House of Commons - Health Committee

Commissioning - Health Committee Contents

Written evidence from UNISON (COM 43)

EXECUTIVE SUMMARY

UNISON has many concerns about the White Paper, and its impact on patients, staff and the NHS. For the purposes of this inquiry, these include the following:

— Attempting to force through so much change so quickly will be hugely expensive and will produce instability that could affect the quality of services and patients' ability to access them.

— The creation of a larger role for the private sector is planned despite a track record of proven failure and despite concerns about conflicts of interest.

— There are significant question marks about how those responsible for commissioning will be held to account.

Rather than boosting democratic legitimacy, the plans amount to a substantial downgrading of the role of democratically elected councillors in scrutinising health services.

— There will be geographical variations in the level and type of service available to patients.

— Mental health services and specialist services to treat patients with rare or complex conditions could suffer.

— The White Paper is a missed opportunity to promote integrated care, and initiatives that promote good practice and save the taxpayer money could be compromised, along with patient safety.

INTRODUCTION

1. UNISON is the major trade union in the health service and the largest public service union in the UK. We represent more than 450,000 healthcare staff employed in the NHS, and by private contractors, the voluntary sector and general practitioners. In addition, UNISON represents over 300,000 members in social care. There is also a wider interest in the NHS among our total membership of more than 1.3 million people who use, or have family members who use, health services.

2. UNISON has submitted an overall response to the government's Liberating the NHS White Paper—the union's submission to the Committee's inquiry should be read in conjunction with this.[10] UNISON welcomes the opportunity to respond to the Committee's latest inquiry, but given the very critical report on the same subject produced by the Committee's predecessor just six months ago there is a danger that the new inquiry will be viewed as an attempt to gloss over the previous Committee's concerns. UNISON believes the onus is on the new Committee to address and act upon the conclusions of the previous report, particularly to attempt to test the value for money of the purchaser-provider split described as representing "20 years of costly failure". Providing some background to the new government's health plans is important, but there is a wider consideration as to the actual validity of commissioning that should also be up for discussion.

CLINICAL ENGAGEMENT IN COMMISSIONING

3. The Committee asks about variation in clinical practice. Much has already been made of the potential of the White Paper to produce a "postcode lottery" with patients experiencing varying levels of service across different parts of the country. Part of the remit of SHAs is to provide a strategic overview and coordination of services within their region. The White Paper suggests that there may be some form of regional outposts for the NHS commissioning board, but it is not certain how many there will be. With a lack of regional coordination it is possible that neighbouring GP consortiums could offer quite different services to their populations, a problem that Pulse has pointed out could be exacerbated by the fact that "some areas of the country are hugely more prepared for the challenges of GP commissioning than others".[11]

4. The government states that overspending consortiums will not be bailed out, raising questions about whether patients could see particular treatments suspended until their consortium gets its deficit under control. The level of autonomy given to consortiums by the White Paper includes encouragement for them to "strip out activities that do not have appreciable benefits"—but who decides what these are and does this mean that some patients could lose access to vital services?

5. There are wider issues around health inequalities. A report by the National Audit Office found that richer populations tend to have more GPs per head than poorer ones.[12] It is doubtful whether the NHS commissioning board will be able to influence the distribution of GPs or whether councils will have sufficient power to affect a change that benefits the poorest.

HOW OPEN WILL THE SYSTEM BE TO NEW ENTRANTS?

6. The Committee asks about access to commissioning expertise. UNISON is concerned that the White Paper confirms that GP consortiums will be free to buy in commissioning support from private companies. Given the novelty of the new system for most GPs, commentators suggest that doctors will need "a great deal of organisational support".[13] It is quite possible that many consortiums will want to bring in expertise from NHS managers at PCTs or SHAs before they are abolished.[14] But not all will choose to go down this route and companies can be expected to poach a number of NHS managers before they can cross directly to consortiums.

7. It is likely that the White Paper will in effect take the FESC (framework for procuring external support for commissioners) much further, despite the previous Health Committee raising major questions over whether "the taxpayer is getting real value for money out of this costly exercise".[15] Even under the current system, in which few PCTs have so far chosen to use the FESC, there have been problems. Apparently the scheme's suppliers have committed to guaranteed savings of £18 million, but by the summer of 2009 £15 million had been spent on the scheme[16] with no discernible achievements. At Hillingdon PCT, where the first FESC contract was awarded to Bupa, the experience has not been a happy one: in August 2008 the chair of the PCT said he "could not see how these projects would result in value for money".[17] It was also revealed in August 2010 that NHS Northamptonshire had ended its FESC contract with United Healthcare a year early.[18]

8. The government has published nothing alongside the White Paper about how it will tackle conflicts of interest with private companies looking both to offer commissioning support and to deliver services. The existing FESC framework does at least attempt to address such matters, but even this falls short. For example, the list of government preferred suppliers includes organisations such as Unitedhealth Europe that also deliver provider services in England. The DH attempted to allay fears by ensuring that commissioners are not working in areas where they also provide services. It is still possible, however, for a company to advise a PCT (or in future a consortium) on its commissioning decisions in advance of making a bid to provide services in that area. Moreover, once a commissioner has successfully recommended a service for outsourcing that service must be open to competition at a later date in order to abide by procurement and competition law, thus opening up a healthcare market for these same companies to come back and provide services in.

ACCOUNTABILITY FOR COMMISSIONING DECISIONS

9. In terms of patients making their voice heard, UNISON is concerned about plans for the new Health Watch, which as the "consumer champion" changes the health scrutiny emphasis away from citizen involvement and towards consumerism. The consultation document also proposes that local HealthWatch should help individuals "exercise choice", suggesting that these bodies could act as proponents of the market in addition to their role as scrutineers acting to improve services on behalf of patients.

10. In terms of the role of the NHS commissioning board, UNISON is concerned such a body will not be able to hold commissioners and GPs to account. There will be no PCTs or SHAs and given the vast range of responsibilities the board will have, there is a danger that accountability could suffer. Similarly the National Patient Safety Agency is to be abolished with its responsibilities transferring to the board. Without a dedicated body to promote patient safety, will focus be lost at a time when fears are growing that new superbugs such as NDM-1 are on the rise?

11. The White Paper and consultation on the new commissioning proposals refer to each consortium having an "accountable officer" but there is no detail on who this should be and what their responsibilities would involve. Experts have suggested that while the roles of accountable officer and financial officer are critical, accountability is about more than just these roles; it is about a system and having the appropriate governance and culture in place.[19]

12. Even now some rogue operators do slip through the net. For example, the GP run company Take Care Now was the subject of a damning report from the CQC following the death of a patient who was given an overdose of diamorphine by a locum doctor in 2008. Without strong accountability mechanisms, the new system could make it harder to isolate and punish rare cases of malpractice.

13. In terms of public health, there is concern that local authorities will increasingly be encouraged to focus on the delivery of actual healthcare services (through health and wellbeing boards and the local Health Watch) rather than wider issues of public health and prevention. Professor Steve Field of the Royal College of GPs has acknowledged that "there is a risk here, especially as not every GP has a great knowledge of public health".[20] Even those local government leaders who welcome their new public health responsibilities acknowledge that in the current financial climate there "may be a challenge that says, can we afford this? Is this our core business?"[21]

INTEGRATION OF HEALTH AND SOCIAL CARE

14. Although the government claims its proposals will strengthen integrated working between health and social care, there is little detail in the White Paper to back up this assertion and no meaningful health-local government interface. In fact, the accompanying consultation document on outcomes confirms that there will be separate outcomes frameworks for the NHS, public health and social care, which may inhibit integrated working. Speaking on behalf of providers of care, the English Community Care Association voiced a "major concern" that the White Paper "does not acknowledge strongly enough the pivotal role of social care in the development of an integrated approach to supporting citizens."[22]

15. There is too much focus in the personalisation agenda on personal budgets when other ways of ensuring more personal and appropriate care would be more effective. The White Paper suggests that personal health budgets will be extended without considering whether the existing pilot process has demonstrated their success or not: the pilots will merely be used "to inform a wider, more general roll-out". Personal health budgets could also encourage pressure for patients to be able to top-up their care with their own money. Managers involved in the initial pilots have voiced such concerns, in addition to issues around equity, in a report on the early experiences of the programme.[23]

WHAT WILL BE THE ROLE OF LOCAL AUTHORITIES IN PUBLIC HEALTH AND COMMISSIONING DECISIONS?

16. The White Paper and accompanying consultation on local democracy legitimacy make much of government plans to bring democratic legitimacy to the NHS but the detail does not back up this positive rhetoric. Plans to create health and wellbeing boards within local authorities will be at the expense of health overview and scrutiny committees (OSCs), which the Local Government Association states "have made a real difference in championing the public interest and challenging health commissioners and providers to deliver better health services."[24]

17. More significantly, health and wellbeing boards will actually lack the essential democratic ingredient of OSCs. OSCs consist entirely of democratically elected councillors, whereas health and wellbeing boards will only have to include one elected individual (likely to be the mayor or council leader). The rest of the board would be made up of unelected individuals, such as senior local government officials and representatives from GP consortiums. Although there will be local discretion as to the exact make up of boards, there need be no involvement from backbench councillors. Independent elected representatives should have the right to investigate commissioners and providers of healthcare, and to demand answers on behalf of the citizens they represent. As currently constituted, the plans represent a major downgrading of the councillor role in scrutinising local decisions.

18. There are also question marks about just how much influence health and wellbeing boards will be able to exercise over GP consortiums, particularly as consortium boundaries will not necessarily mirror those of the local authority—at the moment this is easier as PCT areas are largely coterminous with local authorities. This disparity could hamper partnership working across health and local government.

HOW WILL THE NEW ARRANGEMENTS STRENGTHEN COMMISSIONERS AGAINST PROVIDER INTERESTS?

19. The Committee asks how vulnerable groups of patients will be provided for. This is another major area for concern. Charities have expressed fears that mental health services could suffer under new plans, with GPs themselves expressing concern about their ability to commission these services.[25] A survey by Rethink found that only 31% of GPs felt equipped to take on the role of buying in mental health services for patients.[26]

20. End of life care is another area that charities are concerned for. An ageing population means that more people will be dying with more complex needs, and Help the Hospices have stated that "our biggest concern is that people will die badly if GPs are not supported to develop the knowledge and expertise they need to commission the best palliative care." In order to preserve fairness and transparency for the vulnerable, services "need to encompass not only mainstream health services but also meet the social, emotional and psychological elements that are so central to hospice and palliative care."[27]

TRANSITIONAL ARRANGEMENTS

21. The previous Health Committee noted that "constant re-organisations and high turnover of staff" have not helped the NHS. Previous reorganisations of the NHS have generally taken place at a time when financial resources are not being squeezed. This time, however, the NHS as a whole is expected to make savings of around £20 billion over the next four years. The White Paper itself contains plans to make huge cuts of more than 45% in management costs, so major structural change is to be achieved with far less money and fewer managers. Those working for SHAs and PCTs will be expected to bring about massive change, despite the fact that their organisations are in line for abolition within the next three years.

22. Forcing through so much change, and in a very short timeframe, is bound to produce instability. Something which NHS chief executive David Nicholson acknowledged in his letter to fellow NHS leaders following the publication of the White Paper: "Learning the lessons from past reorganisations, there is significant risk, during this transition period, of a loss of focus on quality, financial and performance discipline as organisations and individuals go through change."[28]

23. In terms of safeguarding good practice, good initiatives that have helped staff to provide better care for patients (and more efficient care for taxpayers) could suffer as a result of the review of arm's-length bodies associated with the White Paper. The chief executive of the NHS Institute for Innovation and Improvement has stated that there "must be" some risk that the Institute's work on quality improvement could suffer now that its remit will transfer to the NHS commissioning board.[29]

24. There are particular fears that the impact of successful programmes such as the Institute's Productive Ward series will be lessened. Evaluations of the initiative have found that it has "huge perceived value and local impact" as it seeks to free up nurses to spend more time with patients by streamlining processes such as handovers; it aims to help the NHS save £9 billion. National Nursing Research Unit director Peter Griffiths said: "It does seem clear that it will be harder to develop, coordinate and marshal resources behind these sorts of developments in a more decentralised system."[30]

25. In terms of transitional costs, there is likely to be a massive expenditure at a time when the NHS can ill afford waste. The Department of Health has already set aside £1.7 billion in 2010 for reorganisation, with other commentators suggesting the overall cost will be much higher. Writing in the British Medical Journal, Professor Kieran Walshe of Manchester Business School estimates that "the proposed NHS reorganisation will cost between £2 billion and £3 billion to implement at a time of unprecedented fiscal austerity".[31]

SPECIALIST SERVICES

26. With the profit motive set to become a more important consideration for those competing within the healthcare market, it is logical that providers will focus most of their attention on offering those services that make the most money, meaning that those yielding less cash may be ignored. This could have major consequences for patients suffering from rare and complex conditions who find they are increasingly unable to get treatment near to where they live. National and regional specialised services will be the responsibility of the NHS commissioning board, but the Specialised Healthcare Alliance has voiced "immediate concerns" about the need for regional structures to support specialised commissioning.[32]

October 2010

10 UNISON response to the White Paper, http://www.unison.org.uk/file/A11861.pdf Back

11 www.pulsetoday.co.uk/story.asp?sectioncode=35&storycode=4126761&c=2, 11 August 2010. Back

12 National Audit Office, Tackling inequalities in life expectancy in areas with the worst health and deprivation, House of Commons, 30 June 2010. Back

13 David Furness of the Social Market Foundation, quoted in The Guardian, "Private health firms scent big opportunity in NHS outsourcing plans", 17 July 2010. Back

14 Health Service Journal, "BMA GP leader lends support to managers", 22 July 2010, p 5. Back

15 House of Commons Health Committee, Commissioning, fourth report of session 2009-10, March 2010. Back

16 House of Commons, written answer from Mike O'Brien to Norman Lamb, "NHS: Procurement", 15 July 2009. Back

17 Hillingdon PCT, Notes of the Audit Committee held on 1 July 2008. Back

18 www.e-health-insider.com/news/6141/pct_ends_united_health_contract_early, 9 August 2010. Back

19 Health Service Journal, "GP governance: handle with care", 12 August 2010. Back

20 "Fears public health may be hit in shake-up of NHS", 29 July 2010, www.bbc.co.uk/news/health-10789911 Back