Written evidence from Professor Calum
Paton (CFI 07)
SUMMARY
— The
Health Bill is likely to return commissioning to a worse version
of the often-chaotic state which prevailed from 2001 to 2006.
— The
new "reforms" are not evolutionary in terms of NHS structure
and organisation; indeed, they are highly disruptive. But they
are not likely to be revolutionary in the medium- or long-terms:
it is likely that "devolution to the frontline" will
be a mirage, as before. "Meso-level" institutions for
performance management will have to be reinvented.
— The
government is fudging the conflict between collaboration and "competitive
markets" in the NHS: it has failed to answer the sceptics
concerning the possibility of local cooperation between GPs and
hospital doctors. Integrated services are only possible under
the "any willing provider" regime if they are not local
"monopolies". This will lead either to the abandonment
of integration or untenably high costs (to create the capacity
for local competition.)
— The
NHS has recently seen a proliferation of "policy by euphemistic
slogan" eg World Class Commissioning (WCC), which the Committee
rightly labelled "ridiculously named" in its 2010 report.
The latest slogan, "the Nicholson challenge", has an
equal capacity to rebound on its authors.
— Choice
and commissioning are intrinsically opposed, unless the latter
is a synonym for planning services by region, area and locality
(among which patients or non-budget-holding GPs are free to choose)
as opposed to the "market" function it has become, where
criteria other than choice come to dominate (despite much rhetoric.)
1. The Health Bill—Radical or Cyclical?
Earlier comment focussed upon whether the bill was revolutionary
or evolutionary. For example, Chris Ham originally implied the
former, commenting on last summer's White Paper, Equity and Excellence.
More recently Julian Le Grand described the latest "reforms"
as evolutionary, building upon the Blairite agenda. To me, the
new reforms are neither revolutionary nor evolutionary, and indeed
these words may blur their real likely effect.
2. Most certainly the Bill is not evolutionary
in terms of NHS organisation and structure. It drives a coach
and horses through what we academics like to call the "meso"
level tier (ie between the centre and localities), in abolishing
both PCTs and SHAs. The latter had only recently (in 2006) been
reconfigured into regional organisations—as had existed
before the 2001 re-organisation, Shifting the Balance of Power
(StBoP), created nearly 30 smaller SHAs. PCTs had been created
(as a country-wide system, as opposed to a "voluntary"
option) also in 2001; and then themselves reconfigured into a
smaller number.
3. Yet neither is the Bill revolutionary.
Even were "power to frontline GPs" considered revolutionary
(about which we might debate), it is already clear that the "new
New NHS" will have as its commissioning agencies (in some
cases already) large consortia of GP practices which are likely
to grow larger over time. That is one of the reasons the reforms
can be seen as cyclical. Like StBoP, their ill-fated predecessor
sponsored by former SoS Alan Milburn, they are born in the rhetoric
of "devolution", "decentralisation", "power
to the frontline" and the like; yet the reality may well
be very different. Indeed it will have to be, if loss of control
at "local health economy" level is not to make the "Nicholson
challenge" not so much a pipedream as a nightmare.
4. We are likely to see a cyclical pattern.
Just as StBoP was short-lived (but long-lived enough to underpin
much dysfunction, including the "financial deficit crisis"
of 2005-06), the brave new world (again) of "local"
commissioning will have to be quietly abandoned. In organisational
terms, this will mean re-creating meso-level institutions which
sit between GPCC and the "centre" in whatever guise
(ie the NHS Commissioning Board, the Department of Health and
the Secretary of State.) Otherwise, local health economies will
lack the control and accountability required to achieve strategic
objectives efficiently.
5. Thus to provide continuity (of the desirable
sort), the reforms will have to betray themselves in the implementation
phase. The question arises, then: why the upheaval?
6. In a nutshell, even more than with StBoP,
these reforms—through stripping away the meso-institutions—may
force both the inappropriate devolution of certain functions and
the inappropriate centralisation of others. All is not as it seems—which
is not to suggest conspiracy so much as a failure to learn from
even the most recent history.
7. Future Institutions. New institutions
will have to fill the lacuna in performance management left by
the reforms. The intention—that external "regulation"
will replace internal "performance management" —will
only come to fruition if (for example) Monitor becomes a system
performance manager rather than a "market regulator."
8. It is not only performance management
which will be required. While "consortia of consortia"
can do some strategic commissioning (ie for services which are
too complex or "cross-boundary" for individual GPCC,
yet slipping the net of national commissioning by the Board),
agencies will be required to reconfigure and plan services at
regional/area level. Whether these are regional offices of the
Department of Health ("back to the future") or management
agencies acting on behalf of groups of consortia, the function
will be required. These management agencies will require the usual
functions (strategic planning; finance; et al) which are barely
mentioned in the Bill.
9. In terms of the reforms being part of
a cyclical process of "re-disorganisation", the ambition
that GPs be at the heart of commissioning was also at the heart
of StBoP, which proposed the Professional Executive Committee
(PEC) for PCTs. These mostly lost influence, and GPs mostly lost
interest, over time. This is because the scale and scope for effective
commissioning meant either that unrealistically large numbers
of GPs would have to be involved (except for the most local, community
services and most simply-defined hospital services) or management
agencies would take over.
10. It can be argued that, this time, as did
not happen even with Practice Based Commissioning (PBC), the GPs
will control the process, instead of being controlled as in the
past. There is some truth in this. But, over time, the vast majority
of even these GPs who stay interested will be "non-executives."
Two questions therefore arise: how powerful are non-executives?;
and how legitimate is it that the governance of GPCC (and their
larger collaborative "joint commissioners") is not in
the hands of a public body but in the hands of one part of one
profession?
11. The guts of commissioning "9 to 5"
(or "8 to 8" one hopes!) will have to be done by professional
managers. The real question is whether these come from the private
sector or the public sector. If much of the latter cadre melts
away, then the hope of saving management costs may well be dashed.
12. The government's response to the Committee's
earlier reports on management costs is deeply unconvincing. It
is not based upon analysis but upon a "fiat." Additionally,
in gauging transitional costs, no account is taken of "opportunity
cost" (bluntly, lost benefit from spending scarce management
time on "non-strategic" things instead of—for
example—the three components of the "Nicholson challenge"
(ie developing extra-hospital care; a lower tariff; and controlling
the pay bill.)
13. Integrated services? Just as unconvincing
is the government's response on the issue of whether the "market"
(Any Willing Provider; Monitor as an "anti-trust", pro-competitive
regulator) is compatible with the prospect for meaningful collaboration
between GPs and hospital doctors. Any such collaboration will
have to go "against the grain" rather than with it.
The government's response to the Committee in effect states that,
even although tenders for hospital services cannot be written
to favour any one (eg local) provider, the local hospital doctors
can still help the GP "commissioners" write the tender
(to enable "integrated care" designed along "pathways.")
One has to ask: has whoever drafted this facile response ever
talked to a busy hospital doctor? Why would the latter labour
collaboratively to service a system which is suspicious of collaborative
relationships? We may note that some of the most respected commentators
who believe in aspects of the new policy also point to the dangers
of the "purchaser/provider split" being too rigid or
doctrinaire (eg David Colin-Thomé; Michael Dixon.)
14. It is also argued by the government (quoting
the King's Fund, 2010) that "integrated providers" (one
assumes they mean systems including hospital care, community services
and GP services) can flourish in the market-place as long as they
are not local monopolies. Has anyone in the Departmental "silo"
working on integrated care talked to a colleague working on costs-saving?
How much would it cost to replicate an English version of California-style
Health Maintenance Organisations in the NHS?
15. Hard Choices and Dilemmas. If the national
Board is to commission primary services, then having GPCC commission
"extended primary services" which collaborate with hospital
services is not likely to be efficient or to lead to an alignment
of incentives: the two should be complementary and commissioned
holistically.
16. The national evaluation of past policy most
relevant to the "new commissioning" is the evaluation
of the "total purchasing pilots" (TPP) (Mays et al,
1988.) There are many differences, but a key result—as also
from some US and European comparisons—was that, to be effective,
GP commissioning will be expensive and will need long-term nurturing.
One cannot think of a less propitious environment than the current
fiscal climate against which to banish the cynicism which is so
prevalent at "street level" in the medical profession.
Additionally, TPP seemed to work better for "extended primary
care" (see 16.above) (ie an amalgam of traditional primary
services and wider, extra-hospital services) —ironically,
almost the antithesis of GPCC s' responsibilities. Budgets to
GP groups may be less suitable, on the other hand, for population
imperatives such as reducing health inequalities: GPs get involved
in commissioning, in the main, as a result of local enthusiasms
and "pet projects", not wider goals. Here again, there
is a danger of repeating 2001-06 in a worse form as the local
enthusiasms of small commissioners come into conflict with system
imperatives.
17. The division into centrally-commissioned
services and GPCC-commissioned services is not as convenient as
it seems (see 8. above) A flaw with both the 1990s "internal
market" and the post-2001 commissioning regime was that different
commissioners made commissioning decisions which were not coherent
in the aggregate ( not "joined up"). For example, specialised
services commissioned from particular hospitals may require a
"critical mass" of complementary services, which themselves
depend upon GPP decisions. Local GPCC decisions concerning the
scale, scope and location of secondary services may require coordination
with other GPCC decisions. Between 2001 and 2006, the need to
reinvent this wheel (slowly) saw much waste and "planning
blight." If this is to be avoided this time around, we will
require a system which is devolved in rhetoric and centralised
in reality. Since the meso-level institutions are abolished, the
centre will have to do what regions/SHAs were doing or should
have been doing in the past ie managing performance and not just
monitoring it.
18. Choice and commissioning are awkward bedfellows.
Some of this is inevitable. For example, under the last government,
the "Darzi reconfigurations" put quality and appropriate
scale and scope of services above choice, in reality if not in
rhetoric. "Choice" is a politician's sine qua non;
whereas, in implementation, the hard reality of combining it with
fiscal realities and clinical necessities often reduces it to
merely one goal among many. Ongoing evaluation suggests that the
differences "on the ground" between the "market
choice" regime in the English NHS and the very different
approaches elsewhere in the UK are minor. Overt "commissioning"
moreover is in clear tension with individual choice (ask an American
who is suspicious of the NHS!).
19. GPCC are likely to push hard for "price
competition" (ie the—reduced—tariff as a maximum,
not a regulated norm), as they face new responsibilities in a
cold fiscal climate. This holds out the danger of quality lapses
. A previous evaluation of the 1990s internal market suggested
this is not just an abstract worry. A major priority for the NHS
ought to be to learn from the current Public Inquiry into Mid
Staffordshire NHS Foundation Trust. The weakness of internal performance
managers (including the SHA regime) may be an important lesson.
It is difficult to see how abolishing such tiers completely might
help.
20. The Hardest Choice of All. Bluntly, there
are three objectives of which two are attainable: cost-savings
of 4% a year; integrated services for a wide range of "clinical
pathways"; and competition. The government asks for all three
-without any evidence that they are jointly attainable, and much
to suggest that they are not.
21. An Alternative. There is much myth about
the inevitability and desirability of the "purchaser (commissioner)/provider
split." The Committee's 2010 report rightly drew attention
to the fact that this may have produced lots of cost without commensurate
benefit. The usual response however is to call for "improved
commissioning" or the like (as with WCC.) This mirrors the
call for "improved purchasing" during the 1990s internal
market. Yet the fundamental direction of travel may be flawed.
22. Integrated organisations organised at district
or area levels containing both primary/community services and
hospital services are attacked on two grounds—that they
are "anti-competitive", "Old Labour" (ie the
"forces of conservatism" in Blair's term) or both. Yet
the pre-1991 NHS did not have integrated organisations: the GP
service was separate from both hospital and community services.
No-one is suggesting a retreat to a golden age.
23. It is possible to have "choice without
(much) market", just as it is possible to have "markets
without (much) choice"—the prevailing situation post-1991
and post-2001, despite prevailing perceptions based upon ideological
closure. With this approach, GPs are non-budget-holding, and are
free to refer patients in line with patients' preferences. Where
patients choose non-local services, money flows with them (the
partial absence of this being a problem with the pre-1991 NHS,
although not as severe as advocates of the "internal market"
implied.)
24. "Commissioning" then becomes a
synonym for needs assessment and the provision of services to
meet these needs. Ironically the best scale/population size for
this function is probably the sort of Health Authority we had
from 1997 to 2001, with a regional tier (lean but strategic) to
"performance manage" the system as well as to coordinate
the provision of regional specialist services. But such a Health
Authority would be an integrated organization, with GPs sharing
executive (and perhaps non-executive) authority with other professions.
GPs are neither heroes nor villains, so to deliver 80% of the
NHS budget to them (mostly as non-NHS employees) is surely bizarre.
25. For the marketers to argue that such a system
would be "inefficient" invokes images of motes and beams.
I am under no illusion that this approach is on the political
table in England (as opposed to the rest of the UK.) But the "development
needs" of such a system would be parsimonious by comparison
with the bloated and often wasted investment in failed market
systems.
Calum Paton[21]
[22]
February 2011
21 Professor of Health Policy (1993-2009) and Professor
of Public Policy (2009-date), Keele University; Chairman, University
Hospital of North Staffordshire NHS Trust, 2000-2006; Editor-in-Chief,
International Journal of Health Planning and Management (Wiley
Blackwell) Back
22
Relevant Publications: "Radical Change or Groundhog Day?",
Public Servant, November 2010; "The Coalition and Health
Policy: Too liberal a dose of conservatism?", Public Servant,
July 2010; "Commissioning in the English NHS", British
Medical Journal (BMJ), April 15, 2010; "What the NHS Can
Learn from Stafford", Public Servant, April 2010; "NHS
Confidential: Implementation…..or how great expectations
in Whitehall are dashed in Stoke-on-Trent", in Exworthy,
M et al (Eds.), Case Studies in Health Policy and Management,
Policy Press, Bristol, 2011 forthcoming; "New Labour's Health
Policy: Assessing the Blair Years", in Powell, M (ed), Modernising
the Welfare State: The Blair Legacy, Bristol, Policy Press,2008;
"The NHS After New Labour-Healthier than New Labour?"
in Casey, T (Ed), Britain After Blair, Basingstoke and New York,
Palgrave, 2008; New Labour's State of Health: Political Economy,
Public Policy and the NHS, Ashgate, 2006; Competition and Planning
in the NHS: The Consequences of the Reforms, Stanley Thornes,
1998. Back
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