Policies for Change: NHS Reform

Report of an event organised by the The Smith Institute in association with Asthma UK and ACCA (Association of Chartered Certified Accountants) Tuesday 13 September 2011 at the British Academy, 10, Carlton House Terrace SW1 18.15 – 19.15 with a reception afterwards.

The attendance list shows 121 invited guests and three platform speakers: the Rt. Hon. Andrew Lansley, Secretary of State for Health; Neil Churchill, Chief Executive Asthma UK and Research Fellow, The Smith Institute; and Mark Millar, Chief Executive Milton Keynes NHS Foundation Trust and ACCA Council.

The guests included representatives of organisations having special interest in chronic conditions especially asthma; NHS managers working at national and regional levels; government organisations (the Audit Commission (2), the Equality and Human Rights Commission (3);  the Royal Colleges of Midwives and Nursing and the Royal Pharmaceutical Society; professional associations; well known accountancy firms; drug and private healthcare companies; lobby groups and opinion monitors;  Monitor; the medical press; academia; one Lib Dem MP (Dr. Graham Winyard MP for Winchester and Chandlers Ford) and one trade union (Unison).

Neil Churchill, Chief Executive of Asthma UK & Research Fellow at the Smith Institute, welcomed everybody.  He said that 66% of NHS expenditure was incurred in treating chronic conditions such as asthma and diabetes.

Mark Millar, to introduce the main speaker, said that there was ‘no dissension within the management of the NHS over the ills of the NHS’.  He said that colleagues in finance agreed the diagnosis:  historic increases over the last 10 years are not sustainable; David Nicholson was “bright and bold” to require £15 – £20 billion necessary savings.  There was a need for ‘proper, adequate management’ and ‘we would like some stability’.  According to a recent report private sector health leaders seem less confident than a year ago about competition. The debate over the closure of Chase Farm was about competition and cooperation.  He quoted Andrew Lansley: “We know what we need to do and we have been very good at delivery”.

The Secretary of State, after recalling with affection that 27 years before he had met the late John Smith, then Shadow Health Secretary, said “when we are ill we want the best possible care and the best possible outcomes”: in long term conditions this means the mitigation of symptoms and release from hospital. Given the support for the event from Asthma UK he chose to use the example of England’s 3-5 million asthmatics, (among the highest number in the world) with 1,000 deaths annually, needing fast, accurate diagnosis and treatment. He maintained there was currently an NHS “overly bureaucratic process”. Data (no sources) showed a five fold difference between Primary Care Trusts’ A&E treatment of asthma emergencies.  He cited recent reorganisation of services at Southampton, at Guys and Thomas’s, in Essex and Surrey as examples of improvement.  “All care in the NHS should be like this.  None of these need the structural changes in the Bill” but “We need the Bill.  We have to dismantle a top down system…set clinicians free.. empower clinicians and patients …involve local authorities” He maintained, “Only ‘Dobson’, over the past 20 years has not tried to carry out these changes”. (referring to Frank Dobson, Secretary of State for Health 1997 -1999)

Questions from the floor followed, three at a time, twelve in all. Some were hard to hear when questioners at the front of the room facing the platform faced away from the majority of listeners (no sound system).  The Chair did not repeat the questions. Notably the Liberal Democrat MP Graham Winyard challenged Lansley to the effect that the upheaval of change was not necessary.

Subjects ranged from what the National Tariff for long term conditions would be and the role of specialist nurses (from the RCN); how to ensure public health was not fragmented (NHS Brent); outcomes for over 75s (Age UK); the varying sizes of  Clinical Commissioning Groups (CCGs) configuring pathways and problems for local authorities working with them; the problem of small groups of “intransigent” GPs (‘Front Line Consultants’); free prescriptions; the high cost of “empowerment” and how to ensure investment (Kings College London School of Nursing & Midwifery); whether mandates to hold Commissioning Groups to account were robust enough to ensure compliance with filling in data (Macmillan Cancer); why, to take these measures forward it was necessary for structural re-organisation, with people so unenthusiastic (a former NHS Director); “vested interests”; whether support would be assured for a mother’s childbirth choices – home or obstetric unit (R.C. Midwives); what to do when treatment is refused to patients (citing examples in the last year).

Mr. Lansley sought to reassure.  On specialist nursing and tariffs: guidelines were only guides.  A tariff could be shifted “from an episodic to a pathway basis”: a ‘year of care’ tariff or a ‘pathway’ tariff, were “tools for the job”. A consequence of involving local authorities in health improvement carrying with it  the risk public health initiatives would be outside the NHS –  I always knew the consequence of giving local authorities public health responsibilities carried with it a risk of no longer being embedded in the NHS – but we wanted to give it to Local Authorities for a reason – to work alongside all their other key areas of responsibility. However if there are any uncertainties they will specifically look at the NHS contribution and those relationships …and we would have to support those relationships”.  If there was any uncertainty, an NHS Future Forum “workstream” was to look at the NHS contribution to public health, among whose determinants were employment, housing and education.

The NHS had spent decades trying to get all organisations of the right size but CCGs did not have to do everything (that was a sin of PCT land”).  Data about the over 75s was difficult to collect.  Free prescriptions (“an ideal world”)  would cost £480 million; £104 pre-payment annual cards helped those not exempt.

The Secretary of State agreed that empowerment does cost money. The aim was for savings at every level to be invested.  He was “a great believer that data has a bigger impact than any structural changes because the mandate to the outcomes framework will support the duties in the Act such as equalities, continuing improvement and the support for research……..   ”.

For the first time a Secretary of State would not ‘interfere’ beyond the point of being clear what the NHS must do.  “Nobody’s ever done this before’.  On the shift from the duty on the SoS to secure the NHS for all ‘It will be the duty of the SoS to oversee the various Commissioning Board targets –not just shrug and put out another piece of paper when things go wrong….’.   ‘What is a comprehensive health service?” the answer in the past has been, whatever the SoS said it was”.  Devolvement was disliked because people like a centre.

About maternity services he said that over the last two years the rise in midwives matched the rise in birth rate. He alleged “The last government did not realise till 2006 that the birth rate had been rising since 2001”. Now there were more than 500 more midwives than in 2001. Tariffs would have to support the choices mothers make of home or obstetric unit for a birth.  ‘No decision about me without me is essential”.

If a clinician refused treatment it must be for a rational cause not because of “them” telling the clinician what to do. Later that was no coherent answer to solving the plight of patients in Pathfinder areas whose GPs are already turning down advised prescriptions from hospital consultants on the premise that the ‘cost will prevent us offering another patient a hip op’ or stated lack of expertise in managing the prescription – Lansley’s response was ‘ it’s all the fault of the PCTs’ but when asked which protocol these patients should follow to obtain their treatment along, given that legislation was not in place and with too few staff at the PCT to help, he replied that ‘they should go back to the PCT – they will have the answer

To a query from Mark Millar about being “behind the curve” of cost and demand, Andrew Lansley said he believed ‘we had made more progress in 2010-2011 and though not all returns were back more than half of Trusts do expect to meet their cost improvement programmes.  They were “still on track for the 4 years”. ‘Although the numbers look ok and people keep saying that structural upheaval is not necessary  – they are looking at the wrong thing. They are not looking at the 40% tariff target and they are not looking at the 20% re-shaping services target – neither of which are on track, we are behind on delivering the things we need to do – ‘albeit we don’t know the changes we are looking for until they happen’.

On the concerning matter of social care…….’all the mechanisms are retained for pooling which will help to drive integration of services for the benefit of patients – albeit there will always be severe limitations on how these can be used…hopefully the patients themselves will be able to  enable them to be more flexible….’.

Mr Lansley maintained that GPs had been disappointed by so many previous Government initiatives begun and then dropped. He justified the opposition to the Bill from GPs thus : Initial GP enthusiasm has been eroded by debate – I can understand their worry that it will be a Duke of York march up and down the hill….but this is about outcomes and making sure that clinicians give time and support to patients’.  This will not be the case. They would not be like the army of the Duke of York this time.  “To secure the NHS for the future clinicians had to have responsibility to decide”.

On what he continually referred to as vested interests, Lansley recalled a television programme about the Borgias.  “The Prince sets out change. Everyone is against it. Machiavelli advises ‘you have to do it quickly’”.  To which he added “but not regardless – you need to take people with you – as over the last year. We are making these changes purely because of vested interest – to redress barriers and to do better in the future.   When change is resisted by vested interest – DO IT QUICKLY!! Only then will they listen, adapt and be flexible….”

This was the climax of the peroration.

Neil Churchill said the Secretary of State was “absolutely right” and thanked him. The formal meeting ended at 19.15.

Andrew Lansley stayed to chat and share a drink for about an hour.  In the group we joined, just before he had to leave, the subject returned whether the Bill’s structural changes were necessary to enable the outcomes and benefits asked about in the previous hour’s questions to be achieved.  The Secretary of State said ‘they could be achieved without the change’   “So why make the changes ?” he himself then asked.  His answer was that’ in two or three years time everyone will see and be grateful that the changes were for the best’. 

Notes by Roger Gartland and Jos Bell written 13.9.11.