Written evidence from Dr Giri Rajaratnam
(COM 99)
1. BACKGROUND
My views are based on my experience from 1990
as a public health physician working for health authorities and
their successors, the PCTs. Please note that I am submitting this
as a citizen of the UK and not in any official capacity and therefore
the views represented in this paper are mine alone.
2. CONCEPTUAL
APPROACH AND
IMPLICATIONS FOR
MANPOWER
In my view undertaking planning and commissioning
of programmes of care does require some conceptual view of what
that includes. The attached diagram provides a feel for that which
I use and which I believe gives me the necessary discipline to
achieve the outcomes but also value for money. There are a couple
of points to be made:
(a) There is a set of processes which are recommended
for undertaking a needs assessment which brings together the technical
issues and the key stakeholders (including users). However, this
can be very time consuming but depending upon circumstances can
be a very useful tool for building consensus on the programme
of interventions needed and therefore investment.
(b) You will note that it does not talk about
structures and processes. This is because, depending upon the
colour of government, the structures and processes change.
(c) Applying this framework does require high
levels of knowledge, skills and experience. It is useful to list
some of these; epidemiology, understanding of health, ill health
and disease, human behaviour, concepts of cost utility, management
and financial systems, critical thinking and information analysis
supported by careful judgements about when and how to involve
users. Undoubtedly, the NHS manpower does have many of these skills.
However, taking advantage of those skills has been very problematic.
The major challenges are to do with inappropriate time scales
and poor management and financial systems. The latter is particularly
important as it is lagging well behind advances made in some of
the other sciences underpinning the NHS.
(d) The financial systems issue has been a particular
challenge as until recently, no attempt has been made to fine
tune financial information to reflect the health care process.
The huge advance in recent years is the development of programme
budgets which were originally suggested in the 1970s but derided
by the Governments of the 1970s.
3. COMMISSIONING
(a) Clinical Engagement: Health Authorities and
PCTs of the past two decades have all had mechanisms of clinical
engagement. What has changed has been the involvement of non GP
clinicians (hospital and community). This has reduced considerably.
However, in my view, the challenge is about clinical ownership
of difficult decisions. Although engagement is important precursor
it does not guarantee ownership. A good example is to do with
urgent care where there is sufficient evidence to place primary
care within A&E units. Despite this, it has been impossible
to implement this in a way that was true to the scientific literature
and to monitor.
(b) There are some developments which will help
to get clinical ownership of decisions; firstly, map of medicine
which enables clinical groups to focus on clinical pathways and
secondly, programme budgets which will allow clinical colleagues
to bring together the clinical with financial consequences in
a constructive way. One of the QIPP programmes is taking this
forward.
(c) Undertaking a needs assessment using the
attached diagram as a basis is time consuming as is the process
of getting clinical consensus. The NHS as a system does not allow
for the time that is needed to do this well.
(d) Other development which will further support
commissioning is the increasing use of commercial marketing techniques.
These are being adapted for use in the NHS context. Examples include
population segmentation systems (Health Acorn, Mosaic) as well
as digital systems to get health messages to communities.
(e) The last commissioning report of the Health
Select Committee noted the poor analysis of the data as a major
challenge. Although I have sympathy with that view, the big challenge
is the inability of the NHS to look at data critically and make
informed judgements. Data quality has improved and will continue
to improve. However, from a decision making process, the NHS will
never have perfect information but the NHS will still need to
make decisions. Currently, the approach is to look at huge amounts
of data and then decide to do things that often do not bear any
resemblance to the data often because colleagues do not appear
to be able to conceptually order the data. Epidemiology however,
does give one approach; notions of "time, place and person"
as a way of organising the data. The classic example is the approach
taken to analysis of the demand for urgent care. The inability
to organise the information precludes the ability to gather intelligence
from that data set which precludes taking a range of actions that
can be demonstrated logically to have a meaningful impact on urgent
care.
(f) Despite the importance of both social sciences
as well as the physical sciences in the business of the NHS, an
understanding of what that means is lacking in the NHS. As Heston
Blumenthal has shown, it is important to be innovative but being
so, does require considerable testing prior to being offered to
the customer. Moreover, he also showed that if you changed a well
known recipe either in terms of the constituents or the manner
in which it is prepared, the results can vary in unexpected ways.
Again, testing assessing and so on, are very important parts of
the process of innovation. Despite the good work of the Modernisation
Agency in disseminating the notions testing in the work environment
as opposed to research environment, I do not believe that the
NHS or Ministers who have responsibility for Health understand
these two concepts.
The result is a considerable waste of public
money and more importantly in the context of opportunity costs
tragic. Classic examples include the amount of time taken to implement
aspirin in the management of heart attacks in the 1990s and in
the 2000s the similar delay in implementing stroke units.
I labour this point because I am unclear whether
GP commissioners will be any clearer in making these types of
distinction and more importantly, whether they will be given the
freedoms to do.
4. ACCOUNTABILITY
I think if we are to make the accountability
system more real to local communities, then the focus has to be
on the proposed Health Watch. There are two important points to
make in this regard;
(a) The current LINKs programme has been considerably
constrained by local authorities who see this group as: (a) being
in competition with elected members, (b) interfering when they
criticise local authority provided services and (c) not worth
the effort and therefore not support them effectively or efficiently.
(b) I think it would be more appropriate for
the local Health Watch to be accountable to the national Health
Watch but also have support from the local public health team.
I would suggest as a starting point half a day week from a public
health specialist to support the Health Watch team undertake the
work needed to hold the local NHS to account on behalf of users
in that locality.
5. INTEGRATION
(a) Reducing inequalities in health outcomes
does depend upon the close co-operation of the NHS. It is therefore
vital that GP commissioners have a duty to be part of the proposed
Health and Wellbeing Board and to get sign off of their commissioning
plans from that group. It is vital that the DPH has the knowledge,
skills and experience to be able to provide a critique of the
commissioning plans to the Health and Wellbeing Board in the context
of health inequalities.
(b) Although this is important, it is even more
vital that general practice as service providers are able to play
their full role in reducing inequalities. There are two parts
to this: firstly, as deliverers of some of the most cost-effective
interventions in health and secondly, the clinical registers held
by general practitioners provide a unique database that will enable
partners to target their interventions. An example where I have
tried and failed is to do with the affordable warmth interventions
over the past three to four years. There are particular groups
of patients who are at very high risk; those with chronic obstructive
airways disease. Although, the organisers of the affordable warmth
schemes were willing to prioritise these patients, my attempts
at persuading GPs to use their registers to target a particular
group of patients were unsuccessful. What this really means is
that the commissioning of primary care services and other contractor
services are important from a health inequalities perspective
and therefore it is vital that these commissioners have a duty
to explain their intentions to the Health and Wellbeing Board.
(c) The major theoretical advantage of the move
of the DPH and his/her team to the local authority is the potential
to influence the mainstream LA business (adult services, children's
services etc). In order to do so, the DPH needs to have the authority
and in the context of the local authority structure, he or she
needs to carry "special" authority and more importantly
should be expected to have an independent view of the health of
the community.
(d) GP commissioners will require considerable
development in the context of joint commissioning and working
as part of the wider team involving social care and other providers.
Otherwise, I think there will be difficulties in tackling the
needs of people with complex disability or complex disease.
6. OVERALL CONCLUSION
It is clear from reading through the literature
comparing health systems across the world that there is no perfect
system. Each has its own unique set of advantages and disadvantages
based upon the particular social paradigm in which they have been
developed. What is common to them all are financial problems and
to a limited extent integrating the different sectors of health
care.
The approach taken by the current Secretary
of State for Health on behalf of England is good in parts but
overall does not have a sense of system coherence. It is not easy
to see how the proposals tackle the really important health issues
facing England; eg, implementation of cost effective interventions,
integration of services particularly for vulnerable groups, behaviour
change and ensuring value for money. In the short term (next five
years), there is the additional financial challenge to be addressed.
I think there is a huge risk of fragmentation
of both commissioning and provision than ever before. More importantly,
I think there are real risks to local communities and therefore,
I have no hesitation in predicting that there will be further
reforms within two years of implementation which will undo much
of what is proposed in the White Paper.
October 2010
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