The Socialist Health Association (SHA) is a membership organisation which promotes health and well-being and the eradication of inequalities through the application of socialist principles to society and government. We have an extensive and varied membership which provides a wealth of information, knowledge and experience of the care system, both academic and practical.
The changes proposed in the White Paper will produce chaos at a time when services are in great difficulty generating risks to the quality of service for patients. They contain no coherent proposals for public accountability and they weaken democratic control of our health services.
Key Issues
The White Paper does little to directly address the issues confronting the NHS:-
- Lack of integration with social care (and within the different parts of the NHS Itself) resulting in disjointed care for patients
- Lack of any genuine democratic influence or control over key decisions around allocation of scarce resources, service configuration and priorities
- Unnecessarily large variations in outcomes and outcomes – well below the standard achieved in other developed countries
- High and increasing costs of management and administration caused by the internal market – with little or no compensating benefits for patients.
We agree with many of the desired aims which are simply restatements of current policy objectives but they can more easily be achieved with far less disruption and cost.
Market Approach
The White Paper is designed to accelerate the replacement of a publicly owned and integrated National Health Service by a privatised and fragmented market system. We believe that extensive use of markets is inconsistent with our free at the point of need model of health service. The evidence from the attempts at market led reform shows that use of financial competition has not brought about the reforms that were claimed. The considerable progress made within the health service over the previous 13 years is due to increased investment and targets. not the market system. The failure of market led reform so far is implicitly accepted by the White Paper.
Redisorganisation
The Coalition’s initial promise was a good one “We will stop the top-down reorganisations of the NHS that have got in the way of patient care. “ The coalition have not learned the lesson which it took Labour 10 years to learn – that reorganisation is a diversion not a solution. It will be disruptive, alienate many of the key staff within the NHS and have transition costs of at least £2bn, which would be better spent on patient care. Attempting system change on this scale, whilst reducing the cost base of the NHS by £20bn, is beyond the capacity and capability of NHS management, and carries a high risk of destabilising patient care and the capacity of the NHS to respond to events.
Commissioning
We need commissioning in the sense of a function which plans and decides on the allocation of resources and determination of priorities. The vital role of commissioning should be the responsibility of elected representatives, supported by the knowledge and experience of GPs and other care professionals.
The information about the role of the NHS Commissioning Body is insufficient to enable a view to be taken, but the weakening of democratic accountability this appears to imply should be opposed. There will clearly be a continuing need for strategic planning nationally and regionally. It is not clear why this important function should be delegated to the biggest quango in the world. We do not believe that Ministers should evade responsibility for the working of the NHS. Given that the Secretary of State is still telling hospitals how to organise their affairs (Andrew Lansley to announce end of mixed wards by year’s end Daily Telegraph 15th August 2010) we find it hard to believe that he will actually let go of the reins of power.
The development and use of GP Consortia as recipients of £80bn of public funding poses major risks. GP Consortia are not the best way to access the knowledge and experience of GPs. There should be involvement and some accountability but not responsibility. GP Consortia will only ever be able to do part of the job and conflicts of interest abound. There is an irony that responsibility for key decisions about use of NHS funding will now be given to the one significant body which opposed establishment of the NHS and which has consistently chosen to remain outside the NHS preferring to act as small business based suppliers. We do not understand how GPs can commission for an area if patients can register with any GP they like.
We do not think that commissioners should turn to private companies to carry out all or some of the commissioning for them. This will effectively privatise commissioning and will carry risks of conflicts of interest with commissioning being determined by the needs of the private sector.
We accept that PCTs are nowhere near being World Class Commissioners, although competencies are improving. GP Consortia are not likely to acquire the necessary competencies in any short time scale. If these changes do progress then every consortium must pass the kind of rigorous independent assessment applied to applicant Foundation Trusts before they can acquire control of public funds. They must be statutory bodies subject to all that implies in terms of openness and transparency and public accountability. They would need a duty to involve patients and the public and mechanisms to allow them to do so. The relationships between individual patients and their doctors are not sufficient for this purpose. For consistency consortia should have to compete and bid for contacts to commission services in a locality, not be automatically awarded contracts based on geography.
These proposals do not address the huge variation in the quality of primary care, and, specifically, how the poor quality of some primary care, especially in more deprived parts of the country, is to be improved.
Social Enterprises
We support the genuine development of social enterprise organisations where this is supported by an affirmative ballot of all staff affected. Trying to turn existing NHS Trusts into social enterprises merely to save money at the expense of the staff is doomed to failure. Greater clarity is required around the form of social enterprises and the Staff Foundation Trust , Community Foundation Trust and other models. There must be far greater clarity about how social enterprises will be vehicles for community ownership and how they are to be governed. Existing regulation does not prevent some existing social or charitable organisations from aping the bad practices of some commercial organisations.
Foundation Trusts
We accept that Foundation Trusts will be responsible for the provision of a high proportion of NHS provision but they should be vehicles for genuine community ownership. They must be made far more accountable to their members with a strengthened role for the elected Governors. Major changes in policy or service delivery by any Foundation Trust should only proceed if agreed by the Governing Body after consulting the membership.
The White Paper proposals would take Foundation Trusts largely out of the NHS (while pulling GPs into it) which will have serious accountability and developmental consequences.
We believe that there should be restrictions on private patient income to ensure that Foundation Trusts continue to be essentially providers to the NHS rather than general businesses. Additional non NHS income should only be permitted when it can be demonstrated that this is not detrimental to the care of NHS patients.
Outcomes
Measuring outcomes is important and we welcome the development of a comprehensive framework based on evidence. This should be used as a free and easily accessible knowledge base and as a source of information on benchmarks not as the basis for contract or performance management. Management to outcomes will lead to perverse and unintended consequences just as managing to targets did. The most important outcomes such as reduced health inequality and improved life expectancy are only achieved over prolonged periods by integrated action by many organisations and so are impossible to use in relation to judgments about any single service or organisation. There are large areas of provision – mental health most notably – where there are no useful outcome measures.
Accountability to local communities and individual patients
We want a system that facilitates and legitimises both participatory and democratic accountability with local people able to become involved and effective as co-producers of health care. The rhetoric in the White Paper is good but the design is not there.
We support the concept of Health & Well Being Boards based in the Tier One Local Authorities but these should be made up of Councillors with other participants present as advisors and observers. These Boards should have the strategic responsibility for public health and for commissioning all care in the locality, although this responsibility could be delegated.
We want to see patients with greater involvement and control over their treatment. We support personal budgets and direct payments if appropriate support is provided and systems are in place to avoid this approach leading to greater inequality.
Local authorities should indeed be able to veto commissioning changes with which they do not agree, but this is a far weaker involvement than that by Health Overview and Scrutiny at present. We think elected local authorities should be given fundamental responsibility for commissioning.
We support the role for an independent patient led system for involvement, which could also assist with advocacy and in complaints resolution, but are sceptical that HealthWatch as proposed will be any more effective than LINKs.
The NHS should support and encourage the development of participatory democracy through community development and co-production. That is, commissioners/planners would see their local communities as assets with whom to work and as joint problem solvers. We see the state as enabling the development of strong local communities and working together with them. This approach to Big Society ideas is not about shrinking the state but is about harnessing local energy with a state that does things differently and more intelligently.
Public Health
We welcome the clarification of responsibility for Public Health and the establishment of Directors of Public Health within Local Government but this falls far short of the integration of responsibility for all aspects of care within a single democratically accountable organisation. Responsibility for translation of health care needs into service delivery remains confused and fragmented. The funding of public health ought to be increased year on year as a share of total health spending.
Regulatory system
We do not yet have enough information to comment on the changes to the regulatory system but would support major simplification of the current complex and confused systems where many regulators (estimated at one time to be over 70 for a large acute trust) all demand attention.
The key issue of how to deal with services or organisations which “fail” has yet to be addressed. Using Monitor as the guarantor of the continuity of vital health service provision is wrong in principle and likely to be unworkable in practice.
We accept that there may be a case for reducing the number of Arms Length Bodies but do not accept the exaggerated claims about the savings to be made, as many of the functions will simply be transferred to other bodies or to the Department of Health.
Social care
No sustainable solution will be found to the key problems which confront our health system until agreement is reached around the funding of social care and the integration of all care into one single system which we believe must be free at the point of use and funded out of general taxation. In the short term reductions in social care funding will cause major problems for the NHS. Progressing other reforms before this issue is resolved poses a high risk.
The market fetish
The reform programme which forms the basis of the White Paper is based on the assertion that extending the use of markets and increasing the involvement of the private sector will deliver greater efficiency and improved patient outcomes. This is a delusion. Only a small proportion of patients are ever going to be in a position to make a choice between different providers, and the evidence is that most of them prefer their local provider. The significant economic decisions in every health system are made by doctors, not patients.
We believe that the NHS as preferred provider was both logical and economically justifiable given the risks of contracting outside the NHS. Tendering and other market approaches has sometimes produced evidenced improvements in care but these are isolated and generally small scale examples. We believe that NHS and other care services are interdependent and fragmenting the system into numerous separate “service lines” each being tendered and contracted separately will be detrimental to patients.
The evidence in this country most recently from Civitas, and evidence provided to the Health Committee suggests that use of markets has not produced the outcomes claimed as justification. Internationally the evidence does not show any link between degree of use of markets and either health outcomes or system efficiency. The country with the greatest market usage has the highest administrative costs and scores poorly on almost every international comparison of outcomes.
Bureaucracy and Efficiency
Reducing expenditure on management and administration may be desirable but the more complex commissioning and contracting environment proposed in the White Paper to further develop the market will increase, not reduce, bureaucracy and administrative costs. Reducing management costs in the middle of this reorganisation carries serious risks to the safety and quality of services. Much of the increase in management costs in the NHS has been due to the introduction and use of market mechanisms with the associated fragmentation of the NHS into multiple semi autonomous organisations to simulate a market; increasing transaction costs by between 10 and 14%.