the system
was expensive to administer and the predicted benefits for patients
did not materialise. No formal evaluation was done (Smith and
Wilton 1998). In 1997 fundholding was abolished as had been
promised in the Labour Party election manifesto.
ANSWERING THE
COMMITTEE'S
QUESTIONS:
1. "World-Class Commissioning":
what does this initiative tell us about how effective commissioning
by PCTs is?
1.1 The "World Class Commissioning"
(WCC) programme began in December 2007. The evidence given by
the DH to the committee in its first session confirmed our fears
that the phrase "World-Class Commissioning" has no substance
to it but is an idea which is being implemented without piloting—see
the quotation below (our emphasis).
"The World Class Commissioning programme
is designed to raise ambitions for a new form of commissioning
that has not yet been developed or implemented in a comprehensive
way anywhere in the world. World class commissioning is about
delivering better health and well-being for the population, improving
health outcomes and reducing health inequalities" (Transforming
Community Services 2009a).
1.2 What the DH is doing under this umbrella
is further indoctrinating PCT board members and executives into
adopting a market model of the NHS despite there being no evidence
that this is the best way to organize health care and much evidence
to show that it is the worst possible model as exemplified by
the US system which has administrative costs estimated at 30%
and 47 million uninsured and more still underinsured..
1.3 The 11 competencies that the DH decided
were necessary (DH 2008), include "stimulating the market"
and "making sound financial investments" which we believe
have no place in a tax funded co-operative and collaborative system
which is what provides the fairest health care. One competence
which is self-evidently useful is that of the service specification
but we could see no mention of this in the many documents on the
DH website which are full of worthy phrases and ambitions but
extremely vague about actual practice.
1.4 What the WCC programme tells us about
what PCTs are actually doing about commissioning, is negligible.
They tell us for example, how many PCT board members have answered
an evaluation survey of the assurance system pilot in February
2009. But the following statement of September 2009 suggests
that they are so immersed in their aspirational project that they
have lost touch with reality. World class commissioning (WCC)
is transforming the way these services are commissioned, leading
to improved health outcomes and reduction in health inequalities,
adding life to years and years to life." (World Class
Commissioning: an introduction 2009b) (our emphasis)
It is possible that in ten years time these
ambitions will be realized but such outcomes cannot possibly occur
after such a short time.
1.5 So our answer to this question is :
"Nothing".
2. The rationale behind commissioning: has
the purchaser/provider split been a success and is it needed?
2.1 We do not believe that the purchaser/provider
split has been a success and we do not consider that it is needed.
As stated earlier hospitals and community services functioned
effectively before this split was introduced and the block contract
model for hospital services was a way of dividing resources between
the competing demands of specialties and patients which had low
administrative costs—and is still used effectively in many
countries, such as Canada, which has performance indices at least
as good as Britain's.
2.2 The only specialty where services were
improved in the 1990s was in the provision of termination of pregnancy.
Legal abortion is a discrete area where doctors may exercise their
statutory right of conscientious objection which led to unacceptable
variation of provision. There was already a well established charitable
sector. The proportion of abortions done or paid for by the NHS
rose steadily from 50% in 1990 to 91% in 2008.
2.3 Not one of the 27 Keep Our NHS
Public groups in England, which are spread across the country,
reported any change in services which could be attributed to the
introduction of the purchaser provider split or commissioning.
2.4 What the purchaser/provider split does
is to facilitate the entry of private and corporate providers
into the NHS which as a result will drive up the costs of health
care and may well drive down the total amount of care available.
3. Commissioning and "system reform":
how does commissioning fit with Practice-based Commissioning,
"contestability" and the quasi-market, and Payment by
Results?
3.1 First we must correct the use of "quasi-market"
in this section. There is no doubt that the DH have been engaged
in creating a real market since the creation of the latter in
2005. The private sector is in no doubt about this as evidenced
by their submissions to the Health Select Committee's enquiry
into the implementation of Lord Darzi's Next Steps review (HoC
Health Committee 2009). Sue Slipman, Chair of the Foundation Trust
Network, in a fringe meeting in Sept 2009 at the Labour Party
Conference stated that Foundation Trusts operated in a market
and therefore could not have "ordinary" people on the
boards but must have those with commercial experience.
3.2 Gary Belfield in his evidence to you
referred to the market. The creation of the Alternative Provider
of Medical Services (APMS) contract in 2003, the Framework for
External Support for Commissioning in 2008 (DH 2009c) where
13 organisations, mainly US health corporations advise PCTs
on commissioning, of the Co-operation and Competition panel in
2009 and the insistence of the DH that the GP led health
centres imposed on PCTs by the DH in 2009 must use APMS,
are all parts of this strategy.
3.3 Contestability and Payment by Results
(PbR) are also untried ideas which in theory will improve services
and reduce costs.
3.4 As the Audit Commission noted "Payment
by results creates an unprecedented level of financial risk for
both PCTs and trusts, and greater potential for financial instability
across the NHS as a whole" (Audit Commission 2005).
3.5 There is no good evidence that forcing
the NHS to compete with private companies will improve services
and the transactional costs are high. The Conservative party released
figures this year stating that administrative costs had risen
by £6.9 billion for PCTs and £4.5 billion
for hospital trusts in the last five years (Durham 2009) If these
are correct that is over 10% of the NHS annual expenditure. A
small in-depth study from The Centre for Heath Economics in York
showed that the extra expenditure on implementing PbR for PCTs
ranged from £90-£190,000 and for hospitals from
£100-£180,000, with little benefit (CHE 2006).
3.6 The fact that the Secretary of State
for Health has recently stated that the NHS should be the preferred
provider does not stop the enormous waste from competitive tendering
and it remains to be seen whether his statement will reverse the
market driven structures that have been destroying the ethos of
the NHS silently and by stealth. As an example, a GP practice
in Hackney recently spent £40,000 tendering (successfully)
for a GP led Health Centre and the PCT apparently spent £3.5 million
on this exercise (Hackney KONP 2009).
3.7 PbR is an expensive innovation, which
could be dispensed with and replaced by block contracts. The transactional
costs are high and there is no evidence that they cut the overall
cost of care in the NHS. Involving staff in ways to reduce expenditure
without detriment to patient care would be much more likely to
do this.
3.8 "Contestability" in a market
with a plurality of providers is another threat to the NHS. Fragmentation
of services and the loss of co-operation with the introduction
of a competitive model is wasteful and inefficient. There is no
evidence that competition improves the way that health care is
delivered but there is evidence that it increases costs and inequitable
provision (European Health Care management Association quoted
by Lister 2005).
3.9 Well trained and motivated professional
staff, managers, doctors, nurses and others who work in the NHS
strive to deliver good care. What was missing in the early days
of the NHS was meaningful feedback about services from patients.
In today's climate this feedback will be accepted and needs to
be built into the system. It will be acted on by professionals
who derive their job satisfaction by doing their work well.
4. Practice-based commissioning.
4.1 The experience with GP fund holding
did not suggest that this was a sensible way to proceed. We see
a potential conflict of interest in practice based commissioning.
4.2 The size of a GP practice is too small
to plan services and the skills needed are those acquired in Public
Health training not the GP Vocational training scheme with its
emphasis on the individual doctor patient relationship.
4.3 The British model of General Practice
has been admired globally and is thought to have contributed to
the relatively low cost of the NHS because of the GPs' gate-keeper
function.
4.4 There is also a potential for a conflict
of interest between the needs of the individual patient and the
services commissioned for the practice population. The trust between
patient and GP which is the cornerstone of good general practice
will be eroded if the patient thinks that her/his treatment is
being affected by the fact that the budget allocation by the GPs
for her/his condition is insufficient. Also the skills required
for effective commissioning take time to learn and GPs already
have an enormous and growing workload with services being devolved
from secondary care into the community.
4.5 "Commissioning is the process of
assessing local health needs, identifying the services required
to meet those needs and then buying those services from a wide
range of healthcare providers, which can include hospitals, dentists,
opticians, pharmacies and voluntary organizations" (PBC a
guide for GPs 2009d). It is interesting that the private sector
is not mentioned in this list. yet PCTs have been tasked to source
15% of services from for-profit providers—an example of
disingenuousness, to say the least: if this is the government's
policy, why is it not acknowledged?.
4.6 Reading though the documents on the
DH website one is struck by the absence of any hard data. Surveys
every three months of a 25% random sample of the almost 9000 practices
with a 65% response rate showed that about two thirds of practices
supported pbc, had been given an indicative budget and had provided
new services in the practice as a result of this initiative (PBC
survey 2009e). Is this commissioning?
4.7 It appears from the examples given that
hospital based services are now being provided in GP surgeries
which may well be a good thing for patients, but does this collaboration
between GPs and PCTs require the WCC programme to make it happen?
4.8 In October this year Dr Colin-Thom
was quoted as saying that the policy of PBC
had failed and was "a corpse not for resuscitation"
and although he said he was quoted out of context to your committee,
he was not alone in this view. Steve Furness head of he Social
Market Foundation said it was time to stop ploughing money into
expanding GP commissioning. He said to the HSJ that at least £100 million
had been spent on trying to reinvigorate practice based commissioning
through entitlements and that it was time to "turn off this
tap"."(Gainsbury and Ford 2009).
4.9 If practice based commissioning means
that GPs assist PCTs in designing services, then it seems a good
idea, but if it means taking on the task of commissioning services
for their practice population the criticisms above apply.
5. Specialist commissioning
5.1 If this refers to rare conditions then
planning of specialist services needs to be done at SHA level
with considerable input from senior clinicians as even at PCT
level the numbers involved will be small.
6. Commissioning for the quality and safety
of services.
6.1 We can foresee another wave of civil
servants and private sector consultants or advisors being employed
to push the quality agenda whereas the evidence from pre-commissioning
days is that professional staff will always do their utmost to
provide a good service.
6.2 As regards to safety, putting systems
in place to guard against error is a professional responsibility
and where this falls down it is usually because of a lack of sufficient
staff or inadequate training for the post. Improving staffing
levels and maintaining a culture of openness about mistakes and
what can be learnt from them will do more than attempting to "commission"
safety (DH 2002, DH 2006, DH 2007).
6.3 The Care Quality Commission already
oversees services and PCTs monitor adverse events, which are often
a reflection of system failures as recently reported Dr Foster.
The President of the Royal College of Surgeons is quoted as saying
"Too many hospitals are too concerned with meeting NHS-imposed
financial targets at the expense of clinical standards."
(29.11.09 The Observer). This was also the case in Stafford
where the drive to achieve Foundation status led to clinical staff
being cut and standards falling.
6.4 The failure by the Department of Health
to monitor the standards of the Independent Sector Treatment Centres
has led to some preventable deaths (Panorama 2009) with a private
company spokeswoman defending the lack of blood in a surgical
unit—something that would not be accepted in the NHS. A
government minister stated that the lack of monitoring was "to
reduce bureaucracy". This is not the way to ensure there
is a culture dedicated to safety.
6.5 The Health Select Committee recommended
that the Department of Health should proceed with caution in introducing
financial incentives to improve quality. "Schemes such
as Advancing Quality and PROMs which link the measurement of clinical
process and patient outcomes must be piloted and evaluated rigorously
before they are adopted by the wider NHS." (HoC 2008)
6.6 We do not see the need for this initiative
which will spawn more bureaucracy at considerable cost.
CONCLUSION
Reading through the documents on the DH website
about commissioning reminds us of the story about the Emperor
and his new clothes, and remember that (to paraphrase Raymond
Tallis) "when the emperor is restocking his wardrobe, he
usually shops in the USA" (Tallis, 1988). We hope that the
Health Select Committee will speak up like the little boy who
asked why the Emperor had no clothes.
I have started to read the written submissions
to the committee which arrived at the end of last week, and whilst
there are one or two managers who consider that WCC has been successful
the majority of the submissions I have read point out the deficiencies
in commissioning in general or for particular conditions. Some
examples of good commissioning do not seem to be as a result of
WCC but of individual PCTs working with clinicians to improve
services.
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Centre for Health Economics (2006) The administrative
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28.11.09
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January 2010
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