Wednesday, 14 July 2010

NHS Reform

I have read through the NHS white paper, "Quality and excellence : liberating the NHS" that was published 2 days ago.

It perturbs me.

This is unusual. Usually I can look at things with a "glass half full" kind of take on it, looking for positive opportunity and what it can enable us to do better. Most papers and policies and DoH edicts have not immediately been embraced as wondrously helpful, but on unpicking things I've usually found something that we can use to push commissioning buttons or support change we're making or that strengthens a case to resist dismantling of/meddling in services.

This paper's "vision" is all very positive.

The implementation superficially is neutral but on thinking it through I see it as concerning, with significant opportunity for negative effects. The detail scares me. It's noteworthy that there has been much comment with GPs being less than enthusiastic or critical or pessimistic about the changes to PCTs and commissioning.

What perturbs me is not the ill ease of grappling with uncertainty, which is normal/continuous life in the NHS. Change and uncertainty and wrestling with unknowns is a normal state of affairs. No, what worries me is the implications and explicit intentions of the white paper. I'm worried since it erodes the NHS.

As reported, the intention is for GPs to commission health care. More than an intention, it's forced upon them (since no sane GP would volunteer for this role). It's a poisoned chalice that's offered, and no mistake. GPs are then seen to be responsible for all deficiencies, since they've failed to commission the right services. Rubbish access for paediatric ADHD clinics, no easy access to tattoo removal, no service for aymptomatic varicose vein removal, it's all laid at the GPs door (a door that can't be closed). Rather than government cuts and suboptimal resourcing, it's then poor GP management that results in inadequate healthcare provision. Mmmm.

Worse, how are GPs going to spend the hours and hours necessary to commission care? It takes ages to go through each service. Just to commission older adults' mental health services (with community services, liaison services, early onset dementia care, forensic care, in-patient services, day hospital services, memory clinics, memory therapy day care, Mental Health Act arrangements, psychology services, Cognitive Stimulation Therapy etc) is a lot of detail to think over. Then do it with adults of working age and crisis services. Then with child and adolescent services. Then with forensic services. Then learning difficulty services. Then drug and alcohol services. Then IAPT and community mental health services. The with partners like MIND and Alzheimer's Society and Age Concern and others. Then do that for every other bit of health. There's no way GPs can absorb this activity. Hence the intention that as reported that the money will go, ". . . to private corporations which will buy hospital and community health services on behalf of GPs."

GPs are private businesses already. This paper strengthens and extends this, generating a situation where large companies can pick off small GP practices (then sack the expensive staff, like GPs, and go for First Contact Practitioners) and through block contracts/large consortia can then purchase Secondary Care from hospitals to get what they want. Except what they want, as a business, is a good balance sheet for their share holders.

A company buys/owns/represents all the GPs in my locality. The GPs advise the company on what they want then the company negotiates contracts and commissions services. The private health company, maybe it's BUPA, maybe it's another, then thinks where it wants to spend it's share of the £80 billion pounds. Does it give it to an NHS hospital? Or does it give it to a sister company or to itself, commissioning services from a BUPA hospital?

I'm perturbed since I see this paper as a mechanism for dumbing down healthcare (through eroding quality to save costs), devolving blame (but not power) to GPs and effecting the privatisation of healthcare, to the marked detriment of NHS care.

Much badness.


Cockroach Catcher said...

Well put. Cannot agree more. In many parts of the country, some consultant services (such as knee and hip work) were provided entirely by Private Health care even before the new govt. came in.

Allyson Pollock reckoned that UnitedHealth is poised to buy up the hospitals.

There are two kinds of Hospital medicine, one that Insurers can make money and one shunned by them.

We all know who were employed by these private Health Insurers: Ex Health Secretaries and advisers.

Ak Sağlık said...

A beautiful page. I liked.

isla said...

excellent, insightful blog that hits nail on head - I fear the GBP who love their GPs may not grasp the implication of the proposals till way to far down the line.

Joble said...

I agree, the scheme fulfils the two key aims of the government, namely to finish privatising what is left to privatise in the NHS, and to avoid flack of following through on their policy of pulling random numbers and percentages out of their various shadowy orifices ("40%? Yeah that sounds like a number, say we need to cut that.") as to how much we need to cut from public services in order to make them sufficiently rubbish that no one will care if they flog them.

Glad someone read it, we tried to put it on TV at work but were outvoted and ended up watching The Hits. Snoop Dogg offered very little commentary on this issue.

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