Written evidence from Dr Corinne Camilleri-Ferrante
(COM 30)
BACKGROUND
I am a medically qualified Consultant in Public
Health Medicine with many years' experience of commissioning,
screening, teaching and training. Prior to that, I trained in
Paediatrics. I present these as my own views on the White Paper
Liberating the NHS. They do not necessarily reflect the
views of the organisations for which I work.
EQUITY AND
EXCELLENCE: LIBERATING
THE NHS
1. I welcome the concept of commissioning
for outcomes.
2. Safeguarding the health of the population
requires the joint efforts of all elements of the health service:
primary care, secondary care, public health and many others. It
also extends beyond the NHS. The only real possibility for success
lies in joining up these disparate parts into coherent programmes
of care, which consider entire patient pathways from prevention
through to tertiary care and, ultimately, end of life care. Commissioning
for wants, not needs, makes this far more difficult and tends
to increase inequities and health inequalities. In addition, it
requires the coordinated efforts of all participants: this is
best organised through a strong Director of Public Health function.
3. I have concerns about the concept of
taking the NHS towards a consumer model of health care. This is
suggested by:
— The promotion of direct accountability
between the GP as fund holder and clinical decision maker, and
the patient. The Minister would like the GP to act as the patient's
"friend" while at the same time managing scarce resources.
These roles cannot be reconciled in such a direct relationship.
— The promotion of the idea that is it
the GP's duty to provide what his or her patients demand, even
if this is ineffective health care such as homeopathy.
— The introduction of the rule of rescue
into the NHS in the form of the cancer drug fund.
4. Most disappointingly, for a Government
which prides itself on being able to take tough decisions and
tackling the economic crisis, there is no evidence that this Government
is willing to tackle seriously the issue of priority setting in
the NHS. There are two predictable consequences of continuing
with such a philosophy. First, inequalities and inequities will
worsen. Second, the NHS will provide less value for money.
5. The NHS has largely ignored the problem
of inequalities:
— 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.
— A recent study reported in the Health
Service Journal found that those GPs that overspent their budget
generally served better off areas while those that serve poorer
areas were generally underspent. Furthermore, middle class patients
tended to access certain treatments at a lower threshold than
those from poorer backgrounds. This suggests one of two forces
operates within the NHS: either both GPs and clinicians cannot
resist demands from middle class patients, or there is systematic
bias in decision making in favour of the middle classes. Rather
than address this situation, the reforms will worsen it. In a
consumer based model of health care provision the following happens:
— those that have the best health always
manage to secure the best access to health care; and
— there is a tendency to over treat.
6. The second consequence of the move towards
a demands 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 and to focus
on health outcomes rather than process measures as a means to
monitor the performance of the NHS. Yet at the same time the NHS
is being asked to fund treatments which either have no effect
or poor effect.
7. It is disappointing that there is no
evidence of leadership in the priority setting debate, with little
thought or consideration being given to the consequences of funding
health care services on demand. There is no discussion of what
will necessarily be displaced if doubtful wonder treatments are
funded. Opportunity costs remain a very real issue which is not
addressed.
8. A number of concerns also arise in terms
of the reorganisation of care. Firstly, I believe that there is
insufficient understanding of the range of tasks undertaken by
the PCT which simply cannot be handed over to GP consortia without
major support. And secondly there is insufficient understanding
of the task of commissioning, from strategic planning to procurement.
Good commissioning is based on a thorough understanding of the
needs (not wants) of the population and of the service, as well
as the ability to manage service delivery. There is a danger that
substantial capacity, manpower, skills and experience will be
lost during this very major reorganisation, only for the NHS to
have to spend 10 years rebuilding what it has lost.
9. Training of the next generation of public
health practitioners is paramount to the success of the NHS. This
will be threatened if the current implicit suggestion that public
health can be safely fragmented is maintained. While I applaud
the concepts of closer working relationships with Local Authorities,
and the setting up of a National Public Health Service, I believe
it is imperative that the public health workforce is essentially
kept together, with outposts into other parts of the system.
RECOMMENDATIONS
1. Integrated health care systems should
be developed based on programme management.
2. The Department of Health and the NHS
should pay greater attention to inequities in health care which
contribute to inequalities in life expectancy and quality of life.
Promoting six-star services for the few rather than a five-star
service for all is ethically questionable.
3. Politicians should demonstrate honesty
and leadership by engaging the public and the NHS in the debate
about priorities for funding.
4. Any major reform should be piloted in
a geographic region in a realistic way, namely with GPs both keen
and not so keen on the reforms and with a management budget which
it is anticipated will be available nationally to implement the
reforms (ie there should not be preferential funding arrangements
or financial incentives for the pilot scheme).
5. Public health needs to be accepted as
integral to all the elements of the NHS, not just health promotion
and health protection.
6. A strong Director of Public Health, with
an independent voice and responsibility for the health of an entire
population, is essential.
October 2010
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