John Pugh MP asks for Lib Dem members’ feedback on health issues

As part of the empowerment (sorry about the cliche!) of ordinary members it might be useful if you let us in the Westminster village know how you react to unfolding coalition policy.

I’m tasked as Co-Chair for the Backbench Health Committee to ensure that distinctive Lib Dem policy on health goes into the Coalition Government equation.

So I have decided to seek party members’ views on the much-reported Health White Paper – especially from those who have a bit of hands on experience of the NHS.

Please post here or alterantively e-mail me at [email protected]

The issues are not insignificant, with the perennial issues of cost, efficiency and accountability being thrown into the melting pot by another proposed NHS restructuring. All feedback gratefully received.

With most spending/commissioning power of the NHS scheduled to be handed to consortia of GPs, Primary Care Trusts face oblivion. It would be good to know how ordinary party members feel – specifically:

  • Is the NHS ready for another structural upheaval/reform?
  • How will GPs cope with their new role?
  • And are we going to get a local NHS which is more accountable to the citizen and tax payer?
  • Will the NHS work better for the patient without PCTs and Regional Health Authorities?
  • Can we make progress without these changes ?
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163 Comments

  • Is GP commissioning privatisation by the back door, and what is local community involvement going to be in the future shape of the NHS? Andrew George has urged GPs to get involved with community representatives in shaping the future of local services: http://stiveslibdems.com/andrew-george-mp/andrew-george-mp-to-ask-cornish-gps-to-involve-local-people/

  • Alec Dauncey 14th Jul '10 - 12:11pm

    Please remember that this is only about ENGLAND. Since health is devolved. Please make this clear by using the word “England” far more in all statements speeches etc. Otherwise we leave the electorate confused. We have elections here in Wales next year at which health issues will be decided. MPs have no effective jurisdiction over health here.

  • I second Jonathan’s comment. Watching Newsnight was revealing. With the service thrown into confusion, and everybody’s jobs and professional prospects on the line, what did the professionals have to say? They all just concentrated on the main chance, of course. I can’t blame them. But with Andrew Lansley sitting and listening a few feet away, trenchant criticism from the professionals was in very short supply!

  • I’d echo Steve Hicks’ question regarding privatisation, but also add this – does the reported removal of the cap on private treatment in NHS hospitals mean I will wait longer as an NHS patient than I do now (due to there being more private patients taking up theatres/wards/surgeons/etc)? How can we prevent this?

  • My main concern is democratic involvement and control.

    I have no truck with the unelected PCTs or Trust boards
    but they have to be replaced by something that is really
    accountable to local people.

  • As I’ve previously commented on another thread…

    Re NHS reforms, this may be of interest: http://www.tribalgroup.com/Mediacentre/Pages/TribalpublishesresponsetotheHealthWhitePaper.aspx

    This caught my eye:

    “Denationalisation: this white paper could result in the biggest transfer of employment out of the public sector since the significant reforms seen in 1980s. As NHS trusts become foundation trusts, this will see the transfer of billions of tax-payers’ assets to employee-controlled businesses.”

    Sounds like at least one company is gearing up.

  • Barry George 14th Jul '10 - 8:15pm

    I am not a member but I also echo Steve Hicks’ question regarding privatisation

  • I’m sure its lovely that the Lib Dems have had an impact on this policy but it doesn’t stop it from being utterly mad. Why have a massive (and expensive) reorganisation of the health service when we’re trying to SAVE money? Since when do LDs want a free market in the NHS? This policy (like Gove’s schools policy) MIGHT work if there was lots more money splashing around to pay for it but there isn’t. Why are we agreeing to this?? Its a massive gamble and is going to hurt the people who voted for us.

    Am I the only one that thinks its a good idea for the NHS to have strategic bodies controlling it? By all means cut costs and make them more DEMOCRATICALLY accountable but why are we rolling over and letting the tories bring in free markets to our health (and education) systems by not even the back but the front door???!

    I’ve supported the coalition up to now, even though my job and some of my family’s are threatened by its policies but letting the tories push us into this, which isn’t even in the agreement is a massive leap too far. I feel like I’m just being masochistic staying in this party, our Ministers need to grow some balls and remember who voted for them very quickly.

    PS I know our base is in local government but local councils can’t run everything, not least because they’re about to get massive cuts in their budgets and will be reeling from that whilst trying to take on these myriad powers which are being thrust at them all at once. Slow down!

  • Jeremy Ambache 15th Jul '10 - 11:33am

    I am pretty dismayed with the Lansely plan to major restructure the NHS. Our parties policy is not for restructuring – but more for ‘evolution’ – so that we put patients and carers at the centre of the NHS.
    As proposed moving the GP consortium commissioning – rather than PCTs – is a huge huge change. We will be too small ‘purchasing’ and commissioning units and consortia will then need to develop mechanisms to work together! There will need to be a lot of infrastructure that GPs will need so that they can plan, work with communities, decide priorities, decide budgets, and then commission the whole range of services for their areas. This will be 2/3 years of organisational upheaval with little gain. Definitely not the democratic accountability that the party policy calls for! Another problem with GP consotia commissioning will be the lack of co-terminosity with Local Government – this will make it harder to integrate health services and social care services.
    The proposal for Public Health to Local authorities is good – it makes a lot of sense to bring together public health with the local Authority responsibilities of housing / leisure / jobs/ social care.
    Healthwatch – not a bad move – but should be re-titled Health and Care watch!

  • DAVID YEATES 16th Jul '10 - 4:52pm

    It is essential that General Practice has a PROACTIVE ethic rather than a REACTIVE one. I have recently been out of my way to have some cardiovascular tests carried out as these were not available in my surgery. Everyone over 50 should be invited for an annual healthcheck and allocated reasonable time to discuss any other concerns they have with their GP. I have found that GPs tend to glide too quickly through appointments and don’t probe a patient’s general health enough. I would favour a head to toe check with maybe a questionnaire in advance so that a doctor canidentify potential risk areas.

  • My main observation on the NHS, especially in London, is that the dedication from health professionals is second to none but the attitude of non-medical front line staff is often appalling. I’ve lost count of the number of times my wife and I have been dealt with by grunting, insensitive and generally disinterested or even downright rude staff sat behind reception desks or on the end of telephone lines. The attitude seems to be that as we’re “not paying for it” we don’t deserve any level of service. Some instilling of patient-care values (customer service values, if you must) among non-medical staff wouldn’t go amiss, especially when the “customers” are often feeling extremely vulnerable.

  • mike cobley 16th Jul '10 - 5:05pm

    Quick response just now, more later. Of course, the Coalition reforms are privatisation – it has been admitted openly that they are merely building on the work already carried out by the previous Labour regime, ie the hiving off of support and frontline services to private sector companies. The dumping on GPs of budget management is insane – a small minority will be able to cope with this, and the rest will be easy meat for the private sector/Serco clones who will descend upon them like a cloud of locusts. So bye-bye yet another chunk of the NHS budget on private sector profits, exec salaries/bonuses and shareholder dividends. I have the feeling the the Tories wont be satisfied until we really are just like the USA, where there is a billing department in every doctor surgery, clinic and hospital across the land. Who knows where this could end – perhaps we`ll get to the stage where we will be billed for treatment up front, but we can claim it back through tax or some other kind of deferred compensation.

    No doubt about it, this is gonna get ugly.

  • Nigel Lewis 16th Jul '10 - 5:15pm

    When rest and more importantly sleep is very necessary to aid recovery, then conditions in hospital wards need to be improved. One major cause of disturbance to patients recovering is having to share a ward with one or more of those poor people that are suffering from dementia in one form or another. Yes! I have every sympathy for them as I may become one of them myself one day, and for their families.

    I would hope however, that should I suffer one day from dementia, I would be treated better than many current dementia patients are, especially in the hospital that is in Dr Pugh’s own constituency. Not only are there not the staff to deal, and treat them with care, and most importantly dignity, but they are just shoved into a general ward, often confused, constantly ignored by staff, who seem to prefer cleaning them up some time after they have unavoidably soiled themselves, than see to their needs before this happens.

    Due to this, these dementia patients, often in the confusion that is caused by their condition, become noisy and disruptive, and sometimes violent. This results in the rest of the patients who are in need of calm to aid the recovery, unable to get their proper rest or decent sleep, with sleep often made more difficult to achieve anyway, due to their condition or the aftereffects of their treatment.

    The hospital mentioned, say they cannot do anything about it, as do many other hospitals. This cannot be true, it is because they don’t have the will to do it, often quoting the cost. Perhaps a few less persons in management could help regarding cost. This disruption is one of the most common complaints from patients – it is time hospitals were forced to do something about better treatment for dementia patients, with the result better care for them and ordinary patients.

    It is also time that hospital bosses were made more accountable to patients and the general public they serve. They often sit in their ivory towers, filling out self assessment forms to give the impression that their hospital is the best in the country, when it is clearly not. The other tier of hospital management the ‘Trust’ could also be dispensed with as none of them seem to have any real influence over the hospital managers. All hospital management should be made to ‘go back to the floor’ on a regular time scale, without the ordinary staff being aware of their arrival.

    Every hospital should have to give every patients a survey form on their release, or end of treatment, and these should be monitored independently, and the results published in local newspapers, or be made easily available in printed form so as not to discriminate against those who do not have the internet, and published on the internet for those with the facility.

    And I am unanimous in this.

  • donald cameron 16th Jul '10 - 5:23pm

    Given that this is a structure that we need to work within until the next (Labour?) political initiative, here are some reactions.

    (i) Organisation re engineering
    Successful change on this scale will require a massive communications/inspiration/ training programme for GPs over many years. It is the last thing that will have occurred to politicians and civil servants who will be more concerned with a cogently written paper.

    Coming at the start of a new administration is the best that could be hoped for. But sustained change on this scale will require stable leadership. On past form the current Secretary of State can be expected to be shuffled in 18 months

    (ii) Patient Power
    Easily understood (and available) performance data about doctors and procedures will be the key to this. Not easy because it is going to be resisted by the medical profession. Starting with the argument that individual hospitals will try to” doctor” their statistics for competitive advantage. And it will require a new kind of teaming and relationship between GPs and patients to interpret the data (eg Great Ormond Street may not have the best statistics for a particular outcome but they will probably be taking on cases where other hospitals have already failed).

    Ten years ago I was looking for a UK prostate surgeon and after consulting with my GP it became clear that no performance statistics were available, although everyone had a surgeon “friend”. I immediately discovered the extensive data available in the US and the league tables which guided me after I decided to go there for treatment. When I returned to the UK urging change I discovered an entrepreneur trying to get Dr Foster off the ground on a shoe string. Dr Foster is now owned by the Imperial Hospital Trust I think and they managed to blow the whistle on Staffordshire. But I tried to use them recently to find a kidney surgeon and the stuff was almost useless. No comparative statistics, no clinical outcomes, and hugely difficult to navigate.

    I think “brand” will be important for producing and maintaining performance data. BUPA is an obvious brand because they already have an inside track. Macmillan Nurses, Red Cross, St John Ambulance may also be brands that the public would be prepared to trust. Or maybe annual Sunday Times “League tables”. The kind of thing that is having such an incredible impact on the quality of teaching on universities.

    (iii) Rallying Cry
    This does not come through clearly. The paper seems to be talking about lots of different objectives. Patients are not too concerned (I would suggest) about PCTs (who are they?), NHS administrators (who are they?) etc. But quality of outcome is very important to patients when a medical problem forces them to think about this. And by and large the population does not have a clue just how awful NHS quality is in areas that are more coplicated than taking a temperature.

    The whole crusade should be focused around creating an awareness of just how terrible NHS quality is. But this needs very sensitive handling so as not to demotivate the doctors.

    (iv) GPs
    Not sure how mobile the the population is. I suspect that most people stay with their practise (the doctors change) unless they physically move location. And even then, they may stay with the same practise after moving. I have been with the same practise for 51 years in spite of a number of house moves.

    (v) Attitude
    Having been a patient in a number of UK hospitals I have seen at close quarters how deeply ingrained the dependent society is. The idea of a “patient voice” and making choice will not happen easily. I remain convinced that co payment would be a very powerful way to achieve this. Charge the average Brit for his beer and he takes a keen interest in the brand.

    (vi) Motivation
    Patients and doctors need to see “something in it for them”. My belief is that the population is not aware and not interested in health (until there is a crisis and then it is too late) and the doctors (GPs and consultants) are hugely demotivated.There is the need for a huge sales job and above all leadership which can carry the profession. The population will be deaf until they become patients – hence the need to wake them up by hitting their pocket with co payment (with safeguards of course for those who cannot afford to make a small contribution).

  • Visitor to New York 16th Jul '10 - 5:25pm

    Not a single mention of “treatment quality” in all of this.

    I am in New York again for cancer treatment after opting out of the disasters that I experienced in the NHS. When I first found a good American surgeon on the internet (something you cannot do in the UK) he got straight to the point.

    “You are another Brit trying to pluck up the courage to leave your hospital system which you have lost faith in. We hear from many like you”

    The poor quality of our health system is one of the best kept secrets of public policy. It makes me very angry because I pay for it and the politicians are being less than candid.

    At the point of need, it does not matter to a patient whether the mess is due to funding, doctors, administrators, the unions, the Opposition, or whatever other cop out can be thought of.

    Getting world class treatment is what it should be about

  • I am an enthusiastic supporter of the Coalition an dthe policies in the Coalition agreement but these proposals for an NHS reorganisation seriously upset me and I cannot support them.

    Clearly it will involve major cost and upheaval – both extremely undesirable. Why is it being proposed? – It seems to be for an ideological reason rather than quality of patient care or value for money.

    Those above who support the US system should remember that US health costs 16% of GDP compared with the UK’s 8% but the outcomes are similar – in fact life expectancy is lower in the US. There is plenty of choice in the US if you can afford it but plenty of cost too. We should not move in that direction.

    At a time when we are looking for major savings this proposal is crazy. We should not support it.

  • David Clancey 16th Jul '10 - 5:49pm

    If you stopped giving away our money in Overseas/Foreign Aid then you might not have to make NHS cuts!

    Charity begins at home

  • Martin Bailey 16th Jul '10 - 6:03pm

    The proposed new structure for the NHS is an example of Maoist permament revolution: keep changing at all costs, and believe that things will advance towards perfection. Give authority to PCTs. Abolish PCTs. Give huge budgets to so-far non-existent consortia of GPs (who have no financial expertise, so they will need to hire more qualified accounting staff). And did someone suggest giving more powers to local councils? God help us: many local authorities are inefficient, slow, cack-handed institutions that themselves need radical reform. I wouldn’t want to trust my health to Haringey or Newham council…

    What is needed is for the NHS to be cut free from interference by successive waves of politicians. By and large the BBC is an example of a publically funded institution that is free from ministerial fiddling.

  • Paul McKeown 16th Jul '10 - 6:32pm

    @Away with the Birds

    Any budget for homeopathy on the NHS should (and will) be closed in short order as a total waste of money.

  • In general I would say that my GP partnership is reasonably well run.
    A senior partner told me that he was overwhelmed with administrative negotiations.
    I found great difficulty in working with the PCT.
    dealing with the PCT Referrals to specialists don’t work well because the GPs do not have the effectiveness data for patient choice.
    Local visits by specialists are appreciated.
    Ease of access to hospitals a major consideration for me
    Also I was not given a full picture of post of side effects
    Our patient participation group deems to have little effect

    My conclusion is that more assistance to patients
    (especially in consulting those with similar conditions) would drive the system forward
    and that local action is something to encourage.
    and stability is desirable
    I subscribe to Donald Cameron’s remarks above
    Might he be found a job?

  • patrick waylett 16th Jul '10 - 7:12pm

    The whole justification for the changes seem to be to introduce “market” discipline into the NHS. It is driven by dogma not patient care. We have taken this road before during the last Tory government and it was a disaster.
    The “outsourcing” of many NHS services like hospital cleaning etc led dirctly to a big drop in standards and the deaths of patients. The “market” is seldom the answer to anything, it certainly isn’t the answer to health care. It seems like a step towards the American system, which provides decent care for the rich, but little or nothing for ordinary people.

    I am a pensioner and rely on the NHS for monitroing of a serious condition, to date it has been very good. In future it seems it will rely entirely on the quality of your GP and the ammount of money that practice can attract. It is little more than a transfer of rescources from the vulnerable to the wealthy. I am totally opposed to the proposals.
    Not a single word of this was in either parties manifesto, why? Because if it had been it would have lost the election.

  • Visitor to New York 16th Jul '10 - 7:20pm

    Sometimes outside observers see things more clearly than the insiders.

    The Wall Street Journal ran a piece yesterday on the NHS initiative and they reported two messages:

    (i) it is a cost reduction initiative which is driven by the economic crisis

    (ii) GPs will have to drive the change but not all doctors will want the extra responsibility or have the necessary management or financial skills

    Seems like spot on reporting to me.

    Not a mention of treatment “quality” which is the number one issue for me, a patient and funder (taxpayer) of the NHS.

    Sad, really

  • donald cameron 16th Jul '10 - 7:24pm

    The fallacy of the new initiative, which has much to do with chasing efficiency and cost savings is that “free” and “efficiency” are not compatible. Never were and never will be.

    If something is “free”, it leads to monumental waste and efficiency

  • Donald — look at the (not free) US Healthcare for inefficiency and high cost (16% of GDP) and compare it with the (free) NHS which is relatively efficient and low cost (8% of GDP).

  • Let’s take the greed out of this shoddy democracy…I thought that’s what liberalism was all about!. Big business and their profit hunger is what has bought this country to it’s knees. As a ‘low to middle’ earner with a baby on the way I’ve found we get no more than a 60000 household. I’ve worked my arse off to have the pretty good life we had but now we’re having a baby we are due to be skint!….
    If you could let me know how this government is going to help us….fairly soon though as I’ve other options to weigh..

  • donald cameron 16th Jul '10 - 7:46pm

    Barnesian
    I know the US spends more on Healthcare and we hide behind that. And also believe that the best US medicine is only for the rich.

    I have been in and out of flagship American and British cancer hospitals in the last ten years and have come to the view that the NHS is a thrd world organisation. (WHO ranks UK No 18 in the world for health treatment)

    The Americans are on a different planet. It is not easy to disrupt my life for 10 weeks to come here for treatment and pay a bundle of money. But I feel that I have to do it.

    And for interest, I am at Sloane Kettering in New York (leading cancer hospital) where 50% of patients are Medicare and 10% Medicaid patients. So much for the belief that the Americans only treat the rich

    Check out the comparative clinical statistics for disease. The UK scores are terrible.

  • David Bryce 16th Jul '10 - 8:09pm

    A Patients View
    I am not happy with Surgery Managers replacing Primary Care Trust Managers with the subsequent upheaval and probably the job titles will change but the faces remain the same. It seems to me that private companies will be taking over the surgery management next. General Practitioners should be concentrating on the welfare of their patients rather than dabbling in running hospitals.

  • Geoff Heathcock 16th Jul '10 - 8:10pm

    I am worried that at a time when the NHS overall needs desparately to have stability, the Government is now proposing to turn it upside down with no guarantee that other than to shake out the SHA’s and PCT’s, any real cash will be saved in the back room – since the New NHS Commissioning Board is likely to just be filled with the very people you have just got rid of!

    As for more involvement by the Local Council’s – democratically elected by the People you are then proposing to abolish the Health and Overview Committee’s which since 2001 have begun to make no small impact on holding the NHS and its local trusts to account – and uncovered again and again very strange and expensive practice, but also ensured that Service delivery and planning is about the patient, because Councillors serve local communities, if localism is to mean anything in Health then for goodness sake re-think this particular abolition and bring more democracy into the Trusts with elected folk on the Boards accountable directly with the patients.

  • Brian Scott 16th Jul '10 - 8:24pm

    Re NHS reorganisation proposals:
    Have GPs been consulted about these proposals and, if yes, is there a large majority in favour?

    I am concerned that proposed GP consortia may lead to ‘postcode lottery’ and GPs without management experience and skills (bought in or otherwise) could lead to a degradation of service.

    Brian Scott

  • Donald – you say “I know the US spends more on Healthcare and we hide behind that.”
    We don’t hide behind it, it is a fact. The US spends over twice as much per person on healthcare than the UK but the statistics show:
    Female infant mortality rate/1000 UK 4.28 USA 5.55
    Male infant mortality rate/1000 UK 5.40 USA 6.94
    Under five mortality rate/1000 UK 6 USA 8
    Maternity mortality rate/100,000 UK 8 USA 11
    Life expectancy male UK 82 USA 81
    Life expectancy female UK 77 USA 76
    source www. globalhealthfacts.org

    Please don’t hold up the USA as a model for the UK to follow! Not based on the fact that you can afford a topnotch US hospital.

  • donald cameron 16th Jul '10 - 8:44pm

    Barnesian, I suggest that you need to be careful about relative mortality statistics. There are different conditions and demographics in the two countries.

    I am not suggesting that we copy the US in the UK. We need to find our own solution. But I am keen to contribute to the debate:
    (i) as a patient who found NHS high end medicine to be seriously lacking and was forced to look abroad
    (ii) made my own comparisons after experiencing both systems in America and Britain (Mayo Clinic, Sloane Kettering, Marsden, Chelsea, Hammersmith, Charring Cross, St Marys)
    (iii) as a businessman who knows that “free” cannot produce “efficiency”
    (iv) am shocked at how fed up and demotivated NHS doctors seem to be
    (v) am shocked by the systems and controls that I saw in the NHS which I recognised as a Stalinist organisation – something that collapsed more than 20 years ago under the weight of its own inefficiency and hopelessness

    As a patient, my question is “Why cant I get world class treatment in a top notch UK hospitals?”

    For what it is worth, I think that co payment in the UK would wake up the patient voice, move away from the dependent society mentality, and help to produce better quality in the NHS in the same way as university top up fees are doing in universities

  • Roger Sibley 16th Jul '10 - 8:48pm

    This NHS reform plan is fundamentally wrong and is clearly driven by the Conservative aim to introduce commercial groups into the planning and running of NHS services, taking it ever towards the morally deficient and very expensive US system of private medicine with the rich hogging the best surgeons, hospitals and facilities.

    It is ludicrous to think that this convulsive upheaval of administration and control will result in any savings for many years to come and most likely will be hugely more expensive. The NHS is, unsually for Britain, a world class service, more cost efficient than private medecine in America and much of Europe. It has been habitually underfunded by Conservative governments and greatly improved in recent years by Labour.

    The quality of services and provision of new technology has recently started to catch up on the best in Europe and this needs to be continued even in a cost cutting era. There is little chance of that happening whilst many very good and dedicated managers are being pushed towards expensive redundancy, expensive early retirement, or focusing their attention on being recruited by the new GP led bodies which will inevitably over compete and drive employment costs up. As a scheme to save money when budgets must be cut, this is sheer lunacy.

    Staff will be forced out one month, and recruited the next at an inflated cost on a contract run by organisations where large sums of money are siphoned off to lawyers, accountants, PR people and hidden back offices that no one in government will have a handle on until the disaster surfaces through ignominy, malfunction, sharp practice and public dissatisfaction.

    The provision of health care will be a confused myriad of services that only those rich enough to spend time and money playing the system will benefit from.

    Saying that patients will have more choice whilst the system costs less to deliver is pure bunkum. Choice always involves extra costs for duplicated service provision, extended travel, evaluation, negotiation, and many hidden management services.

    This reform will destroy any concept of a national health service with equal medical services for all without direct payment, instead it will fragment into multi tiered quality, where the better off will benefit at the expense of the less well off.

    The NHS is better now than it has ever been, and could be made better still if less money was spent on form filling, committees and group discussions. Give the existing managers more power to make spending and operational decisions within the framework of defined goals, and make them individually responsible for the success or failure that results, with promotion or demotion the main driver, but do not break up the organisation in the hope that a better one can be reconstructed by proliferating privateers.

    There is no mandate from th electorate for this smashing of the NHS as it is today and it makes no sense when the government is supposed to be cutting unnecessary spending.

    The Liberal Democrat membership should totally reject this ludicrous schemeand demand the Coalition be dissolved if the Cabinet persists in going ahead.

    The NHS is not at this moment in safe hands.

  • Annie Darby OBE 16th Jul '10 - 8:48pm

    I have worked in the NHS for 27 years and got an OBE in 2006 for service to the NHS.
    I am also a newly elected Lib Dem Councillor

    I support the Coalition but not on this !!!

    Giving all the power and money to GP’s is flawed.

    One thing we have done in our { very successful PCT } is look after those vulnerable groups of patients that GP’s don’t want and provide a safety net.

    GP’s are able to remove patients who they percieve to be ” difficult ” without PCT’s there is no provision. When GP’s employ staff it is difficult for the staff to challenge poor practice etc when you are employed by a PCT you have that back up and autonomy.

    True many PCT’s may have needed scaling back, but to abolish them is a big mistake.

    Also it seems that only GP’s have been consulted by Landsley – no mention of Pharmacists / Nurses etc which has made these colleagues feel very undermined and undervalued.
    Also increasing Health Visitors is short sighted. I am a Health Visitor myself by background, but surely a skill mix approach would be more cost effective.

  • donald cameron 16th Jul '10 - 8:53pm

    Roger, You are wrong that the rich hog the best hospitals in America. This is socialist propaganda.
    I was surprised to find that 50% of Sloane Kettering patients are Medicare. And 30% of Johns Hopkins patients are Medicare. And another 10% Medicaid in bot hinstitutions which are top US hospitals.

  • Geoff Preston 16th Jul '10 - 9:33pm

    Andrew Lansley has some good points. We all want what he wants – better services, more choice, efficiency etc etc.

    One major factor which is deliberatly forgotten in all the blurb, is that there never was, never is, never will be enough money to give every member of our society the care they want and expect.

    Someone has to make difficult choices. Herceptin? Better care for patients with emotional challenges? Faster treatment at A&E? Making list of priorities and being fair is very difficult and subjective.

    We have heard a lot about postcode lotteries. Next it will be GP Consortia lotteries. In the same area, some patients will get quick hip replacements; their neighbour may be told by their GP that the budget for hip operations has been spent. Wait for next year.

    There are some excellent GPs and practices. Others less good. But all staff work for their take-home pay. The needs of the patients are not their priority. The funding will be subtly channelled to personal gain. It’s human nature.

    The market is a great motivator and customer power incentivises providers to improvise and improve services, but GP Consortia will want to attract healthy patients and avoid the very dependent patients.

    I hope it all works but the road ahead is full of challenges.

  • This looks like a costly move, but it may get rid of health service managers in general, which could be a good thing, since they paid themselves a lot to rewrite the contracts of the real workers. On the other hand, it looks like the usual Tory ploy of “divide and rule” – made the units smaller and individually less powerful, so any one of them can safely be ignored.

  • Cheryl Stevenson 16th Jul '10 - 10:16pm

    The NHS has so many problems that cannot be solved by restructuring yet again. It’s difficult to see how the changes outlined in the white paper will actually reduce bureaucracy. The ethos of the NHS needs to change radically for the patient to be ‘empowered’. All governmental ( current and previous) ‘empowerment’ seems to involve taking ‘power’ from one place to put into another which defeats the object entirely.
    I spent 5 years suing the NHS for a simple negligent mistake that caused an immense amount of damage to my family and I. The NHS was unbelievably, insensitive, hostile and extremely obtuse in trying to avoid admitting the mistake and paying compensation. Although I won the case, the compensation paid was totally disproportionate and inadequate to the damage done. I continue to feel totally disempowered and let down by both the NHS and the legal system. The whole episode cost the taxpayer an enormous amount of money and the simple truth is that if the doctors had listened to me instead of intimidating and patronising me the problem would have been prevented.

  • The Rev GDV Wiebe Ph 16th Jul '10 - 10:36pm

    Lets reduce the ratio of managers to the number of nurses, ancilliaries and physicians to what it was say 30 years ago. That will free up more funds and allow the front line to provide more actual health care now too often impeded by the ‘front office’

  • Terry Gilbert 16th Jul '10 - 11:01pm

    What makes John think that ‘ordinary members’ are here? We are only the nerds…. :-)

    For the record, my view is that expensive reorganisation of the NHS should not be an option at a time of extreme fiscal retrenchment. Unless of course, the crisis is being exaggerated to justify Vince Cable’s change of economic policy?

  • ken stratford 17th Jul '10 - 12:19am

    You have gone out of your heads. What are you all smoking?
    Good bye treasured NHS. Hello rich GP’s. More power to council bureaucracy. Goodby to strategic planning.
    I wish I was young enough to emigrate.

  • Radio 5 Live discussion highlighted the fact that NHS locums are provided by private agencies who bear no responsibility for the quality or competence of the individuals forwarded. The woman from the agency said that the responsibility rested wholly with the GP/Trust/consultant who decided to take the locum on. This was in particular related to foreign locums such as the German/Nigerian recently in the news for malpractice due to lack of knowledge of medicine and also of the English language.
    As these agencies are purely money – making ventures with no knowledge of medicine or interest in patients’ wellbeing and this country is desperately attempting to find savings in public expenditure I would welcome research into this idea :
    rather than sacking valuable members of NHS staff with clinical expertise, let’s un-burden the service of these vultures whose vocational talent is limited to foisting incompetent , unqualified and illiterate persons onto the British public at huge expense to the taxpayer;
    let us ,rather, employ qualified and medical staff with a profound understanding of the British medical service and its needs to act as an agency to supply locums in an intelligent and cost – effective way.
    I find it hard to believe that our society cannot supply suitably qualified junior doctors/nursing staff that would be willing to work for £45 to £65 PER HOUR as opposed to incompetent foreigners with little grasp of English language, culture or medical standards.

  • donald cameron
    “For what it is worth, I think that co payment in the UK would wake up the patient voice, move away from the dependent society mentality, and help to produce better quality in the NHS in the same way as university top up fees are doing in universities”
    Firstly : we have ‘co-payment’ in the UK it’s called NI payment as part of our taxation.
    To label the NHS as ‘free’ can only come from someone whose post-tax income is either negligible or excessive – we all pay for the NHS, realise it or no. If you mean that the NI element of taxation should be separated/highlighted and then ringfenced for patient services ( like road tax , ha-ha ) , then I’m all for it – I certainly do not wish my taxes to be squandered on minority interests like the war in Iraq.
    As for universities ah, well.
    They are producing less viable product than ever.

  • donald cameron 17th Jul '10 - 1:16am

    Mark
    I think it would be a very powerful agent of change in the NHS if we all had to pay a one off admission charge to hospital (say £500) every time we used one. Of course there would have to safeguards for the elderly and those without money. This would make people think about what they are getting for their money and they would talk to their GPs, consult the internet and shop around in order to help make an informed decision. We do this with University league tables when deciding which universities the children should apply to.

    This approach is quite different (and in addition to) NI contributions. We take them for granted, maybe forget about them, and go along with the dependency mantra of “its free and the doctors know best”

    When I looked at comparative health systems I was impressed by the Dr Sweitzer field hospitals in Africa. Everyone had to make a contribution according to their means (a chicken, a plantain, a family member helping to clean the hospital or plant vegetables). It was a powerful way of creating respect for the institution, not taking it for granted, and not wasting resources by making it “free”

    We happily spend £100 at the pub on Friday night or £1500 a head on the summer holiday to sit on a beach in Spain. Why does hospital admission have a lesser value?

  • lynne morrison 17th Jul '10 - 8:11am

    If the NHS is going to go through another change then please bring back the practical face of nursing..the S.E.N. I trained as a SEN in the sixties, we were the hands on side of nursing…we fed, bathed, bandaged, dressed wounds and generally cared for the patients. Now nurses all have to have A levels and higher most seem to think that general patient care is beneath them. They dont like making the patents a drink, not do they like cleaning up after them. I know we have HCAs and they in a sense they are similar to the old SEN but sadly lacking in the good old fashioned training of patient care….if we had SENs back on the ward a lot of the appalling neglectful things that have hit the headlines in recent months might not have happened. Please for the patients sake, bing them back

  • Joan Lawson 17th Jul '10 - 8:42am

    I works in training for the independent care sector. I don’t understand how asking GPs to administer budgets will work. PCTs and Social Services have been encouraged to work together and pool their budgets. This ensures joined up community care services. I think the change will be very confusing.

  • I accept that the NHS changes directly affect England as has been pointed out by others in Wales. However there must be concern about the quality of GPs in the future. With the job in England now to be so different from that in Northern Ireland Scotland and Wales will England attract the best candidates? Also how will UK medical education cope with the differing GP roles. Just another angle as I too fear letting in the darkness of private enterprise

  • There is no debate that the current management structure of the NHS is not fit for purpose. I consider there are only two basic possible alternatives.:

    1 As proposed, with GP’s in charge of the budget and the hospitals and all other NHS services as self contained entities in servant/supplier role.

    2 With the hospitals in charge and owning the GP’s.

    Having seen option 2 in operation abroad this would be my preference. Hospitals tend to be more local and smaller and the GP a sort of outreach role. Local ownership of the service is strong. The hospitals tend to shift to focusing on public health management rather than focus on production line operations etc.

    I accept that option 2 is difficult to move to in this country because of the size and rarity of existing hospitals and the private contracting of GP’s. Therefore lets try option 1.

    If you really want to focus minds on health issues, then also give the GP’s the budget and control of health driven aspects of the benefits system (eg disability benefit). And give them the responsibility and budget for contracting in local authority driven welfare services – eg home help and residential care.

    With these two responsibilities GP’s would be driven to minimise their overall spend by increasing spend on medical treatments that prevent patients moving on to more expensive provisions such as residential care. Or reducing spend on expensive medical treatments that can be substituted by less expensive palliative care. And making sure their shirker patients came off dissabilty benefit ASAP!

    A virtuous circle should result!

    Chris York

  • Carol Swain 17th Jul '10 - 9:17am

    I was an NHS Finance Director from 1995 to 2003 and prior to that worked for Regional and District Health Authorities, so in total I have 20 years experience in the NHS. In my time I was responsible for commissioning and for provision of services to Health Authorities, PCGs, PCTs and Fundholders and lived (just) through an interminable series of re-organisationsand target-based regimes.
    GP Fundholding was only marginally successful, and it took YEARS to get the GPs (remember that these were the willing ones) to understand the impact of their decisions on wider NHS provision and stop focussing on small short-term actions at the expense of longer term deterioration.
    There is always an enormous cost whenever a structural change is implemented and effective “planning blight” for a year or so each side of the change means that services usually get worse before they get better.
    The last think we can afford to do at a time when the NHS MUST make its share of savings whilst maintaining or improving quality of services is to embark on the most major structural change yet!
    I am also not sure that the majority of GPs have the time and energy for this.
    My recommendation would be to set up local committees of GPs who would then work with their PCT Board to JOINTLY determine the direction of travel, but leave the rest of the PCT staffing and structure alone.
    Public involvement could be generated by re-establishing the Community Health Councils that were abolished in the 1990s after doing sterling work for decades to hold the entire NHS (Commissioners as well as providers) to account.

  • Not all of us can afford to spend £100 a night at the Pub…! But I do agree that as with dentistry some charges may make patients think a little more about the service.
    Surely this change will cost a vast amount of money/time to implement and G Ps will have to call on ‘ financial experts’ to administer their new budgets etc .
    Please think carefully about this. Will the end result be the one you are aiming for or just a disaster waiting to happen!

  • I do accept Carol’s, and others, concerns about the change management required to implement this. Seems to me the end result is worth the aggro, as i set out above. But it isn’t a quick fix. Probably necessary to start with one PCT and then roll out with lessons learned across the rest of the SHT, finally folding the SHT.

    The key building block is indeed the GP’s. Bearing in mind that they are private contractors already, perhaps the right course is to provide a locally electable and accountable mini PCT. Then invite the GP’s to sign up to it, and those that don’t are out of the NHS!

    Sorry to be brutul but if you want people to change what they are dooing in any way you have to be. People are naturally conservative with a small “c”! And in our circumstances as a nation change of some sort is anavoidable.

    Chris

  • In this period of upsets at all levels, it would be a far-sighted political move to instigate an open-minded review of the model of health and disease which underlies the current organisation and operation of the NHS.

    Individuals with an ailment are cast in the role of patient and are treated as passive sufferers to whom something must be done, medically or surgically, to “cure” them. The body’s capacity to heal itself is not valued. Symptoms, which in the context of the whole person are long-term, logically-developing information about imbalance, are suppressed. Healers are re-cast as administrators, managers and bursars. Substances which can assist the body’s self-regulating mechanisms are transmuted into drugs which cause damage alongside any help they provide, having cost unthinkably vast sums of money to develop, trial and market.

    There are simpler ways of running a healing relationship which cost a lot less money. Perhaps now is the best opportunity for several hundred years to rethink radically that which has not only remained unquestioned, but which is now smothered under vested interests with a lot to lose from revision.

  • Alan Hutchings 17th Jul '10 - 10:44am

    It sounds to me that the proposed changes to the way the NHS is going to be funded by put the GPs in charge of cost for services etc., is a backdoor privatisation of the health service.
    The GPs are already a private service bought by the NHS (the government) by putting more services to them the medical treatment will, when the GP’s money runs out, come to a halt. This is not an advacement, but a retrograde step to save money on paper to make the figures look right. The NHS cannot and should not have the medical side of their budget capped. By all means stream line the admin, but you cannot save money buy putting services out to private organisation and then buy them back. Somewhere these organisations have to make a profit on to of the cost of the service. which means that you either paymore for the same service of the same money for a lesser service. Get a grip of real econonmics.

  • Esther Hague 17th Jul '10 - 11:07am

    Totally agree with Carol Swain.
    Esther
    Physiotherapist in Private Practice

  • I am both a Liberal Democrat Councillor and an employee of a local Primary Care Trust.

    Firstly, nobody in the Health Service thinks that the status quo was an option. Eradicating the SHAs and rationalising the PCTs was expected and mostly welcome. The white paper though has produced a mixture of anger and frustration. GPs are private businessmen and behave as such. Moreover their business practices are often arcane as PCTs or a similar body has always been there to support them through change and/or bail them out when they need it.

    My own role is as an Emergency Planning and Business Continuity Manager. Through the Swine Flu outbreak I and my colleagues spent a huge amount of time and effort trying to get local GPs to prepare appropriate plans to protect their businesses and safeguard patient care in the event of practises having to close due to illness. They simply would not engage unless we paid them to do it and even then proved to be incapable of filling in a simple template and providing situation reports.

    Roles like mine and other specialists employed by the NHS are essential and the skill sets are not held by GPs. The proposed consortia will have to employ people to do this kind of work and it will cost more to the tax payer as a result. At the moment GPs get my services for free as I am an NHS employee. It will make more sense professionally to sell my services on a consultancy basis to consortia from 2013 as I will be able to make at least twice as much money! I don’t believe that supplying professional services on a contract basis to the health service is in the interests of patients and tax payers.

    Another point to consider is the cost to the taxpayer of the restructure in the current financial climate. Redundancies, building leases to be bought out of, building new organisations and the associated branding etc, the cost of moving to foundation status for operational trusts… The system would have to work and remain in place for ten years before we see a return on the investment.

    The governance outlined in the paper is also short on detail. How will GPs be held to account properly? What will happen to FTs that get the green light for their fiscal management but are failing on patient care when they are monitored by separate bodies? It is naïve to assume that if a trust is getting one right then the other will naturally follow.

    Having read the paper and associated documents, including the 13 page letter to chief executives from David Nicholson, my belief is that the Public Health Service, Healthwatch and the National Commissioning Board will grow exponentially as we deliver this change in order to cover the variety of essential work that the consortia either cannot or will not do.

    Finally as a Liberal Democrat who believed he had joined a centre left leaning liberal thinking party, I am ashamed to be associated with such an ideologically driven right wing approach that comes at such high cost to the taxpayer. The government is currently reinventing a number of Tory pet projects of the past. This will go the same way as GP fund holding. The education policies just look like Grant Maintained Schools all over again. I regularly talk to grass roots Tories who are equally frustrated that they look doomed to repeat the mistakes of the past.

    For all of their faults, the last Government took a woeful NHS by the scruff of the neck and improved it massively. Yes, there were mistakes but if this is the best we can do then the Labour claim that they are the only safe custodians of the health service looks like holding water.

  • David Rowland 17th Jul '10 - 11:12am

    I have had excellent service from the NHS with two cancers. I am apalled at the idea that the two week target for a consultant appointment may be removed.
    I cannot see that multiplying the number of bureaucracies from a limited number of PCTs to two or three times the number of GP commissioners will help.
    I have seen the effects of the last reorganisation of PCTs through a relative working in the NHS. Morale was severely damaged and incompetent people promoted to posts that are above their ability level. Let the present system continue to settle down.

  • Esther Hague 17th Jul '10 - 11:12am

    How much money is this new monster called CARE QUALITY COMMISSION going to cost ? Have we not got enough regulation ? Is the Care Quality Commission going to replace alll the other regulatory bodies such as the GMC ?

  • A pensioner 'carer' 17th Jul '10 - 11:14am

    If a system is not working well, it needs improvement , not decapitation. yes, there are faults with the administration in many hospitals- I know that from personal experience, but the medical treatment tht we have both recieved has been excellent. The Lib. Dems. will be committing political suicide if they continue to support this Tory escapade. Our National Health Service is, and has been, the jewel in our crown for decades. To destroy it, instead of improving it will be nothing short of disastrous for thousands of odinary people and will be a costly financial and electoral blunder. How many Lib. Dem. supporters can you afford to lose?

  • Why are we spending £1.7 billion on a NHS reform which will create a conflict of interest between GPs and patients. Hardly a priority in an age of austerity! I thought that the point of the coalition was to avoid the need to appease the far right of the Tory party.

    Andrew Reed

  • richard coupar 17th Jul '10 - 11:36am

    I suggest the Party distance themselves from this policy as far as possible.Every time I look at these proposals they seem more like astep towards a privatised NHS.I’m just glad I now live in Wales.

  • Dr David Polkinghorn 17th Jul '10 - 12:12pm

    I have worked as a GP in S. Yorkshire for 28 years and 4 years in various hospital posts prior to that. Have seen all the reforms and felt their effects directly. The last 12 years has been a double edged sword: massive investment but much disappointment at outcomes. Yes, waiting times are down but not globally. Some targets (e.g. 2 week wait for cancer) have significantly improved care but the overall feel is of clinical disenfranchisement. I hardly have a surgery where I am not frustrated or disturbed by secondary care activity. The “tariff and payment by results” is a dishonest system and (incredibly) an American import by New Labour. If I have a concern that the care delivered for my patients is less than satisfactory I struggle to know what to do. The commissioners are all non-clinicians and do not recognise the pressures of health care let alone clinical priorities or judgements. Any complaints (in writing) get a rapid e-mail but a real turn around in months if there is a resolution. A couple of examples: Many of my patients see specialist nurses for chronic, severe conditions (e.g. parkinsons disease & epilepsy). They will adjust and initiate medication. However the poor patient and carers are frequently sent back to the GP to collect medication. These drugs are often classified as “amber” which means (supported by the British National Formulary) they should ONLY be initiated, monitored & stabilised by specialists before transfer to GPs. I can sign up to a thousand items of medication on prescriptions in a day and (perhaps surprisingly) can fell competent that is is as safe as possible but not with new drugs. The specialists will get paid (to the Foundation Trust) a chunk of money that is supposed to cover all aspects of care: including the consultants opinion, diagnostics and medication. Now you can see the frustration of transferring this to GPs who do not have the same resources.
    Example 2: frequently we fail to get adequate communication following hospital encounters (A&E attendance, admissions & out patients). Because of the way our service works we try to allow rapid access. So we often have patients(& carers) wanting to discuss what has happened, results of tests, what’s going to happen next & a chance to explore their options. . If I haven’t got this then we are both frustrated. It can be due to a failure to write back to the original referring GP. For 4 years we have appended our letters insisting that responses are addressed to referring GP. It has been consistently ignored (there are 11 doctors in this practice, including those in training). When the hospital doctors are asked, verbally, about this we get excuses about systems and “can’t do”. When asking the commissioners (every year) do put this in contracts we get “not important” & ” does not affect tariff”. Well, do you think it is important? Would you not like your GP to have a say in these things?
    There are many aspects of detail where I am certain I could improve the care of my patients (& those of my neighbouring practices) and significantly save money. Look at the Cumbrian model.
    As a fundholding practice we improved our patient care dramatically and rapidly at no extra cost! Hip replacements took 2 years until we changed the contracts and used the private sector (not privatisation like New Labour were doing). Hips took a 4 week turn around within the first quarter of us being in charge. Think of your elderly relative struggling to maintain independence and being told it would be 2 years before restoring it? The same happened with cataracts: none of the local hospitals were set up with the modern “phaco” day surgery and were keeping folk waiting 18 months for the old procedure which needed 3 months of eye drops, not easy if you are elderly. So we sent our patients to the Wakefield rapid eye centre. The procedure was a day case, no stitches, no eye drops and immediate clear vision. Turn around from referral: 4 weeks! Soon the other fundholders did the same. The service came to our locality in a private hospital. Guess what? the local hospitals rapidly trained up consultants (or appointed new ones) and invested in equipment in order to compete. Suddenly patients had the luxury of choice: all this 18 years ago!
    A final example (yes, I know I’m going on): we are sited between 3 hospitals. Our access to diagnostics was poor. The laboratory would insist that all samples must be available for collection by 9:30 am. This was unreasonable and inflexible for our patients. We approached the other labs. One said “would midday and 3:30pm be OK?”. Of course we said yes. Oh yes “would we like a phlebotomist 2ce a week?”; yes, freeing up valuable nurse time. We also got a guaranteed 5 day turnaround for results and a monthly educational update and feedback on efficient use of the lab with what new developments were coming. This actually saved the taxpayer £5000 in the first year alone on the contract, let alone the extra services we were able to deliver.
    So those of you who are criticising GPs please think again: the best and most efficient people in the NHS can be included in our numbers. I know far more talented GPs than I. They also have the wisdom to know their own limits and how to identify resources needed to support or develop services. The snipe that we are”merely small businessmen” is untrue: our drug budget exceeds £1.3M. For the last 12 years we have been taking the blame now we can take the responsibility AND remain accountable. For the first time we have a chance of the “patient voice” being heard. I hope you trust your GP and will confide in him or her. We see 10% of the UK population every week. This means (with our short time model of working) a genuine chance to change things quickly and save money. And no, those of us who do this are not in it for personal gain but the professional satisfaction of getting best care.
    So this public debate is welcome and unprecedented: huge changes went through previously and were disruptive . The last government seemed to be constantly interfering with top down initiatives with almost tabloid motivation. An example is of the way we just could not possibly continue out of hours with the standards (the computer telephone system we needed costed about £40,000) they imposed with minuscule funding (£6000 per GP per year). So we got the blame: I had worked nights almost every week for 25 years. Mostly worked nights and weekends for at least 16 years. This had a destructive impact on work/life balance. Oh, thanks Tony Blair for exempting GPs from EWTD. We still put in the extra: most weekends I have paperwork or I’m doing surgeries. So the media has to be cautious about it’s attacks on us since most will go the extra distance in terms of commitment.
    I’ll not easily forgive New Labour for burying bad news about the NHS. Do you remember the slogan “24 hours to save the NHS”. Well they set targets to achieve within 2 years. When they were announced out came the ban on fox hunting. The public missed how they had failed. Each time fox hunting came up it was almost always when the NHS data was to be revealed. Waiting times got longer in the first 4 years.
    This change will, I seriously hope, be by evolution. We can take what works and use it. Those that obstruct patient care & quality can be dealt with. New & innovative ways of providing care will be developed. These will nearly always be nearer the patient in the community and cheaper with patient or carer involvement in their specification.
    Just to finish off with the final nail in New Labour’s coffin: they imposed “Practice Based Commissioning”. It was, of course, none of this. As practices we achieved virtually nothing in a long time. The processes were bureaucratic beyond belief with a heavy management structure remote from the service. Our locality managed to get investment in an education programme for our diabetic patients as a one off. This had to show immediate cost benefits and not increase expenditure or no development. It was the same every time we had a plan. All the others were rejected (remember it’s NOT doctors making these decisions). One plan we had was to develop a service for patients in residential or nursing home care. There had been an explosion of these homes in our practice area (needless to say we were never consulted about this). It became apparent that care was fragmented between acute and chronic needs. With low paid staff and a relative lack of continuity in these premises we felt patients really needed better, well organised care. We’d be called out almost at random and frequently. Patients were at higher risk of unnecessary admission. Out of hours care might conflict with long term plans and staff could be confused (especially with complicated medication and monitoring). So we wanted a Primary Care Specialist Worker to sort this out (preferably district nurse background). They would do planned care “ward rounds”, be the focus of communication, identify learning needs (including doctors’), respond to urgent requests and deliver protocols for chronic management (even with end of life programmes). This was mapped, modelled & referenced to explain the benefits all round. Since there was no short or long term cost saving it was rejected immediately. There was no recourse to appeal or to resubmit. Just “no”. So you can guess how we felt?
    So bring on the clinical and patient empowerment with this new opportunity.

    (luckily I’ve not had enough time to rant on about computers but……)

  • Its very simple. You have NO MANDATE to do this,. It was not in either Tory or Lib Dem manifestos for the very good reason that you wouldn’t have been elected. I suggest you hold off these plans till the next election (whats the hurry anyway). You can then both put it in your maifestos and we can all vote on it.

  • Andy Rickell 17th Jul '10 - 12:39pm

    Dear John, As a disability rights activist, I would only be happy with devolution to GPs if this is the first step to personal budgets in health where the individual gets choice and control and the GP becomes enabler and adviser rather than principal. There is then the opportunity to tie up with the personalised individual budgets that is the new way forward for other public services eg social care and employment support, in combination with disability and other benefits, and truly empower the disabled and non-disabled individual citizen alike. The last person who should ever have such control over the citizen should be the bureaucrat or the health professional – perish the thought! I would be happy to talk to you further about this. Andy Rickell

  • naseer Nuaman 17th Jul '10 - 1:04pm

    I am a GP , have worked in NHS for last 18 y .The NHS nowadays is similar to Charlie Chaplin act in Modern Times Film in Front of the Conveyor belt (front Line NHS Worker) watched by Managers ( middle Traders ) & Factory is the Government ! . That means orders Come from above ( Ivory Towers) . The Activity of civilians in every country is related to the Society which is Lead by its government. So we have a triad, Citizens , Society and Employers all share responsibilities for the health of the nation. Sharing the cost of the Health Care should be means tested and with involvement of the employer and Society. NHS was created free in 1948 as the society was recovering from the effect of 2 WW. The diseases were due to social injustice, that is poor housing, unemployment,and poverty. The last 20 years we have noticed increase in Lifestyle diseases. No doubts we saw the recent increase in Sexually Transmitted diseases, Termination of pregnancy, obesity etc. Yesterday I saw a young lad had infection in his lymph glands due to tongue piercing!! He paid £50 for the tattooist, but got his medicine free ! You could hear many examples of wasting Taxpayer money. We need to empower the people , They could choose the GPs they like and the hospital or other institute they want, with simple Co payment with the cost.This should be means tested with a share from employer! The Health Service would cut down on the number of employed Middle Traders ( Managers) . No doubt Most European using Bismark ‘s Principle for health funding & system have good and better health Outcome than UK !!

  • Colin Irvine 17th Jul '10 - 1:27pm

    I think there are several aspects to this that need to be dealt with separately.

    1) Which services are to be delivered,and where? I believe this needs to be planned on a Regional basis, as the provision of Regional and Sub-Regional specialties needs to find a balance between a) as few as possible large hospitals, employing lots of specialists and developing expertise by treating large numbers of cases, but who will of necessity be remote to much of the population, and b) a greater number of smaller hospitals which will be more local and convenient for the population but which will develop less expertise. Simply asking hospitals to compete in an artificial market will not find this balance – and it is important.

    2) Do patients want or need choice? The Health Secretary says there’s not enough choice. Everyone I know says there’s already too much. I certainly do. Why?

    a) People, especially those outside London, mostly don’t want to have to choose which hospital to go to, they simply want their nearest hospital to be as good as all the others.
    b) Running the current financial system, there to redistribute funds any time a patient wants to go to a different hospital, is very expensive.
    c) Choice is difficult. For example, the best surgeons will get the most difficult cases and end up with the highest mortality.

    3) Having decided which services are to be delivered where and by whom, how to secure good, effective and efficient care? The current system (Foundation Trusts accountable to the local population) is quite capable of this, if policed properly.

    4) Which route should funding take? Please, please – not via GPs. This doesn’t solve any problem that I can see, and will certainly create a whole raft of new ones – not least the prospect of the large private healthcare companies taking full advantage of what promises to be a lucrative gravy train.

    5) Want to save money? Restrict the bureaucracy to a) planning where people will be sent for treatment and b) managing the resultant supply of treatment efficiently, effectively and compassionately. There are very few surplus managers in NHS Trusts nowadays. You need managers if you are to achieve efficiency and effectiveness. What you don’t need is a plethora of purchasers, whether employed by PCTs as now, or GPs in future.

  • Howard Hollingsbee 17th Jul '10 - 1:37pm

    In response to a comment way up the list – radical reform, sadly, IS needed. Evolution just would not deal with the ingrained attitudes of some NHS staff. For the very many dedicated, hard working and well motivated, thinking staff there is a significant percentage of those who are none of these things, hold dogmatic views about the way health care is provided, not the quality of provision, and are in posions to block improvement. There is nothing wrong with contracted provision, provided contracts are intelligently let, well supervised and monitored and contain termination provisions that really work. The problem, in common with many other public sector organisations, is that these requirements are not met. The debacle of GP contracts and the patient records IT system are examples. Our NHS is not broken, it is though, far too expensive in relation to outcomes, standards of cleanliness and tidiness, and patient perception.
    Removal of the vacuous SHAs is essential – few have been able to understand what they were for anyway, other than an attempt by Government to put distance between its policies and the need to be accountable for them. Maybe the PCTs need to go too. I’m unsure, as there needs to be something to ensure that GPs are not caught in conflict of interest. In any case, a massive internal education programme is going to be needed for them to take on the proposed new role.
    The Trusts, whether as now, or with Foundation status, have to be changed in a way which ensures both accountability and the concomitant authority for the Board. This includes both executive and non-executive directors. Chairmen and Chief Executives are currently only there to be fired when things go wrong after they have done as they were told by the SHA/PCT/DoH.
    Education of all staff will also be needed, to change attitudes based on outdated ideas about a an NHS as employer of huge numbers of people paid by the taxpayer. Those who won’t change would have to go, as will the small percentage of poor performers ,sickness manipulators and time servers. Yes, this can be done without unfair dismissal tribunals or the easy way out, of paying off, if the right HR procedures are set and followed.
    Setting of the policy, as in this White Paper is necessary, but the easy bit. The devil, as always, will be in the detail of its implementation,. The success of this will depend on fundamentally changing attitudes that belong back in the 70s, if they ever truly belonged.
    The aims and objectives of our NHS are as laudable as ever they were: the obsolete supertanker that is the actual organisation must be turned and/or replaced – quality of provision and desired outcomes are the ONLY sacred cows.

  • Charlotte MacCaul 17th Jul '10 - 1:45pm

    Any further reforms must be carefully evaluated before implementation. Whilst local is good, there also needs to be an NHS think tank of clinical experts based at Dept.Health (or meeting there) to take a stratefgic direction. It is no use the bureaucrats taking the lead – that is why the NHS is falling apart. Get rid of the American influence and levels of admin. and management by all means but don’t forget the overarching strategy – perhaps look again at the Beveridge Report and initial setting up of the NHS and the subsequent major disastrous review in the ’70’s. It is interesting to note that as we brought in privatisation into the NHS, so standards went down and clinical expertise was devalued. It is even more interesting to note how the pendulum of change is swinging in the USA as Obama tries to bring in a British NHS ‘free at the point of need’ system. I have worked in the NHS for over 40 yrs. so can evaluate the before and after effects of various reorganisations which happened over and over again and without any real benefit to patients (in my view). We sold off the nursing homes – now look at the difficulties of recruiting the right calibre medical and nursing staff. We sold off the cottages hospitals – now look at the problems of long term nursing care/convalescence as hosp.stays are shortened. And the ongoing problem of an ageing population cannot be ignored. How will that mixture of nursing and social care be providedf? I never felt that the Dept. of Health and Soc.Services should have been separated. Yes have a separate dept. of Soc.Sec. but often social, community and hosp. care need to be brought together to prevfent people falling throught gaps in service. As to mental health (where I worked in the last 15 yers. of service) the personality-disordered are the new longstay, as drugs and other support helps many with mental illnesses to cope with everyday life. Again the interface between illness and work and vocational rehabilitation needs to be considered. I do not envy you this task but with the correct strategtic direction, prioritisation of objectives and tasks we could once again be proud of the NHS. I remain unconvinced about the expansion of private care – those with resources will always get by – and by private we mean profit and something has to give in this situation and it is usually the qualify of care. L:ook at the cleaning contracts – we never had C.diff or MRSA on the scale we have now when the wards were totally managed by the sister in charge. Perhaps that is something we should again consider. Charlotte MacCaul

  • Richard Gregson 17th Jul '10 - 3:07pm

    As a Consultant in the NHS I have lived through several reorganisations. They haven’t made the NHS better – it is still significantly inferior to the French & German & Scandinavian systems in terms of health outcomes (survival after cancer diagnosis, vaccination rates, neonatal death rate, access to hip replacement etc. etc.). The NHS isn’t bad, it is just not very good, and never has been. It has, in fact, failed the UK population for decades, only the public don’t realise this. The New Labour government did realise it, and threw money at it, but this disappeared into box-ticker’s salaries.
    I welcome the reorganisation, and if that means privatisation, so what? If it leads to better health, then good.
    The biggest sacred cow in the NHS, and how it differs from the more successful Continental systems is that patients can’t go direct to a specialist. I think that’s what should change. These specialists don’t necessarily need to be doctors, and so shouldn’t cost too much. They can be specialist nurses, physiotherapists, orthoptists etc.

  • Howard Hollingsbee 17th Jul '10 - 3:28pm

    Thank you Richard, for making my point, but more eloquently , succinctly and with the authority of a consultant. I comment only from the viewpoint of one peripherally involved in governance of an Acute Trust (and with experience of the shiny Spanish hospital system). You have it bang on!

  • Politically, this is very difficult.

    The Lansley proposed reorganisation wasn’t in the Tory or LibDem manifesto, nor in the Coalition agreement.

    I suspect that it will not be supported by most LibDems based on my conversations with many LibDem friends and colleagues, indeed on this comments board.

    What should LibDem MPs do? If they abstain, that will be insufficent to stop it. They will need to vote against it. But that will seriously damage the Coalition, perhaps terminally.

    I suggest that the LibDems put forward an amendment that restricts any reorganisation to a very limited pilot with a review after three years before any extension of the scheme. It is a sensible way forward anyway to minimise the risk to the NHS (and to the Coalition). Otherwise it is a train crash.

  • Jennette Davy 17th Jul '10 - 4:54pm

    Yet another one passed sell-by date. However I have spent over 40 years in the Voluntary Sector and have gained a wide ranging experience of the ‘ills’ that people suffer from. Through from Mental Health to Ingrowing Toenails. Sorry but I don’t think the proposals will ever work. Even with a RHA and a PCT trying to make strategic decisions , nevertheless the ‘Postcode Lottery’ is all too real and brings terrible disappointments and grief to too many people.

    “No decisions about me without me” is a great ambition but I just cannot see how this situation would not be made much worse if groups of Health Centres (in effect the GP’s that work within them) had the commissioning powers. Decisions would be made on the basis of the most frequently seen illnesses seen at that Surgeries and only then to the extent that the budget could afford. There would be little left for the minority of patients needing specialist and expensive drugs, access to specialist consultants, or intensive home nursing care.

    As a 30 something years LD, I’m not sure I want to be associated with the fallout from something so ill-thought through. There has to be some strategic guidance given with the budgets and preferably by streamling management, possibly removing a ‘tier’, making it more transparent, and less dictatorial rather than by abolishing it altogether.

  • Miss C.E. Fozzard 17th Jul '10 - 4:56pm

    Dear Andrew,

    The NHS, as you have discovered, is a huge and complex organisation, which has undergone untold numbers of re-organisations during its 62 years. It is more than a simple purchaser/provider organisation linking primary with secondary care. After 40 years working in the NHS, 27 as a consultant, I have come to a number of simple issues for consideration:-
    1. Patients are most interested in outcomes, not process.
    2. Change is inevitable and should be progressive. It is best when evolutionary, rather than revolutionary so that the staff are more likely to be carried forward with the change.
    3. Any recommendation for more comprehensive commissioning by general practitioners carries risks as well as potential benefits. Extensive consultation with both the users and the providers of service must be undertaken to be successful.
    4. To be efficient and cut out waste, only need and not demand should be available on the NHS. This should include both physical and mental provision in prophylactic, diagnostic and therapeutic form.
    5. If the provider hospital service were to lose one or more specialist department through either the provision of choice, moving the patients elsewhere or by moving that provision to an outside provider, a domino effect upon other departments could sound the death nell of that hospital to the local community. Many patients would be disadvantaged by having to travel further for their secondary care.
    6. Much has been made by your respondents of the role of managers, who were introduced to the NHS in 1982, using the Sainsbury model. But that superstore does not put its most skilled and highly paid staff on the checkout !
    The sole role of a manager is to facilitate the staff, whom he manages, to carry out thr job which they have been trained to do. This has nothing to do with targets or interference with their professional role or responsibility (to the patient). Managers have become too numerous, too many good Senior Nurses have taken over that role and no longer exercise as a nurse – solely as a manager.
    7. No mention seems to have been made to the essential role of all medical and nursing staff in teaching and training. It was under the last administration that one of your predecessors stated, ” I do not need to be told anything about medical education” as he abolishe dthe standing committee advising him on this part of his responsibilities.
    8. Loss of one of the local checks and balances of the patient’s voice concerning quality, and quantity, of care also took place when the previous administration abolished the Community Health Councils.
    9. No organisation can function without funding and the NHS is not exempt from this requirement. But that funding should be used efficiently and not wasted in excessive bureauocracy, especially that of using either a commercial insurance based source or commissioning from profit making provider businesses. The figures given by other of your respondents speak for themselves. The NHS remains the most cost efficient comprehensive system in the world. Those citing the provision in the U.S.A. quote the best that may be provided. The U.S. also provides some of the worst and avoids entirely mentioning the 30-40 million left with no access to health care. Do not go down the expensive and divisive American system.
    10. Finally, choice. That for one may prove to be a limitation for others, just as is the ubiquitous Human Rights Act.

    Thank you for your presentation, sharing your views, to the B.M.A. A.R.M. last month.
    C.E.F.

  • However it gets done, guarantee the primacy of the public sector over the private one.
    Unlike the US, most of Europe (esp. France), has learned their historical lessons that, in every instance, the private interest in championing profits and gains at the expense of public losses and risks is too antithetical to social justice and equality.
    And, again, just as Goldman Sachs et. al., are now the recognized de facto government of the US, let the recognition that France has socialized their banking system, be a beacon of freedom such that privatization of any crucial, social service is anathema to the interests of all progressives and the people throughout the world.
    Onward and upward UK!!!

  • Miss C.E.F. I agree 100% with all your points , though I couldn’t have put it half as well!

  • Francis Deutsch 17th Jul '10 - 6:17pm

    Looking at the US health provisions and providers please ensure that there is no outsourcing of caring, planning or managerial functions to commercial enterprises.
    The removal of many central planning functions requires alternative provisions for equal standards of care, including prescription policy, nationwide (= no post code lottery!)

  • oliver schick 17th Jul '10 - 7:07pm

    Thank god I live in Wales. maybe they will see sense and leave this constant change idea where it belongs- in the round filing cabinet . I used to work for an Area Health Authority and those were scrapped because they were considered as an extra layer but the PCT’s are Area Health Authorities.Labour gave the GP’s a massive pay rise and took away the onus to provide 24/7 care. So who does that now? – the PCT’s . So who will do that in the brave new world where GP’s control everything. Are goodness how many local GP practices going to recruit the weekend cover from Europe ? When did accounting and purchasing skills become part of a medical qualification? Who will provide all the back up support services to GP’s that would be required? . Who will co-ordinate with other elements of the Health Service such as ambulances, dentists , home nurses etc? Small GP prcatices are just not equipped. Make PCT’s more accountable by all means but don’t create several hundred mini- PCT’s . This is policy distaster.

    Having spent 20 years in Belgium, I wholeheartedly agree with Richard Gregson. The GP intervention is often unecessary. If we are to have real choice, the patient should be able to go direct to the consultant of his choosing. The GP is there to provide initial diagnosis of serious ailments or treatment of minor ones and/or advice on which specialist to see but they can and do act as a barrier and layer of medical bureacracy in some cases. If I have an orthopaedic problem, I need to see an appropriate body parts consultant , not a GP .So putting everything through the GP nexus is completely at odds with the succesful continental models.

    And while on the subject of NHS change – just why is the NHS ring fenced against common sense changes to potential savings? Dentistry was virtually excluded some time ago ( having been free initially) but seems to work – perhaps not ideally but its not disastrous. For example, why not charge patients that are hospitalised as a result of RTA’s – costs should be borne by motorists through their insurnace premiums . Why should IVF be free? Research and advice into why a couple cannot conceive should be free but actual IVF treatment is a luxury. If you can’t afford that, you can’t afford the resulting child . There must be many more opportunities to have “common sense” charging within the NHS which does not destroy the basic ethos of care for all regardless of ability to pay. ( As distinct from back door charging for car parks etc) . Allow retailers into hospitals and tender the rent .

    Recruit high calibre purchasing professionals from major private companies and you will save their salaries in a heartbeat . IT implementation is apparently always a mojor issue . Why are most European countries able to do what we cannot? Making GP practices s the key buyers of local services increases the need for high quality information systems that can link into all health providers – it self evidently is unlikely to happen.

  • donald cameron 17th Jul '10 - 7:54pm

    Richard
    I am glad to see an acknowledgement that NHS treatment is second rate compared to other leading countries in Europe and America.

    I had a warm fuzzy feeling about the NHS until I used it at age 50. (Insurance statisitics show that we can expect a major medical episode in our 50’s. I came in on target)

    I was horrified by what I experienced. And then I found that practically everyone that I talked to afterwards had their horror story to tell. I bailed out and went to America. Medicine here is on a different planet.

    And then I started to notice all the horror stories in the newspapers. And then I noticed that malpractice claims are rocketing (currently costing £billions)

    And then I studied the compartive health statistics and the full horror story unfolded

    And then I talked to the DHS who assured me that everything was improving

    And then I talked to (retired) senior civil servants and they told me not to waste time – the NHS is beyond redemption

    And then I talked to Ministers who told me that it is a political minefield and no one dares to touch it

    In the meantime we continue to spend £120 billion a year on a Soviet monster that delivers broken care

  • donald cameron 17th Jul '10 - 8:08pm

    Miss Fozzard
    You are clearly no fan of the US. For your sake, I hope that you never need more than your tempeature taken by the NHS.

    As a doctor you should never lose sight of the importance of benchmarking against the best in the world and aspiring to be even better in the UK. And then get on and do it. We are the fourth richest country in the world. No excuses from the likes of you.

    We have to find our own solution for making things better. No country is different. The Americans need to narrow the gap between best and worst. Worst happened because there are about 40 million outside the health insurance system and they cannot afford to pay. Obama just put this right with his new healthcare bill. At least they are doing something AND RAISING THEIR GAME.

    I found in business that if you empower people they perform. But first of all they need to know the target. I cannot find any focus in the hex White Paper (or anywhere else in the system) of just how awful the NHS is. It is a policy secret!

  • Donald: That read well until the phrase “Soviet monster” which rather gives the game away!

    Incidentally US statistics indicate that around 225,000 people in the US die each year from medical malpractice.

    Source: http://www.resource4surgicalaccidents.com/malpracticestats.html

  • Nicky Vitiello 17th Jul '10 - 8:17pm

    The continental Social Insurance model has three great advantages

    1) It is demand-led. The insurers (who are usually not-for-profit mutuals or run by trade unions and employers’ federations) have to collect enough in premiums to meet the costs of treatment. Thus, funding is determined by the consumer, not the government. Moreover, in France, not only do the insurance schemes pay for medical treatment, but they, rather than the state, pays sickness benefit, so the insurers have a strong incentive to secure prompt and efficient treatment.

    2) It eliminates perverse incentives. NHS hospitals have a fixed budget and each treatment is a cost against that budget. Continental hospitals have no budget and each treatment is a source of revenue; the more they carry out, the more money they receive. Because tariffs for treatment are usual fixed, in agreement with the insurers, they cannot compete on price, but they can compete on quality; in other words, by providing a better service, they attract more patients and earn more money.

    3) Doctors, as self-employed professionals, are very good at keeping their administrative overheads down, because they have to pay them themselves. In France, it is very easy to speak to your doctor – Even consultants tend to answer their own telephone, rather than spend money on a receptionist. Also, because you pay for them, scans, X-Rays, lab reports, treatment notes and so on are yours and you, not the doctor or the hospital, keep them. Some details, such as blood group and allergies are recorded on the patient’s carte vitale, which is a smart card, rather like a credit card. This eliminates the need for expensive databases; you take your dossier with you to an appointment.

    This is what is on offer in many European countries who the UK to shame when it comes to healthcare. France and Italy are 1st and 4th in the table of the best healthcare in the world whilst the UK comes in at a lowly 25th. It is a scandal that as British citizens we have to tolerate more deaths from cancer than our continental comparisons and the utterly scandolous nonsense of NICE who let very ill people go to court, sell their houses because drugs that are freely available to patients on mainline Europe are denied to very poorly people in the UK. It is ok for you politicians with your huge salaries who can afford private healthcare – SORT IT OUT – give us a world class healthcare system – why is it that my very worried friend cannot see a consultant for 6 weeks but if she had the wherewithall she could see the same consultant privately tomorrow DO SOMETHING
    Plus there is a private healthcare provider bankrolling Andrew Landsley – what is all that about??????!!!!

  • Health – We are ready for change accross the board, there is too much waste on management and patient care is lacking in this area. We are tired of the rubbish churned out by labour, friends in hospital in this area are degraded, ignored and left in wet beds to the point of being asked three times to change the sheets. The patient care and dignity has taken a dramatic decline in recent years. The doctors do not seem to have time for anyone who tries to keep themselves healthy and works and we are often feeling let down by the (I don’t care) attitude of some doctors and nurses. I hope that the new idea of getting some of the people who pretend to be ill into work will also put less strain on the health service, as my neighbour constantly demands treatment to keep himself on benefits when in truth he is quite able to work.

  • donald cameron 17th Jul '10 - 8:49pm

    Miss Fozzard

    ***
    You are clearly no fan of the US. For your sake, I hope that you never need more than your tempeature taken by the NHS.

    As a doctor you should never lose sight of the importance of benchmarking against the best in the world and aspiring to be even better in the UK. And then get on and do it. We are the fourth richest country in the world. No excuses from the likes of you.

    We have to find our own solution for making things better. No country is different. The Americans need to narrow the gap between best and worst. Worst happened because there are about 40 million outside the health insurance system and they cannot afford to pay. Obama just put this right with his new healthcare bill. At least they are doing something AND RAISING THEIR GAME.

    I found in business that if you empower people they perform. But first of all they need to know the target. I cannot find any focus in the hex White Paper (or anywhere else in the system) of just how awful the NHS is. It is a policy secret!

  • Alan McLeod 17th Jul '10 - 9:27pm

    I am a junior doctor in the NHS. I have been qualified for three years now and have worked in three PCTs (four if you count my student days). I have identified a few issues. It is my firm belief that the biggest threat to medicine in this country is the poor way in which doctors (and presumably other healthcare professionals) are treated.

    Most (from personal experience) junior doctors feel utterly unappreciated:
    We are regularly expected to work extra hours – there is no option to be paid for these.
    Many jobs have fixed annual leave that is non-negotiable.
    In my personal experience formal teaching is appalling. At my trust we get four hours per month!

    I could go on – as a constructive suggestion I suggest a nationwide consultation with the various health professionals to see what the most pressing problems are. If things are not fixed people will leave for other things. I for example, am leaving the NHS doe a job as a forensic medical examiner. The job was just no good fro my mental health!

  • Alan McLeod
    Hi I am sure you are a hardworking juinor doctor & much put upon however so are we patients that attend A&E in this country – we are usually frightened, in pain, made to sit with threatening drunks, bullied by a dragon of an uncompassionate receptionist who is a mixture of Victor Meldew and Vlad the Impaler & made to think we are lucky to wait ‘only’ 4 hours – the service is appalling – it is not your fault but the hierachy of doctors who are trained by the NHS on taxpayers money but think they only have to be half way decent to their private patients – I have spent hours in A&E with a sick daughter in pain with no explanation as to why or when we can be seen – it goes back to the GPs as well – they are the highest paid in Europe but have opted out of out of hours cover so we the poor NHS patient as well as feeling poorly have to wait for an overseas doctor who is employed by dubious agencies on the make and look at the result – physicians who have barely mastered English, don’t understand our health service – one gentleman was killed by such a man – heaven help you in this country if you every has to go to A&E or are poor outside the hours of 9-5

  • donald cameron 18th Jul '10 - 1:23am

    Alan
    I despair of an organisation when I read a confession like yours. Unfortunately it is exactly what I sensed of hospital doctors in the NHS that I came into contact with, including consultants. Those that I got to know told me your story.

    The NHS cannot be better than its doctors. What you are talking about is organisation failure. In business, I found that the way to build competitive advantage is to focus on “happy employees” and “happy customers”. Thats it. No rocket science. Do those things and you are best in class.

    Good people together make things happen – we should never forget that

  • Can I please urge that whatever is done that as much attention is paid to the way that the change is undertaken as given to what is to be changed.

    The vast majority of change programmes fail miserably because insufficient attention is paid to the process of implementing the change. Large scale change is particularly vulnerable and public sector change attempts even more so.

    There is abundant reasearch evidence pointing out the pitfalls and providing useful points to consider.

    We should not unleash another destabilising rushed change programme. Let’s really make changes that are effective and worthwhile. That would be good for the country, the Health Service and the reputation of the LibDems as responsible and competent members of government.

  • Donald Cameron’s paean to American healthcare is laughable – US style health insurance has got bugger all to do with helping people get better, its about maximising market share/profit and minimising loss. And recently several of these companies have minimised their losses by raising their monthly payment rates, thus dumping those thousands unable to meet the cost (and after all, the poorest are the ones most likely to need treatment and thus be a burden on the company’s core functions).

    As for Obama’s health reform bill, just about every reliable progressive commentator in the States agrees that it is a monumental copout – no single-payer system (ie central funding via taxation as we have – that was kicked into the long grass); no public option (a government-run health insurance offering affordable rates to the poorest in society, likewise tossed), with only a small handful of actual measures to help ordinary people, like forbidding the exclusionary practice of pre-existing condition to deny funding for treatment. But – Obama’s bill does actually mandate people to join a health insurance scheme, thus providing the insurance companies with a flood of new cash, mostly from the federal government. Hey hey! – trebles all round!

    And this is the system you look up to? Whatever problems the NHS has, it still is a glittering pinnacle of human compassion and egalitarianism compared with the machinery of cruelty which is American healthcare.

    QED.

  • naseer Nuaman 18th Jul '10 - 10:22am

    Is the NHS ready for another structural upheaval/reform?
    Yes, NHS needs reforms as Target oriented services lead by managers needs to stop with immediate effect.
    We need new excellence centers to provide world class treatment. UK is tracking behind European countries in Health Outcome however UK has better economy ! The People centered care , should be in their hands , nt in the hands of theHealth professionals and Managers . We need choice
    How will GPs cope with their new role?
    Most GPs aree self employed running their own Private Business contracted to doNHS service, like any contractorr to look after the streets of a Borough in London . That is a fact. Why NOT we let the people have a choice!! You could make your own contract for your health or you could choose the NHS contract . Why we all should be under same Umberlla of Health. Everybody who is sane could make a choice about his life why not about Health. GPs are different and have wide range of skills , but not all of them can work with commissioning of services. Most GPs work about an average of 55 hours per week now, you want more Burden on them
    And are we going to get a local NHS which is more accountable to the citizen and tax payer?
    New NHS card ( not Cardboard one !!) with achip that should be used whenever anybody gets access to NHS service, This would prevent Health Tourism
    NHS services could be provided better if we split Private from Public sector health.
    Health Professionals should not work more than 48 hours per week . Tax payer are funding the NHS, but peopel need to put a nominal fee when using it. For Example £1 when see GP ( this to be paid to NHS funds ) £5 when attends a secondary care , £10 for bed service in the Hospital . The NHS card should be connected to National Insurance enters to make deductions. This means nobody pays on the desk of NHS .
    Will the NHS work better for the patient without PCTs and Regional Health Authorities?
    PCT s merged together to manage their Debts . SHAs should work with research centers for Public Health measures & planning
    Can we make progress without these changes ?
    I am afraid not with this huge financial deficit , We need reforms

  • The NHS cannot cope with anymore changes and from experience in accounting practice I do not think that the average GP could cope with managing the budgets. Admin staff at our local hospital are renowned for being particularly slow in dealing with paperwork (letters to doctors not being sent for days after discharge, maintenance staff taking far longer to fix equipment than necessayr) and overweight nursing staff at clinics seem to spend a great deal of time wandering about with bits of paper when everything could be transferred electronically.
    I do think that costs could be cut by stopping salaries to trust members and pay them expenses only for the meetings they attend (see appointments commission’ sits. vac.) and that a cap should be put on the salaries of trust chief executive salaries, perks, and expenses so that more money is available to spend on the coal face. More money could be saved if when a member of staff is suspended no salary is paid and that suspension should not occur for trumped up charges when someone blows the whistle on bad practice. An example is of a doctor at Coventry and Warwickshire hospital who complained that more beds were dangerously being put into a nursing bay than it was designed for. He was suspended for 5 years with various trumped up charges of incompetance, and eventrually was reappointed. It is no good paring down the front line workers when exhorbitant salaries are paid to managers who introduce time wasting procedures. Perhaps we could introduce the old fashioned and practical time and motion men to sort things out.
    I really feel that practical and not theoretical action needs to be taken

  • In response to Donald Cameron’s post on the 16th July – The rankings you quote are from the The World Health Report 2000 – Health systems: Improving performance, and the ranking of 18th for the UK is from the ‘overall performance’ section of Annex Table 10 Health system performance in all Member States, WHO indexes, estimates for 1997! The report can be downloaded from: http://www.who.int/entity/whr/2000/en/whr00_en.pdf and the data is on page 200 of the pdf.

    Yes, it’s a valid snap shot number but the NHS has come a massively long way in the last 13 years. This figure of 18th in the world was true at a time when the Tories had been in power for many years, and before Labour had any kind of chance to start rectifying the deficiencies the Tories had left behind.

  • @ Naseer

    I’m sorry but you are wrong – billing, money and contrived market structures need to be erased from the NHS. I would be happier knowing that doctors, nurses and surgeons are focussed solely on my treatment and wellbeing. The system you advocate – everyone’s there own contracting unit! – resembles many aspects of healthcare in this country in the decades before WW2. I commend to your attention Nye Bevan’s book, ‘In Place Of Fear’ – the eradication of money-based fear was the prime motivator for the foundation of the NHS. I would fight to my last breath to make sure that such an unjust system never returns.

  • Eunice Wormald 18th Jul '10 - 12:07pm

    When I had a stroke I was unconscious and therefor not able to participate in my treatment I woke up 2 weeks later unable to speak. It would be good if the staff were treained on how to deal with people like this and to be more considerate./ I was unable to open my mouth and just got abuse from a sister. One of the reasons I did not open my mouth was because they had used the opening of my mouth to shove things in to it and this was my only way of stopping this. No one considered why, I was just being a nuisance. I was also given a yoghurt drink that I was allergic to and made me naseus yet no one had the time to talk to me about the drink, the person dealing with this only responded to people who could talk, so I had this yakult for a month before I could say ‘it makes me naseus’.
    When I was taken to hospital in the middle of last winter I was told not to wear slippers or a dressing gown but the paramedics only had one thin blanket to cover me and I was frozen going to and from hospital.
    How is giving GP’S the money going to alter attitudes?
    There is also a rule that you ‘cannot be changed during lunchtimes’ even if you are soaked or dirty cos there is not enough staff to deal with this; blow the patient.
    Most GP’s are very patronising and don’t really talk the patients language, how is asking them to fund the NHS going to work?
    If the patient knows nothing about the team who will care for them how can they choose or if the are dying etc

  • John: You ask “Can we make progress without these changes “?

    I believe we can. Picking up on a point made by Donald Cameron above, I believe that successful organisations have happy customers, happy staff and keep spending within their resources.

    I think much improvement would follow from paying or bonusing managers dependent on patient satisfaction, staff satisfaction and keeping within budget. Health professionals including GPs should have an element of their remuneration related to their patient satisfaction.

    This would really empower patients. The problem with the “choice” model is that, though it empowers the pushy and the information savvy, it disempowers everyone else who are left with the poorer hospitals and GPs. The choice model also costs more as it requires surplus supplies. Most people simply want a good local GP and good local hospital. They don’t want to have to scan league tables and push to the front of the queue to get the best. Many are unable to do this.

    The Lansley proposals are fatally flawed because they are based on “choice and market” model that it is expensive and unfair and driven by ideology. LibDems should have nothing to do with it.

  • Howard Hollingsbee 18th Jul '10 - 1:04pm

    Libdems should have nothing to do with lumping together market and choice. Two entirely separate issues from the patient’s perspective. The market is there already (except where artificially constrained) and competent, hard-nosed contract managers from industry make it work for them. Sounds like dogma ao me, to champion the cause of keeping everything in the NHS in-house. The LibDem way should be to find and employ the best of both worlds. Works in the real world but does depend on the above competences.

  • I for one feel sad that this paper indicates the end of a national institution that makes Great Britain great. RIP NHS

  • donald cameron 18th Jul '10 - 1:21pm

    Mike
    Glad you got that off your chest and had a good blast at the American system.

    I just want access to good healthcare when I need it. Pissed me off when I found that it is not available in Britain.

  • Avril Upstone 18th Jul '10 - 2:30pm

    As a health professional in an often over looked profession (speech and language therapy) I feel strongly that putting the NHS in the hands of GPs is fundamentally flawed. All professions are currently well represented at PCT level and just as we are getting our heads around provider/commissioning division another reorganization comes along. I have only been working 5 years and during that time have had significant changes to either my job or organisation every year. The changes to commissioning is already providing savings by amalgamating provider ams into areas and while I feel that there are far too many managers in the NHS I do not see how this system can be better. Leave us alone to get on with our jobs and protect any changes for a mimimum of 5 years to allow a true decision of the benefits to be gained.

  • mike cobley 18th Jul '10 - 2:41pm

    Donald – glad that you didn’t take significant umbrage at my gregarious dismissal of American healthcare. Of course, standards of care across such a system as ours will vary but here no-one is refused treatment on the basis of the patient’s wealth. My personal experience vis a vis hospital care (from a hernia several years ago and a (cough) circumcision this year) I can say that the care I received was very good and the staff were never less than profession and understanding.

    Didn’t have to take out my wallet, not once.

  • GP commissioning is a ridiculous idea and will lead to privatisation via the back door. The Strategic Health Authorities have only just got off the ground and got a handle on commissioning services.
    The idea of patient choice is utter nonsense too, people want excellent treatment locally, The majority of hospital patients are elderly with elderly relatives and the prospect of having to travel miles for treatment or to visit adds great pressure on people who are ill.
    Hospitals need less people in the middle management structure overseeing targets that are politically and media driven; the Wards need to be given back to the Ward Sisters and Charge Nurses and Nurses.

  • donald cameron 18th Jul '10 - 2:50pm

    Mike
    What I would like is “good at the point f need”.

    “free at the point of need” is actually of no interest to me if it turns out to be rubbish.

    You were lucky and I am glad to hear it. But your procedures were pretty low tech. Wait for the complicated stuff and then we can speak again (assuming that you live to tell the tale)

    By the way, stories of American patients dying on the hospital steps are fairy stories. All emergency cases have to be treated, regardless of wealth/insurance. Its the follow up stuff that causes a problem for those without insurance. But it is what their culture is about: work hard and get rich. The picture of failure is a lesson for the inclined to be lazy to work hard. Its a tough culture, but in the round it has produced an extraordinary country.

    And dont forget that “family” is extremely strong here. Much stronger than the UK. When crisis strikes they rally around like I have never seen before.

  • Oh my God! I agree with Melanie Phillips in the Daily Mail. She says “The last thing that’s needed is yet another reorganisation which may incur even greater costs”.

    There is a powerful range of opposition to the Lansley proposal (which incidentally contradicts the Tory’s pre-election pledge to have “no more top down reorganisations”)

    As well as the Daily Mail, the Economist, Civitas (a right-wing think tank) the Lancet, the British Medical Journal – all oppose the Lansley proposal. Lansley may find he is out on a limb. LibDem MPas would be wise not to follow him there.

  • Cllr Sophie Erskine 18th Jul '10 - 5:34pm

    i think we should be totally sure that such changes are appropriate in an era of fina cial austerity before we go through with them.

  • Paul McKeown 18th Jul '10 - 6:20pm

    @Donald Cameron

    Your interventions are of absolutely no value to this discussion. No mainstream political party in the United Kingdom would dream of transforming public health provision into anything as expensive, inefficient, unfair and fundamentally broken as that provided by the US private insurance model. Fact is the US model has been utterly corrupted by the profit motive, and is almost completely useless, providing worse general health outcomes than those of, e.g. Cuba’s health system, in the economic third world.

    The NHS has its own inefficiencies, but it is relatively inexpensive and provides reasonably fair health outcomes across the length and breadth of the country, across social and economic divides. The political arguments in the UK rage around the means to squeeze out as many inefficiencies as possible, in order to provide even better outcomes for the same reasonable share of national income. The political problem is that any proposed program is immediately by howls of outrage directed typically at the demon of privatisation, which is, of course, never the proposal. To propose to transform the UK model into one similar to that provided by one of our European neighbours, such as the Netherlands, Germany or Belgium, all of which enjoy even higher levels of health provision, would sound to many ears like the simultaneous slaughter of ten thousand sacred cows.

    I don’t believe that the current proposals for GP led provision are dangerous, although I am fairly agnostic and would be prepared to listen to well argued, rational and cool analysis on both sides of the discussion. I do wonder, though, whether yet another reorganisation is needed, unless the belief is strong that large efficiency savings will result.

  • Gillian Maher 18th Jul '10 - 8:12pm

    I am appalled at the way these health “reforms” are being rushed into action without any proper consultation with the professions involved and patient representatives – some democracy!!
    This is just a sell-out to multi-national businesses whose only priority is the size of the executives’ bonuses and the shareholders dividends. Tax payers and patients will be as lambs to the slaughter, without a word of dissent apparently from our LibDem ministers.
    There will be no accountability from these companies; they will ensure that they can hold a gun to the head of any government wishing to control their excesses.
    You have only to look at the way the multi-national companies controlling our food chain can operate with impunity; literally poisoning millions of people with toxic substances, effectively unhindered by governments of every colour, because their ability to challenge them has been pre-empted.The same will happen with health-care if this insanity proceeds..
    In fact the NHS is currently the cheapest mass health service in the world – despite the best efforts of the pharmaceutical companies.
    Yes, the NHS needs re-defining and refining, but it does not require mass destruction as proposed.
    We can certainly progress without these changes – and much more cheaply than by the model now proposed.
    This is why the real changes should be only be implemented after much greater consultation and preparation with all stakeholders, whether statutory, charitable or voluntary.
    We have resources in this country which do not exist elsewhere – it’s an opportunity for real creativity and community participation.
    However all this will be lost once big business gets it’s teeth into the system, because collaboration is not in their interests.

  • mike cobley 18th Jul '10 - 8:14pm

    Paul M – thanks for zeroing in on the deficiencies of the US system and backing up the general argument against us tippytoeing down that route. Interesting that you highlight Germany, Belgium and the Netherlands as ideals to be aspired to, since in all of them the payment for healthcare is funnelled through health insurance companies. Wow, just like America!

    Well, no, not quite like in the States, since in those three countries the insurance companies are highly regulated by government which sets standards on all kinds of payments and structures, resulting in health systems which have quite high public approval ratings. That said, there are still the uninsured who have no right to treatment, 100,000 in Belgium I read, nearly 250,000 in Germany. Very different to this country where NO ONE is turned away, because insurance is not needed.

    For healthcare-eurostyle to work here, we’d need stringent regulations and regulatory bodies sufficiently well-funded and legally armed to make it work. In the light of our darling CBI’s attitude towards regulation of any kind (like whipping out the onion for a full-on weep about how badly British companies are treated, bwah hoo hoo!) and the relentless and ruthless pressure from the Tories and those Friedmanite thinktanks with which we are currently infested, such a regulatory ethos is a long way off.

    Without it, there’s no point. Any move to introduce that kind of system here would have us quickly devolve into America’s kind of crazed profiteering, where the incentives push the HMOs to deny care and sell insurance to the healthy. So, sorry Paul – some of the pieces look good but truth is, all the pieces need to fit.

  • donald cameron 18th Jul '10 - 9:02pm

    Paul
    Clearly you are a paid up member of the Flat Earth Society

    Lets take one thing at a time and seperate the financing of health from the quality of health delivery.

    I am making a simple point. I and many like me have found that we have to go abroad to get first world levels of medical care. Whether its the US, Australia, France, Holland etc is not the point. It would be preferable to find it closer to home.

    I am also angry because I am paying £120 billion a year for the NHS which is turnning out too much rubbish. I am really keen to find a way of improving it. Starting with all those demotivated doctors and consultants who cant wait to leave and set up in private practice or pray for the day when they can retire. The system has to be bombed out if so many of those employed by it are so demotivated.

  • John Nichols 18th Jul '10 - 9:16pm

    The role of government is to ensure that taxpayers money is efficiently used in the NHS and we GPs have to accept this “interference”. Now we are told we have to be more involved in comissioning and that the local PCT will be replaced with The GP Commissioning Consortium. The big question is: what happens to frontline general practice if GPs are being pulled off the front line to run the Local GP Commissioning Consortium. In the past, GPs involved in management have held evening meetings. This is no longer acceptable by the new generation of GPs and manager, so pulling GPs off the front line and weakening the front line efficacy of primary care is a real possibility. The solution would be to put a few GPs in charge of commissioning and employing managers to do the donkey work. But this was what PCTs were meant to be wasn’t it? If the coalition government has a magic formula that will make things work better this time round, then they should be given a chance but I expect a good deal of chaos in the process of reorganisation – I hope I am wrong.

  • I’m trying to get some physio and after registering with a new doctors discovered GP’s in my area already control purchasing of services such as this. A handy leaflet for community “self-refer” physio seemed ideal until I was told my GP wasn’t part of that service so I couldn’t have it. Instead I’m still waiting for an appointment as my new GP also doesn’t believe in opening hours that allow people to visit after work and still waiting to find out how exactly I access physio. Now I just have to wait and see if the rumoured accupuncture is available through my GP or not. Even though I know it works if they haven’t bought it I won’t be able to get it, or will have to go back to saving to pay for it.
    What will happen in future if my GP doesn’t buy in mental health services or enough sexual health services or even enough nurses, will I just lose out because my post code doesn’t match?

  • Valerie Ramsay 18th Jul '10 - 11:03pm

    I think the idea of re-structuring the health service yet again is not a good one. The health service has been re-structured so many times I have lost count. It is very bad for staff morale all this constant change.
    G.P.s are clinicians not accountants and should not be made responsible for budgets which would not be their line of expertise. There would have to be accounability as to how they spent the money and who is to do this? It is suggested it should be our hard pressed councils who are being told to cut costs in all directions, I just do not think it would work or be practical. This all strikes me as being a very knee jerk reaction and needs much much more thought and input from those who run the health service at present. Take it much more slowly and carefully and try to do things which would actually work and be of benefit to both patients and staff. The health service is not perfect as it is at present but what is being proposed would certainly not improve it; in fact I am really worried about it and do not think that the Lib Dems in the coalition should support it.

  • The white paper proposes a range of initiatives that are unwise, and some that are unhinged. The proposals around public health are positively dangerous. Liberal Democrats should have nothing to do with it. The government has no mandate for these changes; quite the opposite, given comments made in the run up to the election.

    Many of the proposals betray their ideological basis and complete disregard for the evidence of the problems generated by previous rounds of reorganisation. It would no doubt be possible to make the envisaged system work, but it would only be possible under certain conditions – around availability of information, serious monitoring and high quality management – which mean that it won’t necessarily be any more efficient/cheaper. It appears that a rather simplistic textbook understanding of the benefits of competition are being rather incautiously applied to a complex problem. That usually ends in tears – when the real world fails to deliver on the positive outcomes the textbook models predict.

    From the perspective of seeking successful organisational change the proposals are a non-starter. Major change that has lasting effects on organisations are rarely delivered in the timescales being discussed and is never delivered without a much more effective approach to change management than the government is likely to put in place. Restructuring rarely, if ever, saves signficant amounts of money in the short term.

    There is no dispute that some GPs took to fundholding in the 1990s and made it work. But quite a lot didn’t. There is no reason to suppose that all GPs will want to, or have the skills to, be effective in a commissioning role.

    Has the government not heard of the benefits of specialisation? While there can be too much planning and management (and the NHS may well suffer from it at the moment), there sure as heck can be too little. And forcing management and strategic roles on people without the training or necessarily the aptitude or interest is one way to explore the consequences of too little. GPs are undoubtedly very bright people but that doesn’t mean we should assume they can successfully turn their hand to anything. We would expect some to be able to work the proposed reformed system to the benefit of their patients and others to flounder. Presumably the latter with then fall into the welcoming embrace of some private sector management ‘solution’ to take the headache away. It won’t be the case of significantly less management post-NHS but substituting management in the private sector or by people who should be in clinical roles for management in the public sector.

    While we have all surely got to be in favour of improving clinical outcomes we should also seek equality of opportunity and access.

    The important thing to bear in mind is that every attempt to restructure public services (in education, health, housing) that has moved to use choice to drive quality has tended to lead to increasing inequality (in both access and outcomes). Those who possess the ‘currency’ needed to the participate in the system (which needn’t be financial) are able to secure better outcomes. Those who lack resources and are unskilled in the role of consumer will tended to experience worse outcomes. That is the nature of markets. This is what we teach students in economics 101 (we also spend some time explaining why the characteristics of health care, specifically, mean that there are a whole host of problems in marketising its provision, but that is a different story). If politicans are happy with that inequality then by all means embrace marketisation and devil take the hindmost. But if such outcomes are politically unpalatable because of their anti-egalitarian nature, then don’t base the system on choice and real or quasi-markets. Choice only becomes significant in the face of a significant quality gradient (if you got good and timely treatment at your local hospital regardless of where you are then you wouldn’t worry about choice). If we were more focused on equality of access then choice would be less of an issue. Someone earlier in this thread suggested returning to Beveridge and the liberal origins of the NHS: perhaps he would be more interested in universality, access and a system that reached the vulnerable, rather than giving priority to choice and marketization. That would seems a good place to start.

  • Gareth Worsley 18th Jul '10 - 11:22pm

    “While there was little robust quantitative analysis at the time
    (Dowling, 1997), a recent study of data from one health
    authority covering 1993 to 1997, concluded that… See More
    fundholding practices were able to secure reductions in
    waiting times of about 8% for their patients requiring
    procedures included in the scheme, compared to all other
    patients (Propper et al, 2002). These waiting times relate to
    the period from the decision to admit to admission, but,
    arguably, the impact of fundholding budgets on GPs’
    decisions to refer is also important. There is anecdotal
    evidence that some fundholder referrals were delayed due
    to budgetary constraints (Bagust, 1994). More recent
    research comparing the period before and after the
    abolition of the fundholding scheme has shown that
    fundholding status reduced the waiting times of
    fundholders’ patients by 5-8% and that these practices
    would probably have had higher waits than nonfundholders
    had it not been for holding a budget (Dusheiko
    et al, forthcoming).”

    Two tier system… remember, this was when common to wait 18 months, what impact would they have when patients only wait 18 weeks. Patients of Inner city non-gp fundholders, seen later at the expense of fundholder patients

    Resourcing
    Research evidence supports the hypothesis that the more
    successful primary care commissioning organisations have
    higher levels of management and other professional
    support (Malcolm et al, 1999; Wilkin et al, 2001; Weiner et
    al, 2001; Regen et al, 2001; Mays et al, 2001; McClelland
    et al, 2001; Dopson and Locock, 2002). The national
    evaluation of total purchasing pilots showed a statistically
    significant association between a pilot’s ability to achieve its
    commissioning objectives and its per capita management
    costs (Mays et al, 2001, p85). Adequate management
    support is considered to be vital if primary care
    commissioning organisations are to gain the confidence of
    secondary care colleagues in purchasing negotiations, and
    of their constituent practices which expect the organisation
    to properly support primary care-led commissioning
    activities. UK commissioning organisations, in general, have
    had low levels of management support when seen from an
    international vantage point (Weiner et al, 2001), and the
    issue of commissioning capacity is regularly cited as a
    reason for the perceived lack of progress with
    commissioning in the NHS, given the wide range of
    responsibilities given to commissioning organisations (Light,
    1998a; Smith and Goodwin, 2002; Dopson and Locock,
    2002; Roche, 2004; Commission for Health Improvement,
    2004). There is no doubt that core commissioning activities
    such as population needs assessment, service
    specification and development/redesign, priority setting
    and resource allocation, contract negotiation and service
    monitoring need proper management and other expertise.
    In addition, with the increasing interest in using managed
    care techniques from the USA as part of NHS
    commissioning, a range of new skills are called for
    including: linking the discipline of managed care with
    programme budgeting processes and Payment by Results;
    developing staff, clinician and patient awareness of new
    approaches to care management; developing new
    incentive structures; analyzing and then risk stratifying local
    population groups; developing predictive models of likely
    health care needs and usage; articulating how the policies
    of managed care and Patient Choice might work together
    (Chambers, 2004).Light (1998b) identifies the following
    requirements for commissioning organisations to be
    successful, based on US experience:
    • Sufficient clout (for which size may be relevant,
    depending on the service) to take on powerful
    specialty hospitals;
    The Health Foundation Primary care-led commissioning 21
    • Technical skills, knowledge and infrastructure to
    challenge ineffective or inefficient practices;
    • Time and training to carry out complex tasks (e.g.
    working with providers to redesign their services);
    • The ability to improve quality and efficiency, and reduce
    variations, in primary care itself.

    Oh shit you do need management (sorry in tory speak bureaucracy) to achieve desired aims of a system. Even succesful GP fundholders had higher management costs….. and your going to chop management costs and achieve what!!

    http://www.gloslmc.com/guidance/previous/PC%20led%20commissioning%2005.pdf

  • Gareth Worsley 18th Jul '10 - 11:25pm

    One early review of the available fundholding literature
    concluded that there were ‘extensive gaps in current knowledge
    about the impact of the scheme’ and that the claims… See More
    that ‘GP fundholding has resulted in improvements in efficiency,
    responsiveness, and quality of care are in general
    not supported by the evidence’. Another review argued that
    ‘few reliable conclusions about fundholding, either positive
    or negative, can be drawn from existing research’. A review
    two years later also concluded that there was a dearth of
    high quality evidence on many aspects of the fundholding
    scheme, particularly in relation to referral rates, patient outcomes,
    and service quality. A review of the scheme’s
    effects on prescribing found that, in the short term, many
    early-wave fundholders had managed to secure economies
    in their prescribing by switching to cheaper, generic drugs.
    However, in the longer term, such savings may not have
    been sustainable. One of the last reviews available to inform
    abolition concluded that ‘evidence concerning the success
    or otherwise of general practice fundholding over the last six
    years is incomplete and mixed’ and, unless further research
    was undertaken, ‘the jury will have to remain out on whether
    fundholding has secured improved efficiency in the delivery
    of health care’.

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314221/pdf/11885824.pdf

  • Gareth Worsley 18th Jul '10 - 11:28pm

    To achieve this, commissioning organisations need
    to be given a degree of organisational stability and a
    chance to prove themselves. Providers have had
    relative stability for some 15 years whereas
    commissioners have been subject to numerous major… See More
    imposed reorganisations.
    As noted in the previous section, one of the main reasons
    for the limited availability of research evidence about the
    effectiveness of commissioning is the regularity with which
    NHS commissioning bodies have been subject to structural
    reorganisation. There is however extensive to support the
    need for NHS (and other) organisations to have structural
    stability if they are to be able to deliver on longer term
    strategic objectives and avoid the inevitable distraction,
    loss of momentum and morale, and costs associated with
    reorganisation (Smith et al, 2001, Fulop et al,2002).
    Although many NHS trusts have been through mergers and
    internal reorganisations in recent years, nationally imposed
    reorganisations (particularly in England) have tended to
    focus on commissioning bodies. Given the time that is
    required to achieve change and demonstrate impact within
    commissioning, commissioners have therefore been in
    something of a vicious circle – damned for not achieving
    adequate change in secondary care services, yet
    destabilised by reorganisations that undermine local
    relationships, result in the loss of valuable expertise and
    skills, and detract from the hard business of exerting
    service improvements and change from providers.

    http://www.gloslmc.com/guidance/previous/PC%20led%20commissioning%2005.pdf

  • Gareth Worsley 18th Jul '10 - 11:36pm

    http://www.telegraph.co.uk/health/healthnews/7894203/NHS-reforms-will-cost-3bn-and-will-not-work-academic.html

    NHS reforms will cost £3bn and will not work: academic
    Reform of the NHS planned under the government’s white paper will cost around £3bn without saving money or improving patient care, a leading academic has warned in the British Medical Journal.

    The coalition government has not learned the lessons of past reorganisations of the NHS and is intent on more massive change without evidence that it will improve the service, Kieran Walshe, professor of health policy and management at Manchester Business School wrote.

    Despite having promised only two months ago that there were would be a ‘stop to top-down reorganisations of the NHS’, the biggest changes are now planned for a generation, he said.

    “Little of the current architecture of the NHS will survive these changes unscathed,” Prof Walshe wrote.

    Meanwhile and editorial in The Lancet medical journal also hit out at government health policy after finding evidence of cuts to vital mental health services in Oxfordshire despite Andrew Lansley, the Health Secretary, pledging that frontline services would be protected from austerity measures.

    Prof Walshe said in the British Medical Journal that ministers were about to repeat the mistakes of the past.

    He wrote: “The white paper, written at breakneck speed in about six weeks, is long on rhetoric but short on detail and specifics. It promises at least seven further strategy or consultation papers on various topics and another white paper, on public health, in the autumn.

    “For someone who has spent more than six years mastering the health brief in opposition, Andrew Lansley seems to have learnt little from the history of NHS reorganisation.”

    He said there have been 15 major structural changes to NHS organisations in the last 30 years and there is ‘little evidence’ that they produced ‘much, if any, improvement’.

    The white paper includes plans to abolish primary care trusts and strategic health authorities and instead force GPs into contortia to purchase care from hospitals and other health providers for their populations.

    However Prof Walshe said there was little evidence to suggest any of the methods for commissioning care, either primary care trusts, GP fundholders or external support agencies, were any better than each other.

    Many different ways of commissioning care have been tried and Prof Walshe said there is nothing to suggest that any of them were better or worse than the others nor that the new GP consortia will fare any better.

    He wrote: “The transitional costs of large scale NHS reorganisations are huge, although they are often discounted or ignored, and the intended or projected savings from abolishing or downsizing organisations are rarely realised.

    “Closing down or merging organisations produces a round of expensive redundancies, early retirements, and redeployment, while new organisations find new premises and appoint lots of new staff.

    “On the basis of the National Audit Office’s survey data, I estimate that the proposed NHS reorganisation will cost between £2bn and £3bn to implement, at a time of unprecedented financial austerity.”

    He said whether abolishing primary care trusts and strategic health authorities in order to set up GP consortia, which may number in the hundreds, will save any management costs remains to be seen.

    However he warned that over the past twenty years the number of managers and management costs have grown steadily.

    The actually process of reorganising the NHS is also a distraction from delivering care to patients as it takes a ‘massive amount’ of managerial and clinical time and effort, he said.

    “It saps morale and creates uncertainty for many people about their careers and futures. In addition, new or merged organisations take time to become established and start to perform well, ” Prof Walshe wrote.

    If the reforms go ahead then government must set out the intended costs and benefits which should then checked and the results presented to parliament.

    A spokesman for the Department of Health, said: “We do not recognise the £3 billion figure cited in this report.

    “The reforms proposed in the White Paper will cut the cost of bureaucracy, saving money that can be used to improve the quality and efficiency of the NHS.

    “The costs associated with and the savings generated by our reforms will be published later this year, but the reductions in management costs we have already announced will save £850 million each year from 2013-14 alone.

    “The reforms will not adversely affect patient care, In fact, they will do the opposite, putting patients first and making health outcomes the best in the world.”

    The Lancet medical journal called on Andrew Lansley to be truthful about cuts to patient services after uncovering evidence that clinicians would lose their jobs in planned cuts in Oxfordshire.

    The NHS has been told to find between £15 billion and £20 billion in “efficiency savings” over the next few years.

    But the editorial said Mr Lansley has promised that efficiency savings will be “reinvested in frontline services”.

    Yet a document handed to the journal shows that many jobs will be lost and patients affected by cuts at Oxfordshire and Buckinghamshire Mental Health NHS Foundation Trust, which needs to save £5.3 million over the next four years.

    The document acknowledges “poorer” services for patients as a result, with “reduction in quality of service through staff changes” alongside “patient and carer dissatisfaction with the service”.

    The editorial said: “The Oxfordshire experience might be common.

    “This is an issue that challenges a fundamental commitment by the Liberal-Conservative coalition.

    “And this is why we ask: Mr Lansley, will you tell us the truth about NHS cuts? Because the reality seems very different from your promise.”

  • My concern may fly in the face of a policy of localisation, but experience has shown that locally controlled services are not necessarily cost-effective or accountable – theoretically sound but hard to put into practice. For example, how much control have we had over the rise in the cost of council services? Central taxes do not go down yet the cost of locally provided services goes up. This particular policy of devolving power to GPs seems at face value to contain many risks and few safeguards for efficiency and cost effectiveness. Too many times have we witnessed over-general government policy with insufficient guidance for its practical roll out. Let’s not repeat the same mistake.

  • VIC JENNINGS 19th Jul '10 - 12:52pm

    I am most concerned about the proposed changes to the NHS. Whatever your views of the last Labour Government, it cannot be denied that there were substantial improvements in the NHS, especially with regard to waiting times. If it is not broken (as under the previous Tory Government) why fix it? I see the proposed changes as privitisation, with private hospitals and primary care what else can you call it. Of course the non-profitable services are not included. When this process is completed the call will come for private insurance, and the Americanisation of the British Health Service will be complete. This will include the disgraceful level of service to ordinary people, 29% of insurance premiums going to the insurer, people being denied their cover on obscure technicallities and many bankruptcies, just like the States. This will result in a static life expectancy or worse, a decrease, and if one was really cynical, then a reduction would go some way to resolving the Care problem. Look at the facts and open your eyes.

  • This is going to cost more money than it will save. It is privatisation in all but name and the start of the breakdown of the NHS. It has been improved by the last government, waiting lists have gone down and treatment has been improved. True there is more that can be done, getting rid of some of the administration, getting more front line staff and stopping ridiculous payouts to incompetent bosses.
    What is even worse is the fact that the Lib. Dems have joined forces with the Tories and become lapdogs to Cameron and his millionaire cronies.

  • John Wilton 19th Jul '10 - 2:54pm

    I worked in the NHS from 1993 until I retired last October, as a project manager in estates, and during that time saw various major national restructurings and local trust mergers. Invariably they cost more than anticipated, failed to deliver most of the planned benefits and consumed an enormous amout of staff and management time that could have been better used providing and supporting patient care. Senior managers, who were generally those most directlly affected, were also distracted by concerns for their own futures. Often talented and experienced senior managers were made redunadant at very considerable public cost.

    I am not at all convinced that yet another major reorganisation will be any different.

    How will it differ from the GP fund holding that the last Tory government brought in, which was then scrapped by Labour? In a rural area like West Sussex, patients do not want a choice between hospitals which are too far away, they want the best possible service at their local hospital.

    John Wilton
    Chichester
    West Sussex

  • Abolition of the SHAs is good news. PCTs less so. I have been a non Exec Director of a PCT and a Mental Health Trust and although the commissioning skills of PCT staff are patchy, GPs do not yet have the skills or time to carry out the function – and will want more money to take it on. This is solvable but will take time and resources to fund GP commissioning consortia and to data share best practice and results. Provider Trusts worth their salt will facilitate this because they have an incentive to make access to their services as easy as possible for the patient and their GP. However, linking health to Local Authorities will not improve services or patient safety. No politician is evergoing to vote to close a bed at their local hosptial

  • donald cameron 19th Jul '10 - 5:19pm

    John
    You and many like you on this thread just dont get it.

    The policy objective should be to achieve first world standards of care in the UK. Educate yourself by studying the comparative statistics and learn what a basket case the NHS is.

    I bang on about America because thats where I came to find good medicine and therefore feel that I can speak from experience. But there are other countries (France, Australia etc) that are light years ahead of us.

    And anyone with any management experience will know that it is not possible for an organisation to perform if the employees are unhappy and if the customers are unhappy. Until these things are understood and put right it is a waste of resource to continue feeding the NHS.

    And finally, anyone who has ever had anything to do with resource allocation knows that “free” and “efficiency” do not go together. In fact they are incompatible. Sometimes social needs mean that something has to be given away in emergency eg earthquakes, post war conditions in Britain. But the Workhouse has passed and we are one of the ricest countries in the world. Unless money is unlimited (and it is not) then the idea of a free NHS is a joke. Especially more so with the rising cost of healthcare due to an aging population and the advance of technology.

    RIP

  • Richard Butchart 19th Jul '10 - 5:43pm

    Can I just say that I was impressed that even the Economist – well known for its support for competitive markets – thought that “. . .the scale, pace and untested riskiness of the proposed changes give pause for thought. There are reforms still in the works that might usefully have been completed first . . .”. My view as someone who has always had excellent treatment and care from the NHS is that this is yet another ideologically motivated top down reform to show that the Minister is taking decisive action. By the time its faults emerge, he will have passed on to better things, leaving his successors to pick up the pieces or more likely come forward with yet more harebrained reforms.
    I did not vote for this and I cannot imagine that many people did.

  • Paul McKeown 19th Jul '10 - 5:55pm

    @mike cobley

    “That said, there are still the uninsured who have no right to treatment, 100,000 in Belgium I read, nearly 250,000 in Germany.”

    If you believe that, you will believe anything.

    Unlike yourself, undoubtedly, I have lived for extensive periods in both Germany and the Netherlands and have seen the results at first hand: excellent. Nobody who needs treatment is denied treatment and the quality is very high. Anything to the contrary is simply propaganda and utterly untrue. In fact balderdash.

  • Paul McKeown 19th Jul '10 - 6:01pm

    @Donald Cameron

    Your speechifying is mere flatulence.

    There may well be “good medicine” in the Us, but, as is well know, only for those with limitless wealth, or with insurance without chronic conditions. For 40% of the US population, standards of health provision are worse than those provided to the general populace in much of the third world.

  • Howard Hollingsbee 19th Jul '10 - 6:19pm

    Back to the essence chaps….
    What’s important, and what should we be focusing on? – outcomes in line with, or better than peer countries, at similar costs.. What DO we focus on? – process. This allows managers and employees alike to fiddle around the edges, interpret guidance in accordance with their particualr ingrained ideology or prejudice. Whole culture change is required – as I blogged above, this is unlikely to be achieved by evolution. Pity. A lot of thought needed, and I’m not sure how GP practice alliances can square the circle of conflcting interests, but we certainly can do without the suits in the SHAs.

  • Howard: You sound like a change management consultant looking for work!

    Outcomes of the NHS ARE broadly similar to peer countries and generally at a lower cost.

    Sure – there are some NHS horror stories, and examples of poor management and waste as there are in all large organisation. It needs good leadership and the right incentives (not all necessarily financial) to improve and that is not going to come “bottom up” from GP consortia seeking to maximise their profits.

    The last thing the NHS needs is another expensive upheaval complete with cultural change consultants and all the rest.

  • Howard Hollingsbee 19th Jul '10 - 7:29pm

    No…! Interested,essentially retired lay person peripherally involved in Acute Trust governance but from a multinational company background who’s seen a thing or two here and other countries. I’m sure we could trade stats, but sorry – the NHS is appallingly badly managed and there are huge potentail savings from carefully considered, intelligently let and hard-nosedly supervised contracting.
    Trouble is, this blog is now so long that we’re all in danger of having to cover it all again. This the point at which I bow out! It’ll be interesting to see if any of the varyingly valuable comments are acknowledged.

  • I find it hard to believe that migrating from the current to the proposed system will not incur significant cost. Furthermore I am highly skeptical that it will end up any cheaper in the long run. I get the impression GPs already have a massive workload and its hardly likely that they will be able to take on all this responsibility without hiring back some of the managers that are supposed to be ‘streamlined’ out.

    I was particularly horrified by the term ‘information revolution’ in the press release. I work in IT and have friends who have worked on the new patient care records system. From what I have heard it has so far cost billions, is way over budget and significantly delayed. That doesn’t exactly give me confidence as a tax payer that these proposals will lead to a reduction in costs…

    If I’d had the opportunity I would not have voted for this.

  • Brian Edwards 20th Jul '10 - 10:07am

    The NHS does not need yet more reform, especially one which moves it even closer to the profit driven private sector. The NHS needs stability and appropriate funding. More emphasis needs to be focused on preventative measures especially food and air quality.

  • Brian Edwards wrote:

    “More emphasis needs to be focused on preventative measures especially food and air quality.”

    Indeed. At present, health promotion is a joint responsibility between PCTs and LAs. Some of these employ joint directors of public health, who try to do what they can with the very limited funding available. Now that the Area Based Grant has been cut by 24%, and the Performance Reward Grant has been snatched away, it seems unlikely that health promotion is going to amount to anything more than a few notices stuck up in canteens warning against the dangers of eating junk food.

  • This white paper is expensive nonsense which opens up the doors to privatisation, potentially at great cost to all of us except the rich. The last thing we need is another reorganisation – and if we did we should remove the purchaser provider divide to make things cheaper. We should certainly root out inefficiency, waste and poor quality as much as possible but we had got to the point when a few well chosen targets were delivering good secondary care to all. Within days of removing the 4 hour target a former student of mine waited 5 hours for a couple of stitches.

    Th one thing we needed to do was renegotiate the GP contract – quite simply that each GP has to offer a drop in centre open 9am to 9pm 7 days a week, themselves or in consortia but locally which could be defined reasonably well, where one can show up and be seen within a specified time (say 2 hours) as well as a certain number of appointments based on a need calculation related to cost and cover, in consortia or themselves, 9pm to 9am with a primary care service. This would immediately cut down the strain on hospitals and make health care much better because all could be seen relatively rapidly and get matters dealt with without hospital involvement or things getting out of hand and becoming dearer , as well as worse for the patient, in the end.

    Oh and lets have democratically elected health boards.

  • Karen,

    “a drop in centre open 9am to 9pm 7 days a week,”

    These places already exist, and they are known as POLYCLINICS. We were about to get a polyclinic in every part of London, until Andrew Lansley came along and scrapped Healthcare for London.

  • Paul McKeown 20th Jul '10 - 1:24pm

    @Jock

    Monetary “profit” is not necessarily a means to create efficiency. If the market in which “profit” is generated is monopolistic or monopsonistic or has other distortions then “profit” may be generated by becoming even less efficient.

  • Paul McKeown 20th Jul '10 - 1:37pm

    @Jock

    I’m not saying that introducing a profit motive into the NHS would necessarily be damaging, but it must be recognised that the interest of the overwhelming majority (99%) of the British public is in maintaining a quality health service free at the point of delivery to all citizens and residents is wrong. If profit seeking mechanisms are introduced, then there must be binding guarantees that the strongly expressed and supported rights of the public are not harmed.

  • Paul McKeown 20th Jul '10 - 1:39pm

    @Jock

    Sorry that should read:

    I’m not saying that introducing a profit motive into the NHS would necessarily be damaging, but it must be recognised that the interest of the overwhelming majority (99%) of the British public is in maintaining a quality health service free at the point of delivery to all citizens and residents. If profit seeking mechanisms are introduced, then there must be binding guarantees that the strongly expressed and supported wish of the public is not harmed.

  • mike cobley 20th Jul '10 - 2:04pm

    @JOCK
    Well, actually, no – the only body capable of enforcing universal coverage of the people’s wellbeing is…the democratically elected state. This is the aspect which privatiseers seldom mention but which irks them to the core, the undeserved (in their eyes) glamour which democracy has and continues to exert over the public at large, despite decades of corporate propaganda. Yes, we still know that it is our right to expect the state – our state, which we elect and which we fund and in which many of us work – to advance the wellbeing of ordinary people. This is an ethos of collective compassion, something that private sector companies do not have. What they DO have is their core function – maximise profit, minimise loss, which is not the kind of efficiency I want to see applied in the NHS.

  • Jock: You say (rather insultingly ) “I understand that modern “liberals” often have a problem with economic concepts” and then go on to show that you yourself have a major problem with economic concepts.

    To improve efficiency means getting the same output for less resource (or more output for the same resource). This definitely does not require a profit measure. It require good metrics and the appropriate incentives. Many private sector companies have efficiency programmes that do not involve a profit measure.

    In fact I do not know of any private sector company that operates an internal market to improve efficiency. That’s ideological cloud -cuckoo land. They improve efficiency through good management.

  • Peter Kellner has just circulated his comments on the political scene based on recent YouGov polls. Here is what he says:

    “Among those who voted Lib Dem on May 6, opinions are divided: just 40% approve of the coalition’s performance, while 36% disapprove. No wonder Lib Dem support has slumped since the coalition was formed. Indeed, of those who voted Lib Dem on May 6, just 46% would vote for the party if an election were held now, while 18% would vote Labour, 9% Conservative and 5% for other parties; 22% are ‘don’t knows’ or ‘won’t votes’.

    In past periods of Conservative rule, moods of anti-government protest often helped the Lib Dems as much as, and sometimes more than, Labour. The early signs from the current parliament are that Labour will be the overwhelming beneficiary if the coalition stumbles”.

    These polls were taken before Lansley published his NHS proposals. I suspect most LibDems will not support them and, if they are enacted, many will defect.
    Nick Clegg and LibDem MPs need to think very carefully about their response to these proposals and not just tag along.

    I think the best response is to propose a very tightly restricted geographic pilot with a review in three years time. This saves face, saves the coalition and saves the NHS.

  • mike cobley 20th Jul '10 - 7:40pm

    @jock

    “Your confidence is touching.” – sorry, you’d be wrong to think that I have confidence in the hamstrung, lobby-poisoned version of democracy that we are currently burdened with. But hey, have a giggle on me. Or a sob – that would be more appropriate to the de-democratisation now taking place.

    “As I said, even Marx knew that a free market was essential .. blah etc” – dont know why you’re quoting Marx, as I`m not a Marxist. I’m actually a critical rationaist, so watch yer step ;-)

    “After 60 years of the NHS why are some wards in Glasgow so far behind in life expectancy even than some of the bottom 10% of the South East’s wards that, excepting the scourge of AIDS, they would compare badly with parts of Africa?” – interesting comparative data, grim, you might say. But sorry to say, the poor health of Glasgow’s disadvantaged has really not very much to do with the NHS. ‘How come, Mikey?’ I hear you cry. Well – as a Glaswegian m’self, I can confirm that that poor health derives from social factors like income, expectations, family environment and, sad to admit, a certain laziness. Dont say that in a judgemental or from my high horse, but merely as a matter of observation. But that laziness and the adoption of lifestyle factors which drive down health come from the ultracommercial ambience in which we all live. Modern commodity capitalism depends on overconsumption, and the soup of advertising and product placement flatters us, feeds us blandishments, tellls how we’re worth it, how we can take control…..

    All I’m saying is, product/commodity advertising plays its part in screwing with our heads, and it is the heads of the poor who get screwed over the most. The poor, the disadvantaged, the trapped, the desperate – yeah, when life has been crap for a long while there isnt the money or the time or the understanding or the motivation to deny yourself crap (but tasty) food (and lets not forget that some crap foods are designed to be tasty). Yes, the NHS should maybe include more of an health outreach for these kinds of communities, but dont try to kid us that 60 years of the NHS or any health system could go toe to toe with the ruthless reach of advertising/marketing design. Only laws could restrict that, which is why we should have a better democracy.

  • Alun Griffiths 20th Jul '10 - 10:59pm

    I’m a GP and I don’t want it – and neither do most of the GPs I know. I suspect the only GPs who will want to get their hands on the money would be the last ones you would want to give it to. These proposals will destroy the NHS, but then that has been the plan for the last 20 years. I’m just sad that my party are helping the process along

  • donald cameron 20th Jul '10 - 11:08pm

    Alun
    As a patient, your comment worries me greatly. It is hard to believe that for such a radical change proposal, GPs were not consulted.

    My impression of my interaction with my own GP over the years is that there is a veil between Primary and Secondary care. GPs do not have very much information about what goes on in their hospitals and who is who. There does not seem to be very much personal contact and human interaction.

    Much that is important has come out on this blog and I hope that Dr Pugh will pay more than lip service to it. I, for one, would appreciate a short reaction from him about everything that has been said. What messages will he take away?

  • how about embracing the big society model, do it yourself operations, unemployed deputising for doctors, murdoch to oversee processes as he is going to be allowed everything else, turn all wards over to private patients so as to turn a few bob to pay off the defecit, and the death tax on the elderley can be collected by helping them by saving money and providing the opportunity for euthanasia. Far fetched? mmmm

  • Anthony Aloysius St 21st Jul '10 - 1:13am

    “Nick Clegg and LibDem MPs need to think very carefully about their response to these proposals and not just tag along. “

    As far as I understand, the proposals came from Andrew Lansley with Paul Burstow’s approval, and have already been agreed by the Lib Dems. It’s too late to “think carefully” about them.

  • Brian Edwards 21st Jul '10 - 10:06am

    PLEASE REMOVE ME FROM THIS MAILING

  • The funding for education and training of front line NHS staff is currently being slashed. This will result in patients being looked after by staff are not competent, or at best who have not been assessed to prove that they are competent.

    This will result in poorer patient experiences and when coupled with less staff available and increased bureaucracy for these staff, will have disastrous consequences.

    In direct answer to the questions:

    The NHS is being rapidly eradicated, so of course it is not ready for the “upheaval/reform”. I wonder if the patients, carers and relatives are ready!

    GPs will not cope. They do not have the insight required to effectively commission services out side of their remit. To do so, will remove them from the vast majority of patient contact. By the end of this Parliament only people who are willing and able to pay, will be able to see a GP.

    The citizen and the tax payer will not have the knowledge or energy to hold the providers or commissioners of their healthcare to account. They will, however, notice the poorer experience they have to endure. I wonder how many people want to hold on for 45 minutes whilst booking a GP appointment with a call centre based abroad.

    PCTs and Regional Health Authorities are far from perfect. They could be leaner, but without them front line services will be significantly worse. There will no be no education commissioning, workforce or succession planning and there was precious little to start with.

    Yes, progress is already being made, allbeit, in a haphazard fashion. There is a need to hold individuals on six figure salaries to account. Their poor decision making effect service users and low paid front line staff the most. All Trust boards should have patient and staff representatives on them.

  • Concerned – couldnt agree with you more. Fake profiteering and fake market structures are not needed – a rational decision-making, resource prioritising process is. And direct enhancement of the ethos of public service. Yes, public service – not dirty words, you know.

  • Ray Netherclift 22nd Jul '10 - 9:14pm

    What’s the rush? We have five years. Thehealth and education reorganisations are massive and should be piloted in one or two areas for a year or more to winkle out the unintended consequences.We don’t want US companies piling in and subverting the ethos and creaming off profits from tax payers money.Incidentally, I hope there has been a hell of a row behind the scenes about Michael Gove’s rushing his bill through Parliament. This is precisely what we used to complain about from Labour.I’ve been in the party since 1949. We’ve got a few more MPs now and i expect john Pugh and his back benchers to make the authentic Liberal voice heard,no matter what compromises have to be made at ministerial level.

  • Catherine Schade 23rd Jul '10 - 1:59pm

    I am very worried and sceptical about these proposed draconian changes to the NHS. This is a huge risky experiment whose benefits for patients are hard to see. My doctor’s surgery runs smoothly now, so why burden them with an enormous administration task they are not trained to take on? I envisage large private healthcare companies are rubbing their hands with glee, anticipating the huge profits they are about to reap.

  • The Labour Party in my view brought the NHS back from near extinction. So much of what was implemented has turned the service from a third world service into a world class service now. If this is the case now why change things too radically. I campaigned hard in Lincolnshire, Sleaford and North hykeham for the Liberal Democrats, and the conservatives came first by a lead of 10k. Not only did my family and friends, many who work for the NHS, vote Lib Dem they are now worried about there jobs as the axe falls on NHS spending. What do I tell my beleagered friends who listened to what I had to say. Don’t get me wrong I believe that Nick Clegg will do the right thing by us all and stay true to our cause I can’t however say I feel comfortable about the dilution of Libral Democrate policies by a conservative government. Please assure me that the NHS will continue to be built to further excellence, free at the point of need and not be foobbed of as an insurance policy.

  • oliver schick 29th Aug '10 - 12:22pm

    GET YOUR ACT TOGETHER! The Liberals face absolute wipe out if they continue supporting the Tory party health care changes. Taking away NHS Direct after also promising to removing Primary Health Care Trusts leaves absolutely nothing in the middle. Since Labour gave GP’s a massive pay rise and abolished their responsibilities for 24/7 care and availability, NHS Direct and Primary Health Care Trusts have been obliged to fill the gap. having a trained person at the end of a phone is a fantastic thing and in the context of the total budget, NHS Direct is cheap and probably effective in terms of the pressure it saves on A&E and Ambulance services which will now become a default option. None of this was in the coalition document . Stick to the plot. Money can be saved by charging drunks for their hospital usage, not taking away vital service links

  • Darren Reynolds 12th Oct '10 - 9:58pm

    Ah, wish I’d known about this page several months ago. The commitment to directly elected health boards is how we in Burnley expected to fulfil our pledge to the electorate to re-open our A&E and protect our children’s ward. We could do with that being stuck to, please.

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