A View from the Swamp

In a post yesterday, I took issue with a few of the points in our conference motion, in particular 9) that talks about a “majority of councillors”.

Well, this had me wake up in the middle of the night and unable to sleep. I’ve now decided that Conference took the notion of “democratic accountability” way too far. Healthcare is as much an industry as is making paint. It is nonsense for a bunch of councillors to tell a commissioning consortium what to do as it is for a councillor to tell Dulux how to make paint. It also makes a mockery of two key goals of the legislation: to make healthcare physician-led, and to remove it from political micromanagement.

Adding a “substantial portion” of elected councillors (point 5), let alone a majority (as implied in 9) replaces national political interference with much more pervasive local interference.

However hidden in all this is the kernel of a good idea: having a councillor or two in a commissioning consortium is a good idea. It allows oversight, local representation, and a channel-of-last-resort for complaints. It also enables communications and easier integration of primary healthcare with the wider Public Health and Social Care services envisioned under the remit of local authorities.

It is also correct that the commissioning consortia need to be accountable, not just to patients but to the tax-payer who funds them and to professional bodies. However, these requirements don’t translate into a need for elected councillors. Instead, they require full transparency, patient consultation, complaints procedures, professional standards and fiduciary responsibility. And ultimately, sanctions for bad conduct.

There is also no good reason for the catchment area of a commissioning consortium to be co-terminous with a local authority. Given living and commuting patterns, in many cases I suspect that it is non-sensical. It certainly inhibits specialised commissioning consortia which may require large, regional catchment areas. It also feels deeply illiberal.

As a consequence of this midnight epiphany, I find I disagree with the thrust of points 4 to 9 inclusive. On accountability of the consortia, that is the section I’m reviewing next, so I may yet change my mind on some of this.

The next installment of my series on the Health and Social Care Bill. I’m still ploughing my way through the white paper . . .

Improving healthcare outcomes

I think the first sentence of this section bears repeating:

“The primary purpose of the NHS is to improve the outcomes of healthcare for all: to deliver care that is safer, more effective, and that provides a better experience for patients.”

How can you argue with that? The section continues with a thoughtful discussion of targets. The key phrase on removing process-oriented targets is “These targets crowd out the bigger objectives of reducing mortality and morbidity, increasing safety and improving patient experience more broadly“. There is more on targets, but sensibly focussed on safety, outcomes and patient experience.

Another key section talks about replacing the relationship between politicians and professionals with one between patients and professionals, reinforcing the removal of political interference.

The NHS Outcomes Framework

This section states the intent to provide separate frameworks for the NHS and for Public Health (and Social Care) and then outlines the NHS Outcomes framework and how it translates in to a commissioning outcomes framework for consortia.

This framework will cover effectiveness (i.e. outcome), safetly and patient experience. The consulting process and the goals and focus (outcomes, safety, and experience) of the framework seem sensible.

Developing and implementing quality standards

This section outlines what quality standards for care will be implemented, the expectations on these standards, and the timescale for rolling them out. It envisions some 150 quality standards over the next five years. At the time of publication, three had been implemented (on stroke, dementia, and prevention of venous thromboembolism). The example shown (on the prevention of thromboembolism) has seven quality statements and looks sensible (but really I’ve not that much idea as I avoid most medical stuff as it is just too icky and I’m rather squeamish).

Overall, the goals and timescale look reasonable, though I can’t assess what fraction of common clinical pathways are covered by 150 or so individual standards.

Research

A short section on the importance of research. While the statements here are admirable, the brevity of the section highlights the woeful lack of scientific knowledge within government! I would really have expected an outline of a framework and some tentative goals (though this is always tricky with research – you never know quite what you’ll find).

Incentives for quality improvement

A complex section on development of payment systems, currencies, and tariffs. I’m not sure I fully understand this yet, and need to read it carefully. On first reading, it seems to promote payment for quality over mere cost but I’m unclear how the payment systems work and whether this intent to provide quality of outcome incentives will or can work. I’ll revisit this after talking to a few who may know!

Overall: Looks sensible, and other than what I think is my own lack of understanding, I can’t find much to quibble about. Oh, yes I can: we need more people with at least a basic understanding of science in government!

A quick aside. In my previous post, I said I disagreed with some of the points in our conference motion. Here’s the list, and my reasoning:

3. Secretary of State to remain responsible for the final decision, if needed, when major service changes are opposed by local democratic scrutiny bodies on behalf of their community.

If we are serious about devolving decision-making to local bodies, this seems odd. The whole point of localism is to allow local decisions. The point might be okay if it defined “major service changes”.

8. The commissioning function (i.e. not back office functions) to be carried out directly by public authorities rather than subcontracted to non-public bodies; using public sector staff and employing the skills of existing PCT staff

Why? The commissioning function should surely be carried out by the Commissioning Consortia, otherwise what are they for?

9. Unless Commissioning bodies have a majority of councillors, there must be scrutiny of all commissioning decisions by local elected councillors either through the local authority, Overview and Scrutiny Committees, or Health and Wellbeing boards (which must have a majority of councillors to fulfill this role)

My concern here is that commissioning bodies remain clinician-driven, not local political entities – one clear goal of the legislation is to remove political interference. It is fine for commissioning bodies to include councillors but the majority should be clinicians.

16. Complete ruling out of any competition based on price for tariff-based services (and not just at the point of referral or the point of patient choice);

Why? If all else is equal (e.g. quality, timeliness, etc), why rule out price?

Continuing my look at the White Paper. I’m slowly arriving at similar conclusions to our conference motion (though I disagree with several of the points in that motion; more on that in another post). I’m also looking at this in the context of the BMA response, which also makes sensible suggestions.

Anyway, let’s look at the first section: “Liberating the NHS”.

Our Values

Not much to argue with here. This section makes it plain that the vision is a service that is fair, equal, and free at the point-of-use. It also identifies the following necessary improvements: removal of political interference, additional autonomy, transparency and accountability.

The NHS today

Stripped of the seemingly mandatory praise for the NHS, this section is fairly damning of its performance:

“Compared to other countries, however, the NHS has achieved relatively poor outcomes in some areas. For example, rates of mortality amenable to healthcare, rates of mortality from some respiratory diseases and some cancers, and some measures of stroke have been amongst the worst in the developed world”

“… the NHS has high rates of acute complications of diabetes and avoidable asthma admissions; the incidence of MRSA infection has been worse than the European average; and venous thromboembolism causes 25,000 avoidable deaths each year”

“The NHS also scores relatively poorly on being responsive to the patients it serves. It lacks a genuinely patient-centred approach in which services are designed around individual needs, lifestyles and aspirations. Too often, patients are expected to fit around services, rather than services around patients.”

To me, this section highlights two things. First, the national myth of the NHS, which surrounds it in a rosy glow and isolates it and its staff from criticism, is deeply flawed. Second, the NHS desperately needs reform. By some measures I’ve seen, we’ve underinvested over the last 25 or so years by >£250bn! [Grr, where did I read that? I'll link to the source if I can find it!]

Our vision for the NHS

The callout box is great, highlighting the need for a service that is patient-centric, clinician-driven, with quality and outcome targets, reduced inequalities, better geographic (localised) organisation and sustainability.

I have concerns over the reality of cost-savings from the restructuring proposed. In the past, these have often been illusory, with serious failings in the implementation of well-intentioned reforms. On the plus side, the proposed legislation is radical and the restructuring profound, so cost-savings may well be real.

Improving public health and reforming social care

Another good idea, addressing a deep lack in the NHS: overall public health. It also covers the need to integrate this with social care (it sets out a timetable for reform of social care).

The transfer of local health responsibilities from PCTs to local authorities makes a lot of sense! Public health covers not just primary and social care, but environmental and infrastructure issues (for example: refuse, education, communications, housing, sports facilities, etc) which necessarily belong to local authorities.

The financial position

Not much to say . . . this section reiterates the need for structural reform and cost savings in administration, but sets this against a backdrop of increased (real terms) spending. It also calls for much increased productivity. Let’s wait and see how this translates into reality. Call me cynical.

In summary: the vision outlined here accords well with liberal principles, though as always, the devil will be in the details of the implementation. Next up: “Putting patients and the public first”.