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Work in progress

The promise of a new Bill and an NHS review confirms there is still work to be done

work in progressIn his first weeks as Prime Minister, Gordon Brown might seem to be giving the NHS mixed messages. In a preview of what is likely to appear in his first Queenís Speech in November, he has promised a Bill to undertake yet more NHS reforms.

The Bill will push ahead with radical changes in professional regulation and while we can expect big changes in the regulation of doctors in the wake of the Shipman scandal, other practitioners will also get a shake up, with greater emphasis on lay involvement in professional regulation and a focus on patient safety.

Other parts of the new Bill will finish work in progress. It will merge the health and social care commissions into one new super regulator for the health and care sector, and look at ways in which access to GP services can be improved.

The Prime Minister and new Secretary of State for Health, Alan Johnson, made it clear that competition is here to stay and that the new government would continue the reform agenda started by Blair.

The signal seemed to suggest business as usual. Over the summer, the media has focused on a recent survey of patient satisfaction with GPs involving two million people. The headlines suggest that GPs are better paid, working fewer hours and that deprived communities get the worst deal. Greater involvement of alternative providers in deprived areas will be needed to improve standards but GPs and health unions remain implacably opposed to this.

Johnson then announced a major review of the NHS, starting now and due to report in June 2008, when the NHS celebrates its 60th birthday.

The review makes soothing noises to NHS staff; it calls for a service which is clinically led, involves NHS staff more effectively and allows greater local decision making, while remaining patient-focused and delivering high-quality care.

The review also floats the idea of a published constitution for the NHS.

Problem-solving

Johnson knows that Labour has a problem. Despite pouring record amounts of cash into the health service and hiking salaries, employees remain disgruntled. He is making soothing noises to the unions and offers the review process as a means to listen to union and staff concerns.

On the one hand, we have the prospect of a Bill in the autumn, and on the other a major review of the NHS suggesting that staff views need to be taken on board in a better way.

The health secretary seems to accept that government has not done well in winning the hearts and minds of NHS staff in delivering change. He also stalled on critical decisions on service changes in Manchester and seemed to want to reduce private sector involvement in the next round of NHS diagnostic and treatment centres.

While all this was going on Andy Burnham, the new chief secretary at the Treasury and former health minister, announced that he is to slash the number of targets imposed on the NHS and other public services. There are currently 110 of these central targets and Burnham proposes to reduce them to 30, leaving greater freedom for local Trusts to determine their own outcomes-based goals.

Issues like waiting times, smoking cessation and financial balance will remain in place. But other than some key national targets, local freedoms are expected.

As we get nearer to the autumn comprehensive spending review, we can expect growth in the NHS budget to be less generous. This will occur at a time when the health service has been through a year of financial pressures that have been horrendous.

The Department of Health claims that the NHS is back in balance this year, but I tend to take figures relating to NHS budgets with a large pinch of salt. In many Primary Care Trust's (PCTs) year-end outcome figures are as clear as mud, and many parts of the NHS have financial management systems that are in the Dark Ages.

Even assuming that the NHS is in balance, the underlying pressures in acute care, especially in London and other big cities with teaching hospitals, remain tricky. The pressures to reshape acute care, bolster the range of services in primary care and improve mental health services remain, and faster and greater change will be needed over the next decade.

Given these pressures, the government seems to be saying 'we will press on with reform', but at the same time ease up on targets and be nicer to doctors and nurses. Can these two apparently conflicting messages deliver a better NHS, working with relatively less money? Will providers be let off the hook of reform?

Politically, the answer has to be a resounding no. If Brown is to win a fourth Labour term, he has to present some NHS success stories to the public and to health service staff. Failure to do so will be leapt upon by opposition parties, lobby groups and the media.

Quick steps

The pace of change in the health sector is faster than ever before and a recent review of services in London suggests that increased investment in primary care, through the development of polyclinics across the capital, is seen as the way to take pressure off acute hospitals.

In theory this is fine, but the public will not wear reconfiguration of acute services, and powerful Foundation Trusts want to encourage patients through their doors in greater numbers. Payment by results and practice-based commissioning both put in place perverse incentives for acute providers to suck patients into hospitals rather than seeking alternatives based in primary care.

A schism of sorts is polluting the Brown policy agenda. The NHS review allows some breathing space and the staff and unions in the NHS will welcome the chance to put forward their views.

Foundation Trusts and other stakeholders will welcome the reduction in Treasury-set central targets. In the shorter term, ministers will have to take decisions on current acute reconfigurations, awarding contracts to existing private sector bidders and allowing more Trusts to move towards Foundation Trust status.

Both Brown and Johnson need time to take stock. Johnson is probably wise to undertake a review and consult staff and unions. As a former union general-secretary, he knows more than most what is likely to reassure people that the government is really prepared to listen. Yet, the review does nothing to stave off short-term pressures.

Brown does need to attempt to carry NHS staff and unions with him. The last years of the Blair government witnessed some rapid and badly managed change, which alienated many NHS staff. If some staff and unions buy into the review, it is likely that change will be better managed.

Brown and Johnson are likely to limit private sector involvement in the NHS, though I suspect this will be marginal. If the government can appear to slow private sector involvement in core NHS services and encourage not-for-profit companies and social enterprises to bid as providers then the unions, NHS staff and the public might be prepared to accept change. This would potentially soothe frayed nerves in the NHS, carry public support, yet still allow new providers, albeit not-for-profit providers, to deliver new services and to reconfigure services in a more acceptable manner.

New tack

Two interesting ministerial appointments have been made at the Department of Health (DoH): Brown has appointed Ann Keen, who is a nurse by background, as a parliamentary under-secretary and Professor Lord Darzi, an eminent surgeon, his second parliamentary under-secretary.

Keen is former general-secretary of the District Nurses Association, a straightforward individual who knows primary care like the back of her hand. Darzi undertook the review of London hospitals before Brown became Prime Minister and will lead the wider NHS review.

These appointments are wise. Having two ministers with solid clinical backgrounds will undoubtedly make dialogue with the professions easier. If the professions can see that two of their own tribes occupy ministerial posts, life will be interesting ñ after all, it will be difficult to pull wool over these ministerial eyes.

More importantly in selling the need for change to the public, a nurse and a doctor as ministers will probably have more credibility. Opinion polls show that nurses and doctors remain among the most trusted occupations. Expect Lord Darzi and Ann Keen to refer to their roots in public discourse ñ a clever move on the part of Brown.

Get stuck in

The pharmaceutical industry should not hesitate in getting involved in the NHS review; it will be important and set the direction of the health service for the foreseeable future. Lord Darzi will welcome views from a wide variety of stakeholders and pharmaceuticals remain an important part of healthcare.

The Darzi review of London services tells us something about his thinking and if companies have not yet read that review they should do so quickly. If a company is to submit views I suggest that it thinks laterally and broadly, not limiting itself to matters that relate only to the industry.

Darzi needs to see how modern pharmaceutical products can support greater possibilities to offer more services outside hospitals, can better manage long-term conditions and support better clinical effectiveness and safety in acute care.

Submissions to the review will need to be well thought through and led by appropriate senior figures in the industry, based on sound clinical advice.

Keeping a watchful eye

The new Bill will need careful tracking over the winter as it will tell us more about the detail involving the regulation of doctors and other professions, the wider regulation of the health and care sector and what challenges GPs are likely to face in 2008.

Whatever is in the new Bill, it is clear that doctors and others will face tighter regulation, increased emphasis on appraisal and CPD activity, and ensuring safer practice.

Health professions will require support with this new agenda and anything the pharmaceutical industry can offer by way of training and development will matter this year and into 2008.

Opportunities for the industry to enter emerging markets in providing services in primary care remain, but I suspect a Brown government will want to encourage greater involvement from organisations in the not-for-profit and voluntary sectors.

This does not preclude appropriate partnerships between a pharma company and a variety of partners in the third sector. If a product range relevant to better disease management, eg, diabetes or depression, links to a strong voluntary organisation in a disease area, then creative partnerships can work well, as long as all parties are clear about roles and responsibilities.

Brown will want to make his mark in the NHS and achieving this is likely to be one of his top priorities. The politics of health will be fierce under Brown and in the run up to an election between now and 2010.

Keeping on top of the political agenda and reading the performance of the new ministerial team will be essential for all companies over the next 18 months. Enjoy!

The Author
Ray Rowden is a health policy analyst and former special adviser to the Health Select Committee in the House of Commons

19th September 2007

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