Professor Steve Field has a tough job. As chair of the NHS Future Forum – the centrepiece of the Government’s ‘pause’ listening exercise – he is the man tasked with bringing peace to NHS reform. As I have argued before, those who expect him to do so are wildly unrealistic. Far from ushering in a period of quiet reflection, the ‘pause’ has in fact turned up the volume of health debate. The objections of critics of the reform programme are disparate and often contradictory. What is more, many are based on ideological differences rather than more reconcilable concerns about practical implementation: for example Andrew George’s concerns about the impact of competition will require more than simply a fine tune to address.
There are also personality issues to be navigated. In developing his recommendations, Professor Field will need to win the support of a bruised Secretary of State, disparate interests within Number 10 and a Liberal Democrat party which has yet to agree with itself on what it wants from the pause. If that wasn’t enough to contend with, then he also has to be aware of interventions from some of the big beasts of health policy over the last ten years, some of which may be as much about carving out a future role for themselves as they are about improving the reforms which are on the table. Number 10 may have denied having its own committee of experts to advise on (or second guess) health reform, but there is little doubt that there are plenty of disparate voices willing to offer an opinion to anyone who will listen.
So, between ‘essential amendments’, ‘red lines,’ charity coalition demands and 6,000-odd responses to the initial White Paper consultations, Professor Field is not short of advice. Nor is his every utterance short of interpretation. Those who follow the health reforms on Twitter will have observed the kremlinology with which greets Field’s every utterance. This weekend’s rather over-spun Guardian story is a case in point. Incremental and pragmatic observations were headlined by a splash declaring that he had branded the reforms as ‘unworkable.’
However, the time for pausing, listening and reflecting is drawing short and soon the business of improving must begin in earnest. So here, for what they are worth, are a few of my suggestions about how the NHS reforms could be improved. I have confined my suggestions to getting the detail right rather than changing the whole thrust of the reforms, as this is in keeping with the parameters of the pause.
Changes to commissioning have attracted the most controversy, probably because they involve structural change and so are relatively easy to understand. However, they are probably amongst the easiest to resolve. PCTs were unloved and poorly understood institutions which often lacked clinical leadership. The initial challenge for consortia is to be no worse at commissioning services – and, in truth, that is not a particularly high barrier.
The initial reforms excluded all other primary care health professionals from a mandatory role in commissioning consortia on the grounds that GPs are the ones who incur most of the expenditure. Although correct in its analysis, this was a tactical error, placing nurses, pharmacists and others on the outside and giving them an easy rallying point. The Bill should be amended to give others a voice in commissioning, placing a duty on consortia to have regard to the opinions of all appropriate healthcare professionals. In doing so, however, the Department of Health will have to take care not to alienate those GPs who are already getting on with the job in pathfinder consortia.
Although less noisy than commissioning, the proposals on competition are far more intractable. Put simply, you either believe in competition in health or you don’t and it will be impossible to win other those who oppose it (a hastily cobbled together listening exercise won’t succeed where years of debate in both the Labour and Liberal Democrat parties have failed). Yet there are things that can be done to clarify what is meant by competition in health.
One of the political weaknesses of those advocating greater competition is that few people understand competition law and even fewer understand how it might apply to the NHS (that is why competition lawyers earn as much as they do). This creates an open season in terms of speculation about the impact that greater competition could have. In truth, competition law already exists, although its application in health remains uncertain. Advisory mechanisms such as the Cooperation and Competition Panel were established to mitigate the threat of cases against the NHS finding their way into the courts,and the creation of a statutory mechanism (in Monitor) may actually reduce the likelihood still further. However, this is besides the point. People feel that the competition provisions in the Bill are a leap into the unknown, and the worry is that this will begin to inform behaviour ("I don’t think I’m allowed to do this, so I won’t do it") in spite of what the legislation does or does not allow. Competition rules in health revolve around the answer to a simple question: "is this in the interests of patients?".
If the answer is yes, competition rules should not come into play. The Bill does not make this clear, and it needs to be amended to make clear that the competition test is whether an activity harms the interests of patients.
An unfortunate consequence of the poor explanation of parts of the reforms is that coordination and competition have come to be seen as opposites. This is or course nonsense: coordination (and indeed cooperation) are a feature of competitive markets (think about a group of companies coming together to pool talents in a bid for a major contract). Purchasers are allowed to stipulate any form of cooperation they want – that right is what competition law is designed to protect. It is only providers that cannot make the purchase of their product conditional on the purchase of someone else’s. However, the Bill should be amended to not only make this clear but also set out how the mechanisms will be established to make this happen.
Expert clinical networks operating at a supra-consortia level – such as those for cancer – could play a big role in smoothing off the rougher edges of competition by facilitating cooperation when it is required by commissioners, as well as making sure that commissioners get the expert input they need. The role they can play needs to be spelt out in the Bill, but not in a way which simply institutionalises existing structures (some networks are great, others less so). Rather, mechanisms should be created for evolving networks so that they can deliver the support which GP commissioners will need. Over time, these networks should be opened up to competition, enabling consortia to choose the support which best suits their needs.
The NHS Commissioning Board should also set out how it will provide expert support to consortia at the programme level (eg cancer or cardiovascular disease), ensuring that commissioners have access to national-level specialist expertise to support them in driving improvements in outcomes.
Changing medical training (either for trainees or on the job) is fraught with political difficulty. Understandably, it is something that the professions care deeply about and jealously guard their role in. The MTAS debacle of a few years ago is a salutary warning of the damage that can be caused when changes are poorly implemented or attract opposition.
The White Paper proposals to devolve responsibility for funding of training to providers (irrespective of whether they are NHS, voluntary or private) are based on the principle that those who deliver the service are best able to determine their human resources needs. But the training of health professionals is prone to rapid market failure (witness what happened in the 1990s), which is why central oversight and collaboration mechanisms are also needed. December’s consultation document on workforce training recognises this, but while the consultation remains without a Government response (yet another casualty of the ‘pause’), the uncertainty about how it all works will remain. The Government needs to take a clear decision at the end of the pause, and write the role for the centre in education and training into the Bill.
Public and patient involvement
The theory that consortia, working closely with local democratic scrutiny and a stronger patient voice, should be closer to patients’ needs is good. Yet the less than glorious record of reforming patient involvement mechanisms has unsurprisingly left many charities sceptical.
In my opinion the statutory safeguards on PCTs have had only a mixed impact, with many commissioners simply adopting a box-ticking approach to engagement (the good ones may well have been good anyway). HealthWatch – with its formal role at the centre and at the local level – may help convey the views of patients more directly to commissioners and providers, but that remains to be seen. Unless and until patient groups are convinced of the merits of HealthWatch, the previous statutory safeguards should be reintroduced to the Bill. They may have little impact, but they represent the hard-won gains of many charities and removing them sends the wrong signal. In parallel with this, the NHS Commissioning Board should be tasked with working alongside charities to identify and spread good practice, so the practical quality bar for user engagement is actually raised.
Nobody believes that the Government wishes to breach patient confidentiality, but the fact that experts in the area have highlighted concerns that this could be a consequence of the reforms should set alarm bell ringing in Richmond House. Such an occurrence could be fatally damaging for the Information Revolution and would further set the professions against the Government on an issue where there is little need for a fight. The Bill should recognise the importance of pseudonymisation and establish the threat of ‘jigsaw identification’ (where different datasets are used to identify someone) as part of criteria about whether information should be disclosed.
As I wrote on the day the White Paper was published, the proposed reforms are a complex set of moving and interdependent parts. If they are to have the desired outcome, then every part of the system needs to work as intended. Hopefully these suggestions could make the machinery and the politics of the new system work a little smoother.