It is good that the NHA party have moved beyond protest and onto the start of policy formulation and have set out 10 points which will form the basis of their contribution to the policy debate. So far the concentration is just on the NHS, not the wider care system. There is much to agree with and we would comment as follows:-
- Repeal the Health and Social Care Act to restore the NHS as a publicly delivered and publicly accountable comprehensive healthcare system. The most practical solution is to back Lord Owen’s NHS re-instatement bill, which we fully support. We support repeal of the Act but in itself that does not restore a publicly delivered and publicly accountable system – something we have never had.
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Re-instate the NHS as the preferred provider of healthcare. This will protect the NHS as a public service by minimising private sector takeover of NHS services. We support the preferred provider concept so that non-public provision is used only where public provision is unable to deliver what is required – we would also look to ways of restoring some currently private provision back into public especially around social care.
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Abolish the Private Finance Initiative (PFI). Renegotiate and buy out contracts at realistic value. Any publicly owned banks must cancel PFI contracts before re-privatisation. Stop and reverse the outsourcing of clinical and support services related to PFI projects. PFI as was has been abolished but an alternative route for new public capital remains unclear. It would be worth another look at possible renegotiation but so far that has proved impossible. Buying out contracts and reversing outsourcing (?) would be very expensive and we have not seen any analysis to show the benefits.
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Moratorium on A+E and hospital closures. Any reconfigurations must be clinically, not financially driven, and must show they have won public and professional support for alternative, improved services. We support the concept but there is no methodology to separate realistically the clinical from the financial; the current reconfiguration methodology is probably as good as anything. What we should oppose is the use of failure regimes to get round proper processes. We should also strongly promote and support local involvement.
5. Reduce the Department of Health’s reliance on expensive external management consultants who have too much influence on health policy. Instead the DH should re-engage with the representative bodies of frontline NHS professionals, as well as patient groups, to develop and plan future NHS policy in the most clinically effective and sustainable manner We support the role of public patients and professionals and all other staff in developing policy nationally and locally – but giving policy making over to the professional bodies would be unwise given their track record. Building capacity in the DH/NHS so management consultants are not needed is right but would increase the headline costs of management and administration and it is not clear where they would be coming from. A limit on consultancy spend (including use of agency and interim managers etc) could force the issue.
- Ensure evidenced-based adequate staff to patient ratios in order to maintain safe, effective, and high quality patient care Nobody could disagree with the principle but the implementation is difficult and evidence is mixed..
7. Improve accountability and transparency of the NHS by: a) bringing back Community Health Councils (CHCs) and combining them with external peer review of hospitals and GP practices; b) Reviewing and strengthening the NHS complaints process and improving the ease of access, and protection for whistle blowers. Since the Plan does not set out the rest of the architecture it is impossible to see if something like CHC’s could fit, and reorganisation of any kind is unwelcome, but the idea has merit. In general we support using information and strengthening voice through pervasive public and patient involvement as a better route than structures.
- Use the purchasing power (monopsony status) of the NHS to improve NHS procurement practices in order to reduce costs of drugs, medical devices and general supplies. We support better procurement like everyone else but how? The NHS appears incapable of doing it.
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Strongly focus on dealing with the social determinants of health, such as poverty, wealth inequalities, unemployment, poor housing, social exclusion, lack of child care etc. Prioritise public health and social care. Absolutely – should be point one.
10. Exempt the NHS from the EU/US Free Trade Agreement, which otherwise threatens to open up our healthcare system to irreversible privatisation by large multinational corporations We support exemption.
Longer term plan – abolish the destructive, divisive and expensive purchaser-provider split There is always a split somewhere it is just about how best to manage the vested interests. We do not support purchaser/providers split or similar constructs which facilitate the market and add (we estimated) around £500m pa to NHS expenditure. But we have to have effective management and planning and some proper accountability over decisions on allocation of resources and priorities – this cannot be left to providers.
It will be interesting to see how the NHA develops its policies as now they just have a set of policy headlines. The key for all of us is not so much deciding what we want but setting out how it might be achieved, how long it would take and how much it would cost.
There are also some detailed comments where we could benefit from their views and maybe start a dialogue:-
- It only deals with the NHS whereas we need a much wider vision for care generally. It still sees the NHS in terms of a sickness service.
- It suggests the return of CHC’s restores public accountability but that was weak.
- It does not deal with how information can be used alongside new forms of communication and social media to fundamentally challenge old models.
- It does not champion shared decision making or community development.
- It is an approach based on an model for the NHS dominated by professionals.
- It does not address the crisis in social care which is perhaps the biggest current concern.
- It does not mention “integration” (which is compulsory nowadays).
- It does not explain how the money flows which is crucial to any “plan”, or how public accountability would actually work to allocate resources or set priorities.
- It says little about the wider aspect of political accountability which was fundamental to arguments over the H&SC Act.
I hope we could find broad agreement on some of these wider aspects. We have moved out of the era where markets and competition ruled; voice is the coming weapon of choice. We need a system which allows patients a real voice – whole patient care and integration around the patient (whatever that is interpreted to mean).
We should move away from the NHS as a stand alone service dominated by acute care providers and with unacceptable variations, huge issues of fragmentation, distain for accountability and for patient and public involvement and suppression of information.
But plans have to be realistic and credible.