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NHS Flashpoint

This year was tough for the NHS, but the issues it faces in 2007 will be explosive

It was a tough year for the National Health Service in England in 2006. Despite the government pouring record sums of money into it, the NHS ended the year with a deficit of more than £1bn.

This has led to a whole series of short-term measures - including redundancies among doctors and nurses - to bring financial balance by March 31, 2007, and to tackle underlying money problems.

Add to this some major restructures of Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs), with all the instability that has ensued, and it is easy to see why most commentators saw 2006 as a bad year.

Across the borders in Scotland and Wales there was less turbulence, although Northern Ireland is going through a major restructure of all public services, including the NHS.

The year saw the government declare that PCTs should cease to be providers of services by 2008, and should concentrate purely on purchasing. This could result in a whole range of community services coming `up for grabs' in England.

We witnessed some forays into private sector provision of GP services in Derby and Worthing, which ruffled many feathers. This means that thousands of front-line staff in community services have no idea who their employers will be. Not surprisingly, this angered the health unions and led to their lobbying parliament in early November.

This lobby was unusual in that while it was organised by the Trades Union Congress (TUC), and naturally attracted the TUC affiliated health unions like AMICUS and UNISON, it also attracted the support of three non-TUC unions, the British Medical Association, the Royal College of Nursing and the Royal College of Midwives.

In an unprecedented scenario, the government seems to have united all staff in opposing its reform agenda for the NHS in England. So what next?

If Prime Minister Tony Blair, or his successor, continues to push reform on reluctant NHS staff, especially the health professions, we are likely to witness major industrial unrest in the NHS during 2007. Essentially, Blair wants to keep the NHS publicly funded and commissioned but wants to free up the provider side.

Opinion polls suggest that the public has little interest in who provides their healthcare as long as it is accessible, of good quality and is free at the point of need. The NHS will be a battle ground.

Rationalisation
At the end of 2006, SHAs and PCTs began to rationalise acute hospital services. Scotland has done this already in Lothian and Grampian and is going ahead with a review in Glasgow, where the public has generally accepted the need for change. In England there have been public protests against such moves. With changing technology and a broader clinical repertoire, it is clear that much more can, and should, be offered to patients in community services and in their homes.

Other changes, including the EU Working Time Directive and its impact on junior doctors' working patterns all conspire to make the traditional, small District General Hospital creak at the seams.

The public remains suspicious and SHAs and PCTs have failed to get clinical opinion leaders on side. This is a problem. If the public remains concerned at service reconfigurations and sees armies of aggrieved nurses, doctors and midwives on strike, who are they going to trust? Not the politicians and accountants that manage the NHS. I suspect that Blair's successor, assuming it is Gordon Brown, will want to calm things down and meet union and staff demands half way. The alternative would be politically risky in the run up to a possible 2008 election.

We are in the midst of the Chancellor's comprehensive spending review, which will determine how much cash the NHS can expect between 2009 and 2012. By 2008, the NHS budget will equate to around 9 per cent of GDP, bringing the UK in line with other mainstream EU countries. Assuming inflation remains in check, the NHS budget is unlikely to grow radically. This makes it imperative that the NHS tackles underlying overspends and confronts waste.

Tighter regulation
A major review of the regulation of doctors and other health professions also took place in 2006. The General Medical Council (GMC) faces an overhaul, along with other regulatory bodies.

At the moment, the council acts as investigator, prosecutor, judge and jury in cases of professional misconduct, which is something that Dame Janet Smith, chair of the inquiry into events surrounding Harold Shipman, had a problem with.

In future, these powers are likely to be separated in cases of misconduct and fitness to practise, with an overarching body acting as judge and jury. With regard to the doctors, the GMC will continue to investigate, prepare and present cases for prosecution, but another body will weigh up the evidence and make judgements. The same will be true for nurses, dentists and others.

The review also suggested a change in the level of proof in cases of doctors facing professional discipline. Historically, the GMC looked for a standard of proof against a doctor equivalent to that which applies in criminal courts (ie, `beyond reasonable doubt'). In future, it is likely to follow that required in civil courts (ie, `on the balance of probability').

In November over 700 doctors signed an indignant letter to The Times newspaper expressing their dismay at this and other changes. The Nursing and Midwifery Council is also sceptical about some of the proposed changes. Following the Shipman case and other high profile mishaps, the public is likely to expect tighter regulation of doctors and other healthcare workers. there is potential for this to become a flashpoint in 2007.

The year also witnessed the unusual prospect of Gordon Brown and David Cameron, leader of the opposition, agreeing that we should `take politics out of the NHS'. Both suggested the NHS might in future be run by a Board of Governors, similar to the Boards which run the BBC and the Bank of England.

The idea seems to be that the Secretary of State would set the budget and broad objectives, leaving an independent Board to run the show. This is unlikely to happen.

The NHS is currently the second biggest spender of public funds: £74bn this year, expected to rise to an estimated £100bn in 2008. The NHS touches the life of every citizen, so it is unlikely that parliament will relinquish control of this public money lightly. Parliament also expects to see a Minister publicly accountable for stewardship of such vast sums.

I suspect the same is true in the Scottish Parliament and the Welsh Assembly. While we choose to fund the NHS largely through general taxation, the demand for the service to be accountable to parliament will remain. So don't hold your breath on major change in the governance of the NHS during 2007.

NICE has also had a challenging year. The decision to fund Herceptin bordered on farce. Following some high-profile legal battles by patients who were denied the drug, NICE did some nifty footwork to issue final guidance on Herceptin to the NHS just three months after the drug was licensed for use in early breast cancer.

Coincidentally, it proved to be convenient for the politicians, so the episode did little to enhance the independence often claimed by those who support NICE.

Contrast this with the judgement on Alzheimer's drugs where, despite huge patient and carer evidence, sufferers were denied access to them. The dementia debacle will run well into 2007, and NICE will remain in the firing line.

ANOTHER DAY
What does 2007 hold for pharma in its business dealings with the NHS? In Scotland and Wales, things should remain reasonably stable, and the different policies in those parts of the UK should be understood and respected.

Northern Ireland is likely to remain organisationally turbulent as new health and social care structures bed in. Any company that can help senior managers and clinical professionals manage change quickly will be in a winning position.

England remains very unstable and less predictable. The new PCT structures will bed in, but it will be months before pharma teams will have clarity about who runs things in primary care. Have some sympathy for PCT senior managers because, until March 2007, many will not know if they have a job, and several will leave the NHS.

As new business opportunities emerge to run services from outside the traditional NHS, companies might see some talented people coming to the job market. If a company wants to bid to run services for NHS patients then the skills of good misplaced NHS managers might be useful.

Practice-based commissioning will roll out more extensively during 2007, but I suspect implementation will be uneven around England. Committed GPs will want to purchase and will undoubtedly have influence over what the NHS buys at local level. Good information on these GPs will be essential in ensuring that local teams build relationships with the early movers and shakers.

Many more NHS Trusts, and possibly community services, are likely to move towards Foundation Trust (FT) status in 2007. These new bodies will need to be more commercial in their approach and build marketing and business skills. Pharma will need to share its knowledge and experience with potential partners in both emerging and existing FTs.

Finally, 2007 will see the roll-out of more independent non-doctor prescribers, especially pharmacists and nurses. Firms will need to analyse training needs and develop a range of programmes to ensure they are confident and safe prescribers.

The author
Ray Rowden is an associate with the Healthcare Commission, but the views expressed here are personal.

2nd September 2008

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