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Budding change

At this early stage, there is no way to tell what the White Paper reforms will bloom into

Flowers growing on a gateBefore and during the election earlier this year, David Cameron made it plain he intended to put doctors and other front-line clinical staff in greater control of the governance and management of the NHS. He did not tell us how he would do it. In Equity and excellence: Liberating the NHS, the White Paper published in July, he left Health Secretary Andrew Lansley to fill in the details.

This White Paper proposes the most far-reaching changes to the NHS in decades and probably delivers what Cameron had originally had in mind. Despite this, since the publication of the new changes we have witnessed a torrent of opposition to the ideas. These include the threat of a legal challenge against the proposed changes from some of the big public sector unions, a lukewarm response from the health professions and a charge from political opponents that this will spell the end of the NHS.

What the reforms entail
What exactly is on the cards? On commissioning, the Government has proposed the creation of a national NHS Board, which will oversee the new NHS landscape. Lansley is consulting on ideas for this new board, including explicit rules on what he can and cannot interfere with in the day-to-day running of the NHS.

Under the new Board will be a financial regulator for NHS providers from all sectors, a beefed-up Care Quality Commission to ensure a level playing field to measure outcomes and clinical standards. There will also be 500 new commissioning consortia led by GPs and their practice staff, who will control £80bn of expenditure, leading to the abolition of Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs) by 2013.

Criticisms about GPs
There have been suggestions that the GP consortia cannot deliver and will lack the expertise to decide what is right for local populations. The critics seem to forget that the current commissioning arrangements have not exactly been an overwhelming success. Many PCTs have failed to deliver clear health improvements for populations and in specialist areas such as mental health, some would even go so far as to suggest that commissioning has been a failure.

The British Medical Association (BMA) and Royal College of General Practitioners (RCGP) have suggested that this is too quick and GPs will not be ready by 2013. This line of argument assumes that all GPs will need to be involved in commissioning, which is simply not the case. The proposed GP consortia will need around 10 or 20 intelligent and committed GPs to provide real leadership. This core group of GPs will call on board other professionals, including nurses and allied health professionals. The consortia of GPs will also require talented managers to support them in their new roles.

As the SHAs and PCTs wither on the vine, GP consortia will have a great pool of talent to call on and will also be free to buy-in private- and third-sector expertise. As long as these new leaders consult with the wider GP communities and carry their confidence, there is no reason why this new set of arrangements should not work and deliver greater efficiencies and, importantly, good clinical outcomes.

Critics also suggest that the GP consortia will be unaccountable. This is nonsense. The GP consortia will be accountable for their functions to the NHS Board and this will be public and transparent. At local level new arrangements for scrutiny of the GP consortia are proposed, which will be led by local government. These new scrutiny arrangements will allow many local stakeholders to become involved in the process.

Crucially the Government is proposing to restore the public health functions of the NHS to local government. Up until 1974 this had always been a local government responsibility in any case. The White Paper will ringfence public health funding and has the potential for a renaissance in joined-up thinking for local and population-based assessment of real local needs. It has the potential to work a lot better than what has gone on around public health in the past.

Criticisms about providers
On the provider side the proposals go much further than the current model of Foundation Trusts (FTs). The plan is to encourage all NHS providers to move towards FT status by 2013. One assumes that those providers who are unable to make the grade will be merged with, or taken over by, successful FTs, but they could also be opened up for bids from other providers in the private or voluntary sectors. BUPA and Nuffield hospitals already run a large number of outlets where all profits are ploughed back into the companies. Could they run a district general hospital in the future? Under this White Paper I suspect anything is possible.

Foundation providers are likely to get even greater freedoms and establish themselves as stand-alone social enterprises outside formal NHS structures. The idea is that the staff of these organisations would actually become shareholders and have a real stake in the success of their workplace. There are many different models for the structure and governance of social enterprises.

Interestingly the Government is looking at the John Lewis Partnership as a possible way forward. John Lewis, which also owns the Waitrose chain, is effectively owned by its staff. This means that the staff members all enjoy the benefits of success, but share the risk when times are not so good. There are no shareholders, and many would say John Lewis is an exemplary employer with a strong brand. If FTs can move towards such a model this would alter the dynamic between the employer and employees in a dramatic way and could, if well managed, provide great incentives and motivation for front-line staff. The crunch point in all of this will be pensions.

There is no reason why staff in these new providers could not have access to the NHS pension scheme. GPs and dentists are all self employed, contracting their services to the NHS, yet they are allowed full access to NHS pensions. As FTs make the transition to new models, existing NHS staff will carry their accrued rights with them. The real question is what will happen with any new staff taken on after the transition is complete.

The unions are not happy that we could see the emergence of a two-tier workforce: those transferred would have full NHS pensions, with new recruits on a less advantageous deal. If these new providers are stand-alone legal entities then it might be assumed that their pension arrangements for new staff are their business. Equally, the Government could say that the NHS pension scheme remains open to these new organisations, which would probably satisfy some union and staff opposition.

The fundamental structure of the NHS is likely to look very different if these ideas go ahead, but where opposition to the plans seems most vehement is in the idea that the public sector should retain a monopoly on NHS providers. Will the patient really care who provides? Non-NHS providers are already active in large-scale elective surgery, niche mental health provision and especially in forensic services.

The patients using such services, and crucially those who commission them, will simply want to know that the provider is safe, competent, properly accountable and offering good value for money to the taxpayer. As long as the founding principles of the NHS remain intact — that is, that the service is largely funded through pooled risk in general taxation and free at the point of need — why should greater plurality of provision be such an issue?

Responding to the criticisms
The Labour Party and the trade unions seem to be on a path of outright opposition to the changes in the White Paper. Is this wise? If the Government presses ahead and these changes bed in and actually work by the end of this Parliament, the voters may prove more than happy with the new NHS. If, however, the wheels do come off and the policy fails, then Cameron and Clegg will face real problems, but Andrew Lansley is not especially ideological and he is absolutely not stupid. He has spent many years in opposition as shadow health secretary and certainly understands his brief.

I suspect Cameron, Clegg and Lansley have come to a conclusion that there is a real need to be clear and radical in the early phase of this Parliament. They now have a five-year window in which to deliver stable public finances and a new NHS landscape, better equipped to face future challenges.

I am not a Conservative or Lib Dem supporter, but I have a hunch that Lansley might just deliver the best elements of his new agenda. If he manages to do so, I suspect the public and patients might just like it.

The Author
Dr Ray Rowden is a health policy analyst and former special adviser to the Health Select Committee

To comment on this article, email pm@pmlivecom

6th December 2010

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