I am a GP and Executive Member for Care and Health on Bristol City Council. I have been a GP for nearly 30 years, but I took on the Cabinet role on Tuesday 11th May 2010 – the day the astonishing Coalition was formed between Conservative and Liberal Democrat MPs in London.
That Coalition has made some bold proposals for our NHS, and for the way that the NHS works with patients, public health, and local authorities. These proposals drew together themes that Liberal Democrats have been campaigning on for many years such as putting patients at the heart of the NHS, focussing on improving outcomes rather than hitting targets and freeing professionals from bureaucracy and central control.
The NHS White Paper caused quite a stir, and it has been brilliant to be involved, both as a GP working with colleagues to ensure robust and accountable GP commissioning arrangements and as a councillor working with the local NHS, public health and patient groups to help develop a shared vision for future health services in the Bristol region. There are questions and concerns, but overall these reforms are going in the right direction and command significant and sometimes unexpected support, based as they are on work done by successive Governments of different political hues.
The Government has now published their response to the White Paper consultation entitled “Liberating the NHS: legislative Framework and Next Steps” and the fingerprints of Liberal Democrat policy and the input of Liberal Democrat Health Minister, Paul Burstow, are clear for all to see!
An NHS based on principles of freedom, fairness and local decision accountability. An NHS that does not regard the status quo as satisfactory, but wants more responsive, improved services for our patients and one that is on a sustainable financial footing. I accept that under Labour, the spending on the NHS is now on a par with spending in European countries, but the red tape and central bureaucracy has meant we don’t yet have the best European standards of care. We can do better.
It is good to see some specific Liberal Democratic policies confirmed in this response.
(1) An extension of councils’ formal scrutiny powers to cover ALL NHS funded services, including public services, private services and voluntary sector services. All providers will be accountable and need to provide information or attend scrutiny meetings to explain themselves.
(2) An enhanced role for Local Authorities, leading with elected members, to deliver improved strategic coordination of commissioning across NHS, social care, and related childrens’ and public health services. What an opportunity for truly joined up thinking!
(3) Development of patient input and involvement by building on the work of the LINks (local involvement networks) and supporting Health Watch to become the local consumer champion for patients.
(4) Freedom to commission services from “any willing provider” – we need the flexibility and choice to deliver the best services to patients at the best price and quality and that may come from third sector or private providers as well as NHS providers.
We have the resources, the organisations, the hospitals, the practices and above all the people to make these reforms one of the most positive landmarks of this Coalition Government. These are challenging times, but we must not be afraid to be bold and decisive and make it happen.
Cllr Dr Jon Rogers represents Ashley Ward on Bristol City Council, and is on twitter.
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51 Comments
Well said, Jon.
Now brace yourself for the firestorm!
1. you are a GP and have a clear financial interest in this decision.
2. Labour increased spending on NHS this coalition will reduce it
3. While you may well be right about the inefficiencies and over centralised nature of the NHS is another upheaval really a good idea at a time of financial cutbacks?
4. Personally i see this as the privatisation of the NHS. and institution GPs opposed like mad because they were happier getting cash out of poorly people back in the good old days.
interesting comments, jon. I wonder what your views are of the abolition of NICE’s role in regulating which drugs will be paid for by taxation? It strikes me that this will mean that drug companies will be th eonly peolpe telling Gps whether drugs are good value for money , and they can hardly be trusted to be impartial!
Also, how accountable are GPs anyway? If they are in area-based consortia in which each GP follows the same commissioning rules, if i don’t like the fact that my own GP won’t buy hugely expensive caner-treating drugs, what feeedom will i have to go to one that does?
And how are GPs liberated from bureaucracy if they are expected to be chief executives of their own mini-PCTs? it strikes me that the proposals drown GPs in bureaucracy by asking them to do all of it!
Very O/T (but I don’t see any post addressing the issue here at the moment) but can LDV note the Lib Dems are up for some very full on lovebombing from Labour soon. It should really be a fun experience.
Ever since Ed Miliband declared David Cameron couldn’t understand working people because the overwhelming reason that “he’s a Tory”, we’ve had posts on LibCon from the egregious Bob Piper of Sandwell threatening Lib Dems that they’d better wake up to fact they’re just “progressives”, “Labour Lites”, “Labour over the water” or whatever, else he’ll call them Tory scum from his high horse, and Mehdi Hasan on the New Statesman saying that the Coalition is just a Tory Government and surely all Lib Dems want to scurry into the loving arms of Labour.
It’s all imbued with the perverse pathological Tory-hating of people who can’t see that Labour could do anything other than right, completely lacking any understanding as to why the warm glow of hating Tories wouldn’t trump getting the country on track and abandoning the welfarist policies of those who seek to bribe the poor to stay in their place. This is before I get onto civil liberties or foreign excursions.
I can only assume there has been some command from Victoria Street to lovebomb the Lib Dems into submission.
Mods: you may wish to delete this comment and write a new post on the subject.
Good post Jon. Short of merging PCTs into local authorities (which would be my own preferred NHS structure, but I realise is now dreadfully old-fashioned!) I think this is probably the best structure on offer to bring the NHS closer to citizens.
@david clayton – Spending on the NHS is going up over the CSR period. Labour, on the other hand, would not commit to saying that the NHS budget was protected, and implied it should be cut to protect other areas.
@david clayton: 1. you are a GP and have a clear financial interest in this decision.
Not that this worthy consideration has ever stopped Lib Dem schools policy being dominated by teachers and councillors… đ
Seriously, it would be a bit strange for us as a party to object to GP commissioning given that we spent most of the Labour years saying that more decisions in the NHS should be in the hands of professionals, not bureaucrats setting targets.
What I would still like to know is will the GP consortia compete with one another (i.e. will surgeries in Bristol be able to be a member of different consortia) or will they be geographical monopolies like Primary Care Trusts? Competition would improve the accountability of the system to patients, and provide a complement to the enhanced role of elected local councillors.
@Dominic Curran: Are they really abolishing NICE’s key role? Where can I read more about this – it would be very silly given that NICE has helped to prevent the NHS’s extra funds being sucked into expensive drugs rather than more care (though of course most of the extra spending did go on increasing wages rather than employing more people…).
I am no expert on these matters but it is safe to say that I’m very uneasy about this, having had almost continuous treatment for the last 18 years I have seen a great improvement to my local hospital over the last decade and hope whatever ‘improvements’ are made it won’t be a case of ‘throwing the baby out with the bathwater’.
What I would still like to know is will the GP consortia compete with one another (i.e. will surgeries in Bristol be able to be a member of different consortia) or will they be geographical monopolies like Primary Care Trusts?
What I want to know is why they are abolishing the PCTs rather than allow them to compete with the consortia to act as commissioners? If they are inadequate, they will be outcompeted over time anyway.
I don’t like applying a dramatic shock to a complex system if I can avoid it – it tends to produce unintended consequences.
Freedom to commission services from âany willing providerâ â we need the flexibility and choice to deliver the best services to patients at the best price and quality and that may come from third sector or private providers as well as NHS providers.
Won’t most of the available providers be owned by the NHS anyway? Perhaps it should be forced to sell off a lot of hospitals etc by the competition authorities.
Your coalition partners have never liked the NHS, are the Lib Dems finally going to grow some backbone?
Targets are being changed, it’s a complete charade to pretend that targets won’t need to be hit, that’s how performance is measured, the removal of ambulance time targets is most concerning, there’s nothing wrong with that target.
There’s no need for competition within the NHS, however it will go some way to the goal of some Tories of a two tier and partially privatised NHS, this won’t end well.
@Anthony: Currently private hospitals largely treat customers who pay either out of pocket or from expensive private medical insurance (often a given as a perk to top people in companies and the public sector). What’s wrong with bringing them into the NHS so that more of their patients will be people who can’t afford private healthcare?
We have a two-tier system at the moment, just as we do with schools. Radical education reformers often advocate subsuming independent schools into the state system to end the segregation between private and state school pupils, but it’s not practical because private school fees have ballooned to levels much higher than public spending per pupil. With healthcare that is not the case, so paying private hospitals to do operations (for example) is a realistic idea. This has been done successfully in Sweden, hardly a right-wing country. What’s radical about keeping private hospitals exclusively for the rich?
@Niklas Smith, I have no objection to private healthcare, it’s an option already, I thought we already did use hospitals outside of the NHS and outside of the local authorities, there were reports of people being sent to France for treatment in the past, where it becomes a problem is when you have competition for these options, we really don’t need Tesco to start running hospitals.
Various people have raised the issue that GP’s are not NHS employees but (in the main) private businesses.
I would be far happier if these proposals made all GP’s employed prior to giving them the purse strings. This would take away both the opportunity to use the changes to make more moeny for their business and the appearance of them doing so.
The only thing I do not understand is.
The Government do not trust G.P’s enough, to decide who is, and who is not, capable of work, and who should, or should not be entitled to sickness benefits.
And instead the government contracts out a Half a Billion Contract to Atos an IT company to carry out Work capability Tests, Medical Assessments, Note {Not a Medical Examination} to asses someone’s capability of work.
And yet they can trust G.P’s with Billions of Pounds, to decide on how the NHS budgets are used in their area’s.
That makes little sense to me
@matt
“The Government do not trust G.Pâs enough, to decide who is, and who is not, capable of work”
That’s because very few of them are qualified to do so. GP’s are general practitioners and (not in any way seeking to demean their considerable skills) cannot be expected to be specialists in all areas they signpost people onwards when a specialist is required. In terms of workplace health this is those who hold suitable qualifications from the Faculty of Occupational Medicine.
GP’s are excellent advocates of individual patients precisely because they do know where their skills lie and when to pass people on to other specialities. It’s not the signposting and commisioning which worries me, rather the fact that they are at arms length from the health service.
These Thatcherite reforms could cost up to ÂŁ3 Billion and are going to be catastrophic, not just for the NHS, but for those seen to approve and cheer them on. Any Liberal Democrat MP with a modicum of common sense will distance themselves immediately from them.
“At the heart of the change is the shift of ÂŁ80bn of taxpayers’ money into the hands of England’s 35,000 family doctors who operate as essentially private businesses. Lansley admitted that he had conducted no surveys of GPs before launching the white paper â despite outright opposition from four in 10 doctors.”
“Robert Creighton, chief executive of NHS Ealing, who is taking over his neighbouring Hillingdon and Hounslow primary care trusts, told a meeting last week that the reorganisations could become “a bloody awful train crash”.”
It’s also obvious that a GP would have inifinitely more experience with medical assessments than a medically unqualified box ticker from ATOS who is paid to disqualify as many disabled people as possible.
@Steve Way
The problem with Atos though, the health care professionals that they employ to carry out the medical assessments are not specialists either.
These people carry out assessments on Mental health patients, with No mental health qualifications whatsoever.
They only receive 12 weeks training.
This was highlighted in the Professor Harrington review on ATOS and the work capability Test
http://www.dwp.gov.uk/docs/wca-review-2010.pdf
unless someone has actually had first hand experience with an Atos Medical Assessment, it is difficult for them understand what it is like.
Most people would assume that it would be carried out by someone who specialises in the field of the patients illness, but this is not the case at all.
People would also assume that the assessment would entail a pretty lengthy medical examination as well, but this is also not the case. The average appointment lasts 45 minutes, and only 2 minutes of this would involve physical examinations.
The health care professionals use computer software called LIMA {Logic Integrated Medical Assessment} which was designed by ATOS
The health care professional spends almost the entire assessment asking a series of questions from which the patient is seriously limited into giving a detailed answer, The health care professional then has a tick box selection to chose from.
The computer software does not take into account personal difficulties, good or bad days e.t.c, and based upon the answers given the software is designed to make an assessment on someone’s capabilities.
An example of this is a question which asks, Are you able to load or unload a washing machine.
If the patient answers yes, the software automatically assumes that the patient has no problem with bending or kneeling. Obviously this is a totally unfair assumption as a computer programme is totally incapable of taking into account individual circumstances.
I have accompanied my father on numerous Atos Medicals and so have first hand experience with how these assessments are done. It really is shocking, and that is why I am so sympathetic towards those on sickness related benefits, as I see what they go through and how they are made to feel.
Anyway, apologies as my post has kind of gone of topic. But my point was, if we can trust G.P’s with the NHS budget, then we can trust G.P’s to decide which of their patients are fit or unfit for work
@matt
I don’t disagree regarding the ATOS assessments but they’re not involved in this issue. Although I also believe that GP’s are not the best placed people to ascertain what work an individual can do as they are then put in a position that compromises their role as patients advocate.
The other big problem with the ATOS assessments is they are a closed system. They do not follow the individual through to ensure their assessment is correct, there is no attempt to ensure they get appropriate work and then (and only then) reduce any associated benefits.
There is no doubt those who can work and are able to work see health benefits. But for those who need significant adjustments, the role of occupational health is not limited to an initial assessment but is a long term support mechanism to ensure their workplace health and wellbeing.
Back on topic though, GP’s can commision care as generally they are the ones who refer the patient for the care, but I do have concerns.
@ David Clayton.
You comment that Labour increased spending on the NHS as if that was an end in itself. This is typical of the mistakes that Labour made whilst in power. Much of the spending went in increasing salaries for consultants and GPs without securing an improvement in outcomes for patients.
Morning
Thanks for all the comments. They raise a number of themes.
(1) Probity
I think these new governance arrangements, and the improved powers of council elected members to scrutinise will reduce, but not eliminate vested interests. GPs have always been very powerful determinants of what services are “micro-commissioned” for patients through the referral process. Over the last 20 years, first with fundholding, then with locality commissioning arrangements and so on, GPs have started to take responsibility for the “macro-commissioning” of services. GP involvement must be scrutinised, but my overwhelming impression of local GP involvement is that the motives are about ensuring our patients have good quality, locally accessible services in an appropriate timeframe. All GPs now practising learnt at University of the impact of poverty, of housing, of smoking, of education, of environment as well as medicines and operations and hospitals on our patient’s health and I do believe we want to work with others to really improve our nations health.
(2) Geography
In the Bristol region, it seems likely that GP commissioning groups will be geographically based, and coterminous with the three local authorities. The emerging model, which is still being consulted on, has the three groups in Bristol, linking with the two groups in North Somerset and the one group that covers South Gloucester. These 6 GP commissioning groups each cover between 100,000 and 200,000 patients, and the total population of the three unitary authorities is perhaps 850,000 and could allow significant commissioning clout.
Worth talking to your local GPs and councillors to find out what shape is emerging in your area.
(3) Competition
There is the provider side, where the “any willing provider” will allow a range of public, private and third sector to offer health services at NHS standards, and at prices that the NHS is willing to pay. I think that is understood and really continues to build on what is already there, though it should stop private providers overcharging which Labour seemed to condone.
There are also questions about the balance between having sufficient “purchasing clout” but still offering choices in commissioning arrangements. Dominic Curran alludes to this in his question on expensive cancer drugs, and it is also tied in with NICE becoming guidance rather than regulation in terms of drug services. I don’t have all the answers, but do believe that a combination of interested GPs, managers, hospital specialists, health professionals, local councillors, public health teams and patient groups can make a good attempt at progressing. Certainly GPs will not just “listen to drug companies”! I think in the future there will be a much greater interest in “care pathways” which track the optimum management for someone with a symptom, risk factor or condition.
(4) GP Interest?
It has been said that many GPs are not interested in budgets and commissioning. I totally agree! I suspect that less than 10% of GPs want to have involvement in the “macro-commissioning”. The other 90% will generally be happy that their colleagues are taking it on.
This is a huge topic, and I feel very lucky to be watching and helping things develop from different prespectives. I am also verygrateful for all the work Paul Burstow is doing. I have attended some of his meetings, heard some of his speeches and joined in on some of his telephone conferences, and it is a truly great experience to feel part of government and have a real sense that views from the grass roots are considered important.
The idea that the NHS and Social Care in our Bristol region may finally be trusted with deciding how we should operate without the heavy hand of Whitehall bureaucracy is something that gets me springing out of my bed in the morning!
John.
A rather biased party political broadcast in my opinion.
For balance – my wife is a GP. In her words: “This is tantamount to privatisation, will cost ÂŁ3bn for little return and will elevate a minority of GP Partners who are in the profession to make as much money as humanly possible to untold influence and earnings potential”.
This will destroy the principle of the NHS. There is no serious professional who counters that. That the Lib Dems seem now to be willing to support this, on top of fees and the backtracking on control orders – as well as the approach to the OE+S by-election (which has been to get the Tories to basically give it up) in my opinion eradicates Clegg’s argument that multi-party governments work. They don’t. They allow the majority partner a bigger majority to force through legislation that normal parliamentary scrutiny would prevent.
@Cuse – and you accused Jon of a biased broadcast! Given your well known hostility to everything the coalition is doing your response is not a surprise.
@Jon Rogers
Thanks for answering queries asked, a welcome event when it happens!
My main point was not answered though, and that is the fact that GP’s are in effect private companies. What safeguards are being put in place to ensure no individual benefits from these changes.
For example could the commisioning bodies (made up of GP’s) be forced to be established as not for profit organisations. Payments for the time GP’s input into the process could then be provided at cost to their partnerships to enable locum cover etc ?
Or do GP’s expect to make profit from the arrangements?
Or do you have a third way not covered ?
There are also numerous functions provided by PCT’s that do not easily fit the proposed model. For example Health Visitors. In my area they are wary of being “owned” by GP’s as they believe there will be moves to broaden their remit (potentially up to 18years old) and to lesson the amount of time, and therefore impact, they can have with patients.
@cuse – your wife has a very jaundiced view of her profession.
It is not privatisation. It is passing power from a national bureaucracy to locally accountable organisations. The commissioning arrangements will be transparent and can be fully scrutinised by elected members through the bold new powers given to scrutiny.
As for “destroy the principle of the NHS“. My understanding is that there are three guiding principles of the NHS…
(a) That it meet the needs of everyone
(b) That it be free at the point of delivery
(c) That it be based on clinical need, not ability to pay
In what way are any of these principles threatened, let alone destroyed?
I can see you don’t like coalitions – my impression is that they have worked well on UK councils, across Europe and in times of war. My view is that our new Coalition Government is a significant improvement on Labour that it replaced and a minority Conservative Government that was the alternative.
@Steve Way Thanks for the clarification.
As you say, General Practices generally are small businesses, with GPs being either partners of salaried employees of that small business. That has been the case since the NHS was formed in 1948.
The strategic commissioning role will need to remain independent of those practices. That will need to be done and seen to be done. The RCGP is concerned that GPs being involved in strategic commissioning of health services may tarnish or undermine their independent patient advocate role.
The funding of GPs involved in commissioning will need to be commensurate with any work done. Current arrangements include payments for preparing for and attending meetings, or honorarium or practice based payments. I am sure there are other models of remuneration, but in my experience, GPs involved in commissioning in Bristol are not in it for the money! They are in it to try and ensure patients get great NHS services.
The scrutiny function will be an important safeguard against any possible rogue activity.
Your second point is about what functions the PCT will pass to GP commissioners and which will go to Public Health or perhaps some regional or national organisations. That is another huge question, and clearly the subject of much active discussion. There also remain questions for me about how will we all deal with failing practices or failing hospitals – these are knotty problems, that have no easy solutions!
“Equity & Excellence” is half-baked. Neither Lansley, nor anyone else involved, it seems, thought their proposals through before committing them to writing.
What exactly is GP commissioning, and what would it look like? We really don’t know, do we? To my knowledge, it has never been tried in this country, at least not since the NHS was set up. The role of GPs, up until now, has been to treat patients, not to commission services. After all, that’s what they are trained to do. The much-sneered-at bureaucrats who work for PCTs, on the other hand, they may not be physcians, but they do have specialist skills in commissioning.
In my area, the GPs have set up a commissioning body which they propose to convert into a shadow organisation next April. Some of those most involved have been forced to step back, because they have found the process intensely time-consuming, and one or two have been “burned out”, I am told. What effect is this having on patients? And this is before the GP commissioning even starts!
It seems inevitable to me that GP commissioning will go down one of two routes: (1) pass over the local aurhotities, (2) contract out to the private sector. Like Councillor Mark Wright, I have no problem with the first of these, indeed I would very much welcome it. There are local government officers who currently commission services for older people, and some are jointly funded by PCTs. But will Pickles allow it to happen? Clearly, Lansley’s intention is that the commissioning is done by his friends in the private sector, with the ultimate aim of privatising primary care (in addition to rich Tories making lots of money).
We still don’t know who is going to monitor GPs’ performance. GPs’ can’t do this themselves, for obvious reasons. The Chief Executive of my local PCT once declared on a public occasion that “many of the GPs (in this area) are rubbish”. Would a GP ever say that about his collegues and live to tell the tale?
I have no problem with health promotion falling wholly within the remit of LAs. Some Directors of Public Health are already jointly funded.
As for scrutiny, some LAs already do scrutinise the health service, and I for one have seen a lot of very good work done. But will this continue? Scrutiny officers, who are paid around ÂŁ40,000 pa on average, and who perform non-statutory functions, are likely to be first in line for the chop when Cameron’s policy of hollowing out the public sector and pumping up the dole queues is implemented in local government as of next April. Scrutiny will be dumped on to Committee Services managers who lack the time and sometimes skills to research their subejcts.
BTW, if Lansley really cares about the NHS, why is he so hostile to polyclinics? Is it perhaps because polyclinics are less easy to stealth privatise than small GP practices?
Oh, and before I forget. If Lansley gets his way, the dreaded PCT bureacrats will shortly be reincarnated as privatised GP commissioners, on even higher salaries and with even less accountability.
@Jon Rogers
Thank you for the article.
I have limited knowledge of how the NHS works, and therefore limited knowledge of the implications of these reforms, but I’ve been very concerned about them.
My main worries are:
(a) that such a massive reorganisation seems to be happening too fast – I prefer evolution to revolution.
(b) that it’s not been properly explained.
Your post at least starts to address the second concern.
@Sesenco asks, “What exactly is GP commissioning, and what would it look like? We really donât know, do we?”
GPs have been involved in commissioning since 1990, when the purchaser/provider split was first introduced, in the deeply divisive guise of “Fundholding”. My practice was one of 11 practices in North West Bristol who fought vehemently against Fundholding, which had no external accountability and only dealt with a minority of specialties in an intensely bureaucratic way.
In 1990, our 11 practices formed the NW Bristol Locality Commissioning Group, which worked together, sharing information about the ways we looked after patients, and the services they needed. We even appointed an Information Manager, Chris Mackintosh, who collated our information and helped us understand how we could get more for our patients by changing the way we referred, prescribed and managed the services available to us. By 1996 we were preparing to become a Total Purchasing Pilot, working with the Primary Care Trust and our local NHS hospitals to decide on the best care pathways.
When Labour won in 1997 we fully expected our model and others similar across the country to develop, but the Treasury and the Department of Health had other centralist ideas. We were told we were moving too fast and that we needed to wait until other areas had caught up. We were slowly dumbed down, to deliver the government’s centrally driven targets. The government announced it’s ill fated “Information for Health” IT scheme, which has wasted billions and set back the local systems, local cooperation and local innovation by over a decade.
So, all that is happening now is that we are picking up where many of us were in 1997. We have learnt lessons from the last 13 years, but mostly that it doesn’t matter how much taxpayers money you put into the NHS if you don’t start with the end in mind, patient care and patient services, it will be largely wasted.
The commissioning discussions in and around Bristol are positive, constructive and challenging. We are being supported by enlightened managers from the PCT, strong health professionals of all flavours, local authorities with vision of what is possible, and public health teams who relish the prospect of working locally for local people.
George Kendall raises the worry that “such a massive reorganisation seems to be happening too fast â I prefer evolution to revolution.”
I can understand that viewpoint, but as I have hinted in my last comment, this is not quite such a major change as some are making out. The speed should be dictated by local circumstances, but the dinosaurs should not be allowed to stop progress. It is a balance, and these reforms do seem to allow those that want to push ahead to do so, but also allow others a slower pace.
The real risk to me is the Treasury and the Civil Servants. They have never liked letting go! Liberal Democrat and Conservative Government Ministers are stating repeatedly that the Localism Bill will do what it says and that the NHS Bill will do what it says. Previous governments have said the same thing, so the proof of the pudding will very much be in the eating.
@Sesenco suggests, “It seems inevitable to me that GP commissioning will go down one of two routes: (1) pass over the local aurhotities, (2) contract out to the private sector.”
I agree that (1) is possible where GPs don’t take it on, but with (3) GP commissioning as in Bristol City region, there will be very close links with the Local Authority.
It occurs to me that option “(1) Local Authorities” is really the default Lib Dem option and perhaps option “(2) Privatised” is the default Conservative option. Option “(3) GP Commissioning” is a Coalition idea. (3) has echoes of Labour and it’s “primary care led NHS”, but Labour has always been scared to let go from the centre.
@Sesenco also asks “We still donât know who is going to monitor GPsâ performance. GPsâ canât do this themselves, for obvious reasons. The Chief Executive of my local PCT once declared on a public occasion that âmany of the GPs (in this area) are rubbishâ. Would a GP ever say that about his collegues and live to tell the tale?”
PCTs currently do a lot with monitoring GP performance. In fact it is often GPs, employed by the PCT, or by the GMC or by the Protection Societies who do the montoring role.
As a GP, my performance is annually monitored as part of my compulsory appraisal and the performance of my practice is monitored by the PCT and the GP commissioning group (certainly in respect of my practice prescribing and my practice referrals and use of secondary care services.
There are well established “whistle blowing” processes, where poorly performing GPs can be more intensively investigated, supported or even prevented from practising.
There are questions how this will continue to work once PCTs are disbanded. There are lots of discussions still to be had about the functions of each of these new 21st century organisations!
And returning to your comment, “âEquity & Excellenceâ is half-baked”
Is that a bad thing? For years we have had to try and digest “fully baked but poorly designed pies” handed down from on high. Now we are making some of the rules with structures, working arrangements, teams etc, etc being decided locally.
I like it!
@jon rogers
you say the additional spending on the NHS has been “largely wasted”….
on what?
Dear Jon
I can’t say I’m an expert on the issues being discussed but just to say your optimism and exemplary good manners in answering queries from both friend and foe deserves applause.
Thanks
Joe picks me up on my statement that “the additional spending on the NHS has been âlargely wasted””
That is probably me overstating it!
As I said more calmly in my original article, “the spending on the NHS is now on a par with spending in European countries, but the red tape and central bureaucracy has meant we donât yet have the best European standards of care. We can do better.”
So much of the additional money has gone to develop systems and departments to count things. Managers, IT systems, centrally and locally cost money. The money spent on Information for Health, trying to develop a single monolithic information system, rather than simply letting local areas develop systems to meet their needs and define data standards for the relatively small amount of information that needs to be passed to others.
Another cost has been the duplication of services – GP services, walk in services, out of hours services, minor injury services, NHS Direct – rather than saying “we want accessible and appropriate services 24/7 – how should we organise that?” the last government introduced a whole raft of overlapping new services. We have had massive private services paid for by top sliced funds which are poorly used. We have had strange systems like “choose and book” which make it quite complicated for people to get appointments and add to the bureaucracy.
Of course some of these developments have given benefits to some, but the extra spent on the NHS has not delivered the benefits that it should.
thanks for the response, I really hate Daily Mail style “all new NHS money wasted” laziness.
to clarify further which of the “GP services, walk in services, out of hours services, minor injury services, NHS Direct” do you think we could do without? It’s just that having used all of them in the last few years (as I am sure everyone with children will have done) I certainly don’t regard them as a duplication. They offer different solutions to different health situations – and mean that many trips to A&E have been avoided!
If you go back 15 or 20 years, your own GP and GP practice answered all those calls and A&E was used generally for emergencies.
Now the attendance at A&E, 999 calls and out of hours calls have gone up significantly despite walk-in centres and NHS Direct, People are expecting a 24 hour service often for trivial and non-life threatening conditions. It has changed behaviour, but not necessarily to any long term health benefit. Either way the new services cost a lot more than the old ones.
GPs lost that 24 hour responsibility and PCTs took over that responsibility 6 or 7 years ago, see this BBC report from 2003 about the rise in complaints as GPs lost that responsibility and passed it to COOPs and OOH services http://news.bbc.co.uk/1/hi/health/3104324.stm
@Jon Rogers, thank you for all the replies, I’ll be honest, I’m deeply suspicious, Tories and NHS do not go, they do not like it, they never have liked it. However the proof will be in the pudding and if the end result is a better NHS, then that’s good all round.
I completely agree that Labour’s improved money did not get all the results it should, although it’s undoubtedly a lot better than it was, there has been a hell of a lot of waste, the flip side is cutting without thinking about it, to cut without a plan is as bad, if not worse, worse than spending without a plan.
Jon.
I note that you prefer to criticise my wife – accusing her of being jaundiced – rather than answer her points. You certainly stimulated animated debate over dinner last night!!!
I also note however, that you failed to answer the substantive points.
1 This is privatisation by the back door. You state that commissioning via LAs is the “Lib Dem” option; privatisation the Tory. How does the legislation seek to prevent commissioning bodies outsourcing all operations to private companies? How does it seek to limit the amount of private input into the scheme?
2 Where in the legislation does it state that bodies cannot or could not charge at the point of delivery? As budgets shrink (ÂŁ20bn of savings within 4 years) is this banned?
3 You claim she has a jaundiced view of GPs. Are you claiming that large numbers of GPs will not end up making significant amounts of money from this programme ? I could name 10 surgeries in my wife’s PCT where the GP partners have publically talked (in the consortia consultations) expect to increase their incomes by significant amounts.
4 How do you justify spending ÂŁ3bn on a re-organisation when the NHS budget is being ‘cut’ in real-terms?
5 Now that waiting lists are lengthening – how do you defend the scrapping of targets – especially considering that actual patient satisfaction with the NHS is at a notable high level?
6 At what point did GPs become consumer champions – which is the intended purpose of this scheme, in the words of both Lansley himself and Oliver Letwin?
7 The consortium constructed will in many ways resemble PCTs – just at a lower organisational level and after the aforementioned ÂŁ3bn spend. What is the purpose in this?
8 Huge Managed Service providers such as Atos, Logica + Capita are positioned to take billions of public money to run these organisations. Can you justify this pouring of public money into private hands?
9 You mention scrutiny as if it will transform outcomes. Can you explain please? The NHS is the most scrutinised public service in the world at present. How will that increase?
10 I agree with the point regarding duplication of services. But you have singularly failed to address the biggest problem of all to patients this scheme will create – treatment in ‘postcode lottery’ terms. How does this scheme prevent this?
Your experience allows you to wax lyrical about the NHS and how wonderful the Coalition is, but in my opinion you seem not to fully understand the ramifications of this latest personal legacy being created by Andrew Lansley. Indeed your comment to Sesenco claiming that it being half-baked is great – terrifies me. The NHS is not a pet-entrepreneurial project where risk should be rewarded and political careers indulged. It is a lifeline for millions of people. I am shocked by your cavalier attitude, as are the Doctors and clinicians I had dinner with last night.
When it comes down to it, it’s the basic questions that the public want to know, how long will an ambulance take to reach me? how long will will I have to wait for an appointment to see a GP? and how long will I have to wait for an operation? oh, and will I have to pay anything?
The public do not care how the NHS is structured, they only care about improved services, over the past decade without a doubt the service has improved, for instance in the early 90s I waited for an operation for 19 months, now the wait is on average 4 months, will these reforms improve the waiting times further for those without private health care? somehow I doubt it with the Tories running the show.
@Jon Rogers “I suspect that less than 10% of GPs want to have involvement in the âmacro-commissioningâ. The other 90% will generally be happy that their colleagues are taking it on.”
That worries me. In some parts of the country, that may work superbly. But in others, the 10% who want to be involved in macro-commissioning may not be the best people to do it. We could end up with strong characters who force through very undesirable policies. I’d find it more reassuring if all GPs wanted to be involved, and there was an election among them for who they thought was best suited to the role.
“it is also tied in with NICE becoming guidance rather than regulation in terms of drug services.”
This also worries me. With the NHS budget no longer increasing, there’s going to be an increasing need to restrict access to very expensive drugs.
At present, NICE is the bad guy, who GPs can blame for refusing access to a drug which provides poor value for money.
Without NICE, surely, GPs will be under intense pressure to prescribe to the articulate and sharp-elbowed, and not prescribe to those who are conciliatory and lacking in confidence. Drugs for conditions with powerful lobby groups will be prescribed, and those for less powerful groups will be neglected.
@nige “will these reforms improve the waiting times further”
I doubt it. Labour doubled spending on the NHS, but at the last election Labour acknowledge that the financial siutation meant they couldn’t promise increased spending on the NHS.
Demand for health will continue to rise, as the population ages and new treatments and drugs are intoduced. Just increasing NHS spending by inflation is going to feel like a massive cut.
@Cuse
To be fair to Jon Rogers, your medical friends didn’t have Jon there to explain his point of view. Maybe you invite him to your next dinner party đ
so what happens if this is a disaster for the health service which will no longer be national.
@GeorgeKendall.
I 100% agree with the points of concern you raise.
There are far, far too many unanswered questions about Lansley’s pet project that will just be thrown over the wall to local consortia who will be told “that’s your problem”.
The problem with that – is that it will become the patient’s problem.
I spend my life analysing outcomes metrics and the only organisations which will benefit froms these proposals are Aetna, Tribal and their like. Jon where is the capacity for commissioning – just think about it?
This is a truly perverse proposal, look at the work of Jarman and my writing partner Professor Simon Jones to see how this is economic folly of the highest order. Professor Carol Propper at Imperial lives in Bristol contact her get a qualified opinion.
@ Jon Rogers
I don’t know what a COOP or a OOH is?
I do know that you didn’t answer my question. And you appear to be blaming patients for advice on “trivial and non-life threatening conditions”. The problem is that us patients haven’t had 7 years training and therefore don’t know if it is a “trivial and non-life threatening condition” until we get advice!
Has there been any independent analysis of the new services, how effective they are etc?
@Cuse
While I am pretty concerned about the health reforms (which may surprise you, as you know I’m a coalition supporter), I haven’t made up my mind to oppose them (which probably won’t surprise you!).
@Jon Rogers
While I’ve asked some critical questions of the reform, but I’d just like to thank you for the effort you’ve put into answering questions in this thread. It’s really appreciated.
And it’s not wasted time. While I have real concerns, I’m not opposed in principle to the changes, and I’ve been very interested in what you’ve written. I’m sure I’m not the only one.
Phew! Lots of comments – thank you all!
@Anthony remains “…deeply suspicious, Tories and NHS do not go…” – I think it is right to remain suspicious, and watch carefully how things develop locally. This is a risk with “Localism” as opposed to the central “command and control” that we are used to in the UK. Under the influence of the Liberal Democrats, this current Coalition Government seem unlike my idea of a “Tory Government” in many ways (ID cards, detention without trial, asylum children, prison reform, Heathrow runway, etc, etc) but as others have said, “proof of pudding…”
Apologies to @cuse’s wife! Glad the dinner party was lively! I speak as I find, and my knowledge of the Bristol GPs directly involved (perhaps 10%) and those supporting those directly involved (perhaps another 60%) are doing it not to line their own pockets, but to try and deliver a top quality NHS service for their patients. Even those (perhaps remaining 30%) who have no direct interest in commissioning are not hostile in the Bristol region, but like all GPs want to be able to deliver high quality, locally accessible services that meet their patient’s needs.
Local GPs, local authorities, local hospitals, local public health and local NHS organisations have no interest in “privatisation by the back door“. If that is the case in your area, then sort it locally. I am sure that a majority of GPs, a majority of councillors and of course a majority of patients would not support it. If your area is poised to place millions in the hands of “Atos, Logica + Capita ” then I suggest you get mobilising with your local allies. I can see no benefit of going down that route in Bristol.
You make a number of other good points about scrapping targets, GPs as local consumer champions, similarity between future arrangements and current PCT, post code lotteries, etc – I believe these changes will allow local services to become more responsive, freed of central bureaucracy, with all key players, including patients, working closely together.
The Coalition is producing a Framework, where outcomes matter more than targets, and local influence is stronger than national. That is a major, radical change in ethos, but the building blocks are already there, they just need reconfiguring in a slightly different way. There are risks. Some areas may not embrace the opportunities, and prefer to wait for the Government to produce a fully baked hard wired blueprint as to how the local area must do it. I hope that will not happen! The NHS has been led from London for far too long, with so many of their centralised schemes imposed on local areas with no thought as to whether there are better local alternatives.
@George Kendall says “In some parts of the country, that may work superbly. But in others, the 10% who want to be involved in macro-commissioning may not be the best people to do it.” – That is why we need to wake up all areas of the country to look carefully at what is proposed locally. I have great confidence that the reform agenda is being carefully addressed in Bristol by all parties. Other areas may not be used to the idea of self-determination, but I am sure that the right people are in every area, and it is our job as politically interested individuals to make sure they have our support and encouragement to do the right thing.
The lead commissioning GPs in Bristol were elected by their peers, in competitive elections. This happened BEFORE the General Election as we were already heading in this direction.
@Bryan asks, “Jon where is the capacity for commissioning“? It is already there – just because PCTs are being abolished in 2013 doesn’t mean that the staff skills are lost. Indeed, one of the important questions is how to preserve and develop those skills during these uncertain times. There are also TUPE implications.
@Bryan goes on to suggest, “This is a truly perverse proposal, look at the work of Jarman [and others]” I am very aware of the work of Jarman, Black, and now Marmot and others addressing health inequalities. Running things from Whitehall has failed to reverse the huge gap between rich and poor, but locally we can address these issues, particularly coordinating with public health, NHS and local authorities. I was introduced at Medical School in 1973 to the work of Julian Tudor-Hart a GP in a welsh mining community who pointed out that those who needed the most services got the least. This is still the case nearly 40 years later, but does not need to be.
@Joe asks, “what a COOP or a OOH is“? – Sorry for the acronyms. They are both ways of delivering GP care “out of hours”. They can be local GPs working in a cooperative or a commercial deputising organisation. The responsibility moved from local GPs to the Primary Care Trusts in 2004 I think. I am not “blaming patients for advice“, I am observing that we now have a plethora of ways to seek such advice, and each of those mechanisms needs to be separately funded. That may or may not be a good way of doing things, but I personally am not convinced that a “one size fits all” NHS is really the way forward.
Actually, can I make a plug for some continuing central legislation where appropriate ! For example, the smoking ban in public places is already saving thousands of lives. Introducing 20mph default speed limits in residential areas would save many more lives. I am sure there are lots of other examples.
The key is subsidiarity! Decisions should be made at the most sensible local level.
The big question is really whether the centre can let go and GP commissioners can be freed from some of the constraints that PCTs currently face:
– Political interference – the “Today programme” test – If ministers are going to be held responsible for what the NHS does (and I don’t think public or media will stop holding ministers responsible) they will tend to meddle. The next Mid Staffs will see a call of ‘something must be done’ and the National Commissioning Board places another set of bureaucratic checks/ targets that GP commissioners must satisfy – and prove they satisfy.
– Patient choice – a good thing, but removes the ability of commissioners to bargain effectively. Hospital X may be substantially cheaper than hospital Y but there’s nothing commissioners can do to stop hospital Y doing the work and getting paid for it.
– NHS financing – GPs by their nature think of health over many years – it is worth spending money helping people give up smoking now, even if the (massive) health and financial benefits are felt years down the line. Like PCTs GP commissioners will have to balance the books NOW. Most of the really innovative stuff my local GPs want to commission would be spend now, save (lots more) later – that attitude gets PCT Chief Execs and Finance Directors sacked and some (all?) of this will be passed on to the GP commissioners.
– Set up to fail – We see massive real term cuts (health inflation is much higher than standard inflation) – and an inability to control non-elective admissions (often because the money wasn’t spent on prevention in the past – see above). There are higher patient expectations on waiting times, quality and availability of treatment (especially if NICE’s cost-effectiveness role is scrapped. Transforming Community Services in many areas has integrated community services with the local hospital, removing competition to in-patient treatments. Oh, and the Gp commissioners will be stuck with European procurement rules that are very different from the days of fundholding.
It makes tremendous sense for GPs to lead commissioning – you probably have the best idea of a patients overall health and how all the different systems and pathways fit together. I just hope that the changes don’t get rid of the useful bits of the existing system while the GP commissioners get lumbered with all the elements in the current system that don’t work.
Lansley’s reforms threaten to “destroy the NHS as we know it”: not my words but by the head of the Royal Collger of GPs.
The latest British Social Attitudes Survey shows the NHS has been regaining public confidence – satisfaction with the way the NHS is run has grown from 34% to 64% from ’97 to 2009 – but a move to a full free market raises the likelihood of the NHS going the way of rail services when privatised, dentistry and local transport monopolies.
Standby for a postcode lottery of longer waiting lists, rationing of tretaments (already happneing in many areas) and then top-ups. And the cuts to services for the old and vulnerable provided by local authority social care will not help either.
As least some Lib Dems like John Pugh have the sense to question whether these reforms deserve support.