Supplementary written evidence from Dr
Paul Charlson (COM 130)
Further my provision of oral evidence today
(2 November) I would make the following points:
— There current NHS has become over burdened
with data collection for targets.
— PCTs have been risk adverse to the point
of stunting innovation, which although has occurred it has not
been significant enough to create whole system change.
— The management of the NHS has become
too large and expensive.
— No change is not a good option.
— The pace of change is fast and will create
expense and a potential vacuum in the transitional period. An
evolutionary change where PCTs hand over to GP consortia is preferable.
— There is a danger of losing the best
managers to other sectors during the transition period.
— Many small but important backroom functions
of PCTs need to continue during the transition.
POTENTIAL TENSIONS
WITH GP CONSORTIA
— The best practices will want to be involved
in commissioning but may also want to be providers. It is unrealistic
to prevent this but it must be managed carefully.
— GP consortia will not be particularly
keen to include struggling practices. These will need to be supported
and brought up to standard.
— Some good GPs will need to virtually
give up clinical practice- this may however prevent burn out.
— Dealing with practices who fail to conform
to out comes set by consortia.
COMPETITION
— In my view NHS hospital trusts have become
too powerful—the balance of provision needs to shift to
primary care and other equal or better quality providers where
appropriate.
— NHS consultants should not be contractually
obliged to work solely for a single trust and should be allowed
to work for other providers.
— AWP contracts need to be policed to prevent
gaming—although currently hospitals do "game"
to improve income. Sophisticated contractual arrangements need
to be in place.
— National list of excluded treatments
needs to be drawn up which should not be funded by taxpayer.
— Patients should be able to seek patient
with any provider via Choose and Book.
— Co-payments for non clinically indicated
non generic medication and certain treatments on the exclusion
list need to be considered.
PATIENTS
— Patients need to be involved in local
GP practice and consortia decision making- simply having a voice
on a consortia board is not enough.
— Patients need to take part in difficult
cost based decision making.
— Clinical demand needs the involvement
of patients in order to manage the cost envelope.
— Evidence based patient need is required.
LOCAL AUTHORITIES
— Will need to work particularly with public
health to achieve outcomes.
— May take over some of the back functions
of PCTs at least in the short term.
CLINICIANS
— Most should continue to work as clinicians.
— Primary and secondary care to work closely
to redesign care. Consultants should be freed of difficulties
around working for other employers as well as their employing
trust to enable this.
— The GP consultation is key to managing
quality and cost. It should be longer. More time should be spent
consulting.
— Continuity of care is important in managing
long term conditions.
— The use of other clinicians is important
in bringing about changes in work patterns required.
— The use of a reliable single clinical
record is critical.
— Use of technology to reduce face to face
work eg telemedicine is necessary.
CONCLUSIONS
The current system is failing to deliver as
much as it should and is weighed down by unnecessary bureaucracy
leading to a bloated and sometimes ineffective management. Clinicians
and patients are often left frustrated as a consequence.
GP commissioning is a good idea. Innovation
and change is required in order to face the challenges of the
future. I feel this will be realised by the White Paper reforms.
The management of the transition and the pace
of change are crucial.
Competition and plurality of providers properly
managed through contracting will produce desired system change.
All clinicians need to work together to design
the best pathways of care.
Patients have a key role in commissioning decisions
and demand management.
True patient choice is needed.
Local authorities do have a role particularly
in supporting public health measures.
Opposition to reform can take many forms but
I suspect some opposition is from those who benefit from the current
system or are change adverse. Terms like "destabilisation"
"privatisation" "not the NHS" are used in
a negative way without looking at what they actually mean to patients.
It is my view that the NHS often runs for the
system rather than for patients.
We should not look at the US health system as
the alternative way forward but those of our European neighbours.
Some elements of several systems(including the US) should be considered.
November 2010
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