Is a patient-led NHS possible?

Wendy Savage MBBCh FRCOG MSc(Public Health) Hon DSc

SHA conference 28.2.06   This report is a combination of Wendy’s slides and Joseph Choonara’s notes

Is a patient-led NHS possible?

I went to a conference last October hosted by something called the New Health Network. It’s run by Margaret Mythen, who was head of policy for the Labour Party for five years in the 1990s. This organisation is driving forward some of the government’s ideas and health secretary Patricia Hewitt gave the keynote address.

Everything she said sounded absolutely perfect, but for me it was just so different from what is happening on the ground. I suffered a kind of “cognitive dissonance”, which is when your perception of reality is completely different from the pictures you’re being shown.

There is a background to the idea of a patient-led NHS. The department of health published the NHS improvement plan in 2000, after three years of sticking to Tory spending levels, and it was updated in 2004.

Its stated aims were to increase capacity, extend choice and reduce waiting times—all of which are laudable aims.

The NHS Improvement plan 2004

Original plan was published in 2000, updated in June 2004

The stated aims are:

  • To increase capacity
  • To extend choice
  •  To reduce waiting times

Important consultations

Choice Responsiveness, and Equity – (John Reid’s baby). 110,000 responses (?) involved patients, NHS staff, began 1.9.03 and ended 10.11.03. Response from DoH published 8.12.03 Building on the Best. People want to share decisions about their health and receive the right information. Services to be shaped round patients’ needs.

Independence, Well-being and Choice: Our Vision for the Future of Social Care for Adults in England March 2005 Direct payments/individaul budgets top priority of respondents

Your health, Your care, Your say widespread consultation September-November 2005 Four sites for the public, Gateshead, Leicester, Birmingham, London.

There were a number of consultations. The “Choice, Responsiveness and Equity” consultation was John Reid’s baby when he was health secretary. It concluded that people wanted to share decisions about their health and receive the right information, and that services should be shaped around people’s needs. None of this business of going to a hospital when it suits the people at the hospital—they should work 24 hours a day, like they do in banks and supermarkets, according to someone in the Birmingham consultation.

Then there was the July 2005 Green Paper entitled “Your Health, Your Care, Your Say”, which launched a new consultation. When I attended the New Health Network conference they had the questions they had asked in the consultation. They were so badly phrased.

The one asking people if they wanted annual health checks asked about checking serum cholesterol and blood pressure, and four other checks. I can see it’s perfectly sensible to check blood pressure every year, because you don’t know if someone is developing hypertension until they have it quite severely and develop symptoms. But doing a serum cholesterol test on everybody? Is that necessary? To lump these different tests together was just crass.

In March 2005, we saw the publication of “Creating a Patient-Led NHS, Delivering the NHS Improvement Plan”. The 2004 improvement plan was called “Putting People at the Heart of Public Services”.

So between 2004 and 2005 we went from putting patients at the heart of the NHS, which I totally approve of, to a patient-led NHS. The 2005 paper goes on to say things like this: “The ambition is to move from a service that does things to and for its patients to one that is patient-led.”

March 2005 Creating a patient-led NHS-delivering the NHS improvement plan.

This moves from ‘patient centred NHS’ to ‘patient-led NHS’ What does that mean?

  • .‘the ambition is to move from a service that does things to and for its patients to one which is patient-led.’
  • ‘these changes are profound’
  • ‘this vision and these changes are very ambitious’
  • ‘the ambition is … change the whole system’

We’ve got a really waffly concept being launched on an unsuspecting public. I’ve read the statements on the NHS website about the progress in creating this patient-led NHS, and one thing that is quite odd is that the patient involvement in this patient-led NHS is minimal, if it’s there at all.

The key elements of the proposed changes are patient choice, payment by results and establishing a fixed national price for each procedure. I was interested to read that they have actually scrapped these tariffs for the moment, because they have accepted that there were major errors in how they worked them out.

Key elements of the patient-led NHS

  • Patient choice
  • Payment by results
  • Tariff payment ie a fixed national price for each procedure
  • ? incentives
  • Multiple providers from the NHS, private and voluntary sectors
  • A strategic shift into primary care
  • Practice based commissioning

Our health, our care, our say White paper January 2006

Patient choices have begun to play a role in developing the secondary care system, including driving down maximum waiting times.

Is this evidence based? Increased funding and NHSE targets are the reason that waiting lists have fallen

If patient choice and Practice Based Commissioning are in place, then health services will develop that are safe, high quality and closer to home, in the community.

Is this evidence based?

In 1989 there was a Tory project called the Resources Management Initiative, where six hospitals were trying to find out exact prices for things. I know from that experience that we didn’t really know how much things cost. Part of the reason why the US system is so expensive is that every aspirin, every plaster, every drip has to be costed.

There is a threat to the whole NHS from the government’s agenda. In July last year Sir Nigel Crisp, the NHS chief executive, wrote to primary care trusts (PCTs). He wrote on 28 July, just as everyone was going on holiday.

He told PCTs, which receive about 75 percent of the health budget and provide basic services outside hospitals, that they had to become commissioners and not providers of services. No thought was given to how services would be maintained or the number of staff involved. The Royal College of Nurses (RCN) embarked on a judicial review. Then in November, Nigel Crisp wrote another statement saying they had reached an agreement with the RCN and they didn’t really mean that PCTs were just to become commissioners. However, the government is increasingly saying that, although the NHS will still be free at the point of use, services don’t all have to be provided by the NHS. Anyone can do it, as long as they have the right standards.

Our health, Our care, Our say

Many good ideas and sentiments but vague about implementation except this clause in Executive summary

29. Allowing different providers to compete for services

In some deprived areas of the country there are fewer doctors per head of the population than in others. We will increase the quantity and quality of primary care in these areas through nationally supported procurement of new capacity with contracts awarded by local PCTs. To assist this process, we will remove barriers to entry for the ‘third sector’ as service providers for primary care.

What is the ‘third sector?

East Derbyshire Feb 2006

Contract awarded by PCT to United Health care Europe a newly created subsidiary of an huge American organisation. Simon Stevens ex-Downing St policy advisor is UK President and Richard Smith ex-BMJ editor is Chief Executive. Neither have recent experience of medicine or management in GP

See Barrett v United Health at Creswell

Complaints that consultation process not carried out properly and good experienced local GP Dr Barrett and multidisciplinary local team not short-listed.

Judicial review organised by patients result due soon

Patient led NHS ?

  • Health care best delivered to large populations pooled risk
  • Planning needs public health input
  • Asymmetry of knowledge
  • Pressure groups
  • Is this just another example of government spin?
  • Do the public want to lead the NHS?
  • Patient responsiveness more important

Threats to NHS as a whole

28 July 2005 NHSE instruction to PCTs to become commissioners not providers of services. No thought seemed to have been given to how these services will be maintained or effect on number of staff involved. RCN sought a judicial review in August withdrawn as DoH backed off in November 2005 in letter from PH.

October Oxfordshire PCT planned to privatise the SHA. DoH did not support this action

Idea of the NHS as a ‘brand’ being floated – it does not matter who provides services as long as free at the point of delivery

New Labour are floating the idea of the NHS as a brand. If you read Naomi Klein’s book No Logo, her thesis is that at the end of the 1980s the big multinationals stopped making things and started using their money to brand themselves, outsourcing actual production. As someone who has spent their working life in the NHS, when I hear NHS managers talk about the brand it makes me feel sick.

Then there’s another question—do the general public want to lead the NHS? Surveys run by people other than the government show that it’s pretty unlikely that they do. They might want it to be more responsive to the patient, but they don’t want to run it.

There also seems to be a belief in this government that business is more efficient than the public sector. Is business really so efficient? Whenever I do something with my bank I’m appalled by how inefficient things are.

For example, if you let the market drive the food industry you get all sorts of inessential foods and drinks, which lead to obesity problems that the health service then has to deal with.

There is an increasing dominance of the private sector. When you look at the maps on the department of health website of the independent treatment centres (ITCs) it tells you how many operations have been done by the NHS, but it doesn’t tell you how many are done by the private sector.

It’s hard to get the figures. Patricia Hewitt gave a speech in January where she said that they had done 250,000 procedures—half operations, half diagnostic procedures. But they say that there is an issue of commercial confidentiality. To me that’s complete nonsense in a National Health Service funded by the taxpayer.

You may have heard about the case of one opthalmology ITC, where a PCT had to pay for a large numbers of operations that weren’t actually done, because the patients didn’t want to go there.

Julian Le Grand, a Downing Street policy advisor, wrote in the Guardian that ITCs were more efficient than the NHS. Well of course they are— if they are not training student nurses and doctors, if they are able to cherry pick the most lucrative and least complicated operations.

You get patients treated like commodities. High risk patients are unattractive, which leads to “patient dumping” as we’ve seen in the US. There is an inability to plan services because patients might choose not to go to your hospital. You have the involvement of US multinationals—from a country where 45 million people have no health insurance and outcomes for maternal and child health that are worse than Cuba. This is a crazy and expensive system to emulate.

Threats for health care as a whole

  • Fragmentation of care, with loss of continuity of the patient pathway
  • Doctors loss of control of which patients they see
  • Unclear clinical governance issues around the private sector and foundation trusts
  • Perverse financial incentives will lead to inappropriate management of patients
  • Loss of staff to the private sector
  • Adverse effects on teaching and training
  • Closure of NHS units leading to less real patient choice
  • Increasing dominance by the private sector
  • Patients become commodities, and high risk patients will be unattractive leading to ‘patient dumping’
  • Inability to plan services as a result of ‘patient choice’
  • NOBODY KNOWS WHERE THIS WILL END UP– not even the DoH or the government
  • Patricia Hewitt 13.12.05: The next 24 months will determine what kind of NHS we will have for the next 20 years. Reform is the solution not the problem

Market-driven politics

Real markets are deeply political-state omnipresent-national politics and the state are always targets-businesses want to enter NHS

Convert services into commodities and workforce into one orientated to profit and get government to underwrite risk.

Market competition transforms commodities

Consequences, inequality of provision, high costs and corruption (eg US health system)

Nobody knows where this is going to end. At the conference I attended, people kept talking about “turbulence”—one of those new buzzwords. A senior NHS manager said, “I want to be a leader in the new NHS, but I’m in the dark. I don’t know where we’re going.”

Patricia Hewitt said in December that the next 24 months will determine what kind of NHS we have for the next 24 years.

“Reform is the solution not the problem,” she said. That’s her view of things, but it’s not mine. I’ve always been more one for the cock-up theory rather than the conspiracy theory, despite my personal experience, but they can’t be as incompetent as they seem to be.

What can we do ?

Join Keep Our NHS Public

Donate money to this campaign

Talk to you MP about the practical problems you have experienced or foresee if Patricia Hewitt continues her ‘Root and Branch reform’ of NHS

Respond to articles or letters in the newspapers, national and local, to inform the public


Launched September 2005 by NHSCA, NHS Fed and Health Emergency

Aims of KONP

To build a broad coalition which will campaign to protect the NHS from further privatisation and fragmentation

To keep our NHS public

Progress so far

Steering group and management team set up, the latter meeting or teleconferencing each week

Website launched this has a round-up of news stories, policy documents and names of those who have signed up so far, joining form and petition

Leaflet for local groups and general leaflet produced and distributed.

KONP meetings held in several places eg Tower Hamlets next due 8.3.06 7.00pm Draper’s Hall Queen Mary

Conference NHS-SOS 25.3.06 12noon-4.00pm at Friends House Euston Rd London NHS Federation and KONP.

Further reading

  • Allyson Pollock NHS-plc (2005) Verso & BMJ articles
  • Colin Leys Market-driven politics (2001) Verso
  • John Lister Global Health Reform (2005) Middlesex University Press
  • Jennifer Dixon Reforming the NHS in England BMJ 2005 v331 p852
  • Donaldson C and Ruta D. Should the NHS follow the American way? BMJ 2005 v331 pp1328-30
  • Lane R and Paton A. Bevan betrayed : the demise of the NHS. BMJ 331 852
  • Late 2005 Education and debate Timmins et al
  • for consultations and progress on implementation of the NHS plan