Written evidence from the UK Commissioning
Public Health Network (COM 21)
BACKGROUND INFORMATION
ABOUT THE
UKCPHN
1. The UKCPHN is a professional network
of senior public health doctors and other practitioners working
for the NHS either in primary care trust commissioning or specialised
commissioning teams.
2. The group was first established in 2002
and now has 230+ members. These members are drawn from all 10
England specialised commissioning teams and the majority of PCTs
in England. As such the membership represents a significant proportion
of public health practitioners actively working in commissioning.
3. The Group's particular interest is priority
setting and has, amongst its members, individuals that are recognised
as having specialist knowledge and experience in this field.
EQUITY AND
EXCELLENCE: LIBERATING
THE NHS
4. The UKCPHN has a number of concerns about
the direction that the reforms are taking Society and the NHS.
5. The reforms purport to promote patient
centred care, which our group would support. However the rhetoric
and the overtones point to the NHS being taken towards a "patient
as consumer" model of health care. Some of the evidence for
this includes:
— The promotion of direct accountability
between the GP as budget holder and the patient. The Secretary
of State has stated that he would like the GP to act as the patient's
"friend" while at the same time having greater and full
accountability for scarce resources. One of the Ministers has
also stated that the "democratic accountability" will
therefore be in the consulting room—not between Citizen
and the State.
— The stated policy position that it is
the GP's duty to provide what their patients demand—even
if this is ineffective healthcare such as homeopathy.
— The introduction of the rule of rescue
(which is the term that has been used to provide substantial resource
to attempt to "rescue" someone from a grave situation
even if the chances of survival are negligible) into the NHS in
the form of the Cancer Fund. The aim of the fund is to give access
to cancer drugs on demand. It is worth noting that the NHS has
about £100,000 per person to spend throughout their life—namely
cradle to grave care which has to secure primary prevention, all
primary and secondary care, medication, community nursing, rehabilitation,
nursing care etc.
6. There are two predictable consequences
of continuing with such a philosophy. First is that inequalities
and inequities will become even worse than they are now and second
is that the NHS will provide less value-for-money.
WORSENING INEQUALITIES
7. Tudor-Hart first coined the term "the
inverse care law" over two decades ago to describe the fact
that those with the best health also received a greater share
of the healthcare.
8. The Department of Health and the NHS
has largely (neglectfully if not disgracefully) ignored this dimension
of equity of access to healthcare. However we know the phenomenon
is still prevalent within the NHS. Supporting evidence for this
includes:
— The fact that NHS budgets still do not
reflect need. PCTs such as Bradford are 6% under-funded while
Richmond and Twickenham continue to receive 20% above their allocation.
— Studies reported in the Health Service
Journal found that GPs that overspent their budget generally served
more affluent areas while those that under spent their budget
served poorer communities. Furthermore, using Patient Reported
Outcomes Measures it would appear that middleclass patients tend
to access treatments at a lower threshold than those from poorer
backgrounds. This suggests amongst other things that GPs &
clinicians may not be able to resist demands from middle class
patients or that there might be a systematic bias in clinical
decision making in favour of the middle classes.
— The attached recent study of bone marrow
transplantation is equally disturbing. This suggests that the
poorer survival in those from lower socioeconomic backgrounds
for a particular type of cancer may be contributed to because
they are not accessing standard treatment.
Repeating similar exercises in any service is
likely to yield a similar picture to a greater or lesser degree.
9. Rather than address this inequity one
can be confident that the reforms will worsen the situation because
in systems where a consumer model of healthcare provision dominates
those that have the best health manage to secure the best access
to healthcare and there is a tendency to over treat and provide
rule of rescue treatments.
REDUCED VALUE
FOR MONEY
10. The second consequence of the move towards
a "demand" rather than a "needs" based system
is that the NHS will become less efficient. It has been stated
that one of the aims for the reforms is to secure better value
for money for the taxpayer with a plan to focus more on health
outcome measures than process measures as a means of monitoring
the performance of the NHS. At the same time the NHS is being
asked to fund more treatments of limited or poor value. The two
policies are contradictory.
THROWING THE
BABY OUT
WITH THE
BATHWATER
11. There are also many problems and risks
associated with such large scale reorganisation of commissioning
which reflects, in our view, insufficient understanding of the
range of functions which strategic bodies such as PCTs and health
authorities before them have to carry out. (Even though a list
of functions is available this does not necessarily translate
into deep understanding of those functions). It is hard to see
how these can simply be handed over to GP consortia without significant
management and administrative support. The proposals outlined
in the reforms are also born out of insufficient understanding
of the task of commissioning which is a very time consuming process.
PCTs and specialised commissioning teams do not, at present, have
sufficient resource to commission everything well—at best
it is possible to commission some of the services well for some
of the time. It seems odd that a lack of resource and capacity
has not been given proper consideration as a reason for suboptimal
performance. So rather than further developing and building on
existing systems there is a danger that substantial capacity—manpower,
skills and experience—will be lost only for the NHS to then
have to spend the next 10 years rebuilding it again.
It is an inconvenient truth to both politicians
and to Society that commissioning is skilled and resource intensive
task if it is to be done well.
FAILURE TO
BE "UPFRONT"
ABOUT PRIORITY
SETTING
12. What has been very disappointing about
the reforms and the rhetoric accompanying their announcement is
that once again politicians have demonstrated little courage or
leadership in the priority setting debate. It is a myth (but a
nice story sold to a willing audience) that the NHS can provide
everything by becoming more efficient. The Committee however would
be hard pushed to find a single commissioner, manager, clinician
or public health practitioner who truly believes that health service
cuts can be avoided in the coming years.
13. PCTs trying to manage their budget have
already come under fire from the Minister in relation to both
homeopathy (which is not effective) and IVF (which is but is not
necessarily seen as a priority). We are also getting some sense
that capacity cannot be taken out of the NHS. It seems that the
"new" interpretation of "comprehensive" is
that the NHS should provide everything—or a bit of everything
(with no help provided, of course, of where the line should be
drawn). Pretending that everything can all be funded from within
budget is at best denial and at worst dishonest.
RECOMMENDATIONS:
14. That the population based perspective,
through which resources might more fairly be distributed and with
greater effect, is retained in commissioning and that patient
centred care is not implemented as patient as "consumer".
15. The preference of this group would be
for integrated health care systems to develop based on programme
budgeting and management. This is an alternative way to have clinical
engagement.
16. The Department of Health and the NHS
should pay greater attention to inequities in healthcare within
England and less on comparison with Europe with a view to improving
inequalities in health outcomes through addressing inequities
in healthcare.
17. The Department of Health should address
inequities in funding and also be careful that risk sharing schemes
across GP practices and consortia do not lead to the poor subsidising
the better off.
18. Politicians should demonstrate honesty
and leadership by engaging the public and the NHS in priorities
for funding.
19. Any major reform should be piloted in
a realistic way—namely with both GPs who are keen and not
so keen on the reforms and with a management budget which is related
to the actual budgets GP consortia are expected to operate. Using
preferential funding arrangements or financial incentives for
the pilot schemes is disingenuous and will not provide the necessary
evidence base for sound policy making.
October 2010
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