Does the NHS Run Better Without an Internal Market?

With Dr Julian Tudor Hart, Dr Tony Beddow, Mark Drakeford AM

Cardiff Central Library The Hayes Cardiff CF10 1FL Saturday 4th February 2012

About 30 people were present, about half of whom were SHA members.

NHS Run Better Without an Internal Market?

Mark Drakeford

Mark began by emphasisiing that the NHS in Wales was by no means perfect, and he had no intention of claiming that it was.

in 2000 Jane Hutt and the Assembly Government had been faced with the question of what to do with the 22 local health groups they inherited, and how to tackle the priorities of primary care and public health.

The system instituted then had 22 Local Health Boards, and a smaller number of provider Trusts. The purchasers were too small and weak, and market mechanisms didn’t deliver the desired improvement. The balance of power shifted in favour of the Trusts, which were more powerful. The subsequent reorganisation formed 7 Local Health Boards, delivering integrated services and eliminating the paper chase of the internal market.

Initial problems:

Jane Hutt was worried that primary and community services would suffer.

How can the patients’ voice be heard? Community Health Councils have been preserved in Wales.

Some Local Health Boardss are very large geographically.

How can quality and performance be assured?

What effect will Lansley’s NHS Reform Bill have on Wales? (NB Wales was not consulted about aspects which affect Wales) There are threats to clinical training, the GP Contract, the prospect of local pay scales, the abolition of a number of joint bodies, and the prospact of dragging the NHS into the scope of European competition law (which operates at the National State level.

Integration of Health and Social care

The Welsh government has not protected the NHS budget against Local Government – it makes no sense. In Wales a wider view of health is taken, and much which determines health is the responsibility of local councils. There are no Care Trusts or Children’s Trusts in Wales. Social Care is still provided by local authorities in integrated social services departments, largely as Seebohm recommended.

There was a lobby for an All-Wales mental heath trust, but the decision was made to put mental health with physical health into the Local Haelth Boards. Each LHB Vice-chair has a specific responsibility for primary and community care, a move designed to ensire that hospital care does not suck up all the reources.

There is an ineveitable conflict between choice and equity. In welfare markets it is suppliers who choose users, not users who choose suppliers. In Wales we think equality of outcome is more important than the illusion of choice.

Tony Beddow

The Welsh system is designed to make evidence based use of resources. We are interested in competition between collaborative units, but specification of clinical work by contract does not work. We do not accept that most NHS staff are primarily motivated by self-interest, and we don’t want a system which sucks people into hospital.

Julian Tudor Hart

The NHS began here – before Bevan – with mutual aid societies. A collective approach to problem solving. Even before 1912 there were conflicts between what doctors wanted and what patients wanted. Doctors were often a break on progress. Julian has written a new pamphlet, called “A New Path Entirely” which elaborates these ideas.

Bevan compromised over the ownership of primary care. GPs should be salaried. The separation between those who plan and those who deliver services is not helpful.

There are problems in General Practice in Wales. Home visiting is rare, and enabling people to die comfortably at home is very difficult.

Allyson Pollock demonstrated the problems of PFI. £1.5 billion has been set aside today to rescue English PFI hospitals. The Socialist health Association failed in this area and we should admit our faults.

On 16th November 2011 Andy Burnham pledged to repael the NKS reform Bill. This appears in the online version of the Guardian, but has never appeared in the printed verson. Was this suppressed?

Jan Williams

There are plenty of challenges for the NHS in Wales – increased length of life, technological development … The NHS is part of a much broader health and social care system. It’s important that, for example, cardia services are not pulled into hospital, and that’s why we’ve established the South Wales Cardiac Network and the Orthopedic Network. 30% of the need for hip replacement is related to obesity, so it makes sense to address the obesity as much as the surgery.

We have no NHS Tariff or Payment by Results. We do have patient level Costing. Cardiff and vales has community directors, who are GPs

Lindsey Davies

There are Wales Wide out of hours services where GPs who are self employed during the day work as employees during the night. But our experiment with salaried GPs was not very successful.

Doug Naysmith

GPs, at least in Bristol, do still do home visits. Everyone may hate PFI but it delivered a load of very necessary rebuilt schools and hospitals for which we do not need to apologise.

During the last 15 years outcomes and patient satisfaction is greatly improved. We need evidence based comparisons of different NHS systems.

Jane Roberts

There have been many positive changes in the NHS in England, though the quality of both GPs and nurses is still variable and more change is needed. How does the Welsh system deliver change?

Richard Bourne

How do you cope with the power of large acute trusts? Primary care is always comparatively weak. – reply that the LHB has all the budget, including that for Primary Care

Tony Beddow

In the 1980’s the Welsh document “Strategic Intent” – focussed on raising the level of health and more preventative work, included local government as well as the NHS.

The English NHS reform plan has no notion of healthcare or well-being.

Co-terminosity and long term relationships help.

There is a worry if you have a credible local champion for non-evidence based practice.

Philippa Ford

There is a close working relationship between Welsh Government and the Local Health Boards. For example, the chairs meet with the Minister, the CEO’s meet with the Director General, the Directors of Nursing meet with the CNO, the Medical Directors meet with the Welsh Government Medical director etc…on a regular basis.

Sundry questions

Occupational health in Wales is much like England – only for NHS staff

How like Wales is the Kaiser Permanente model? – in may ways quite similar.

How important is culture and relationships, as compared to organisational form?

Cecilia Love

Is there an opportunity in devolved nations that are defining an alternative model of working to the NHS in England, to strengthen the link between health and social care, acknowledging that there is no separation between mental health and physical health, so that a more social approach to understanding and treating mental health may work towards reducing the amount of pharmaceutical input or more intense forms of mental health services used?

Will the Mental Health Measure provide adequate care plans for people with mental illness?

Is there local democratic control?

Mark Drakeford

We make political choices. We’ve chosen an planned collaborative service and we belive in the public service ethos. The NHS is a symbol of social solidarity.

This is not a competition. How users think about the service matters. Ideology matters.