Opinion: NHS reform on right track

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

  • david clayton 17th Dec '10 - 3:35pm

    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.

  • Dominic Curran 17th Dec '10 - 3:39pm

    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.

  • 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 “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.

    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.

  • @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.

  • @matt
    “The Government do not trust G.P’s 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 £3 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 £80bn 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 – 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.

  • @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.

  • Stephen Donnelly 18th Dec '10 - 12:32am

    @ 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.

  • 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 £3bn 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.

  • “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 £40,000 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

    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

  • 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!

  • @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 (£20bn 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 £3bn 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 £3bn 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.

  • patricia roche 19th Dec '10 - 4:22pm

    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?

  • 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.

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