Politics of healthcare

Andrew Lansley's reform plans for the NHS seem to have taken many people by surprise. The charge against the Secretary of State is that his proposals to put up to £80bn of NHS funds under the control of GPs were not discussed ahead of the election. But the statement in the Conservative manifesto, 'We will strengthen the power of GPs as patients' expert guides through the health system by giving them the power to hold patients' budgets and commission care on their behalf,' seems pretty conclusive intent.

Perhaps the reforms were not fleshed out in full by the Conservatives, although political and policy experts will have been aware that in late 2009 David Cameron's favourite think-tank, Policy Exchange – the originator of the majority of the Conservative manifesto proposals, recommended a return to the GP fundholding model. The extensive report also floated the ideas of a 'patient premium' and incentivising GPs to work in areas of deprivation, which are now both major strands of Government health policy.

So what about the central idea behind the NHS reforms themselves? With all the concern that is being played out in the media you would be forgiven for thinking that there was wholesale opposition to the idea of doctors having greater control over NHS finances. But if you were to ask health policy experts or actually read the responses to the Government's White Paper then you would discover that most agree with the policy of aligning clinical and financial decision making in the NHS. That is because within any healthcare system clinical decisions account for at least 80 per cent of all healthcare spending.

Just think about it – who decides to send patients for CT and MRI scans; to admit patients into hospital; to perform complex surgery, or prescribe expensive drugs? Doctors. Indeed, over the last decade the previous Labour Government had been trying to re-engage GPs in utilising NHS finances with initiatives like practice-based commissioning which sought to capture the benefits of the GP fundholding and multi-fund model that it scrapped on coming to power.

Moreover, aligning clinical and financial decision making is yielding dividends in other parts of the NHS where Service-Line Reporting in Foundation Hospitals ensures clinicians and managers understand the overall actual profitability of their service. Be it surgery or elderly care, these directorates now understand what impact different decisions have on costs and profitability much like, say, marketing and manufacturing divisions in other £200m businesses.

So what are people actually concerned about? Well, there seem to be three types of opposition. First, there is opposition to the thought of another NHS restructuring – "change apathy" as one clinician described it. Second, there is opposition for opposition's sake – "the politics of healthcare" which is the inescapable fact of Labour doing its job as Her Majesty's loyal Opposition. And third, there is opposition to the pace and scale of the reforms, which comes from a variety of informed sources and is more measured and reasonable. These "pace and scale" concerns also encompass the huge challenge of ensuring widespread take up of the GP-led commissioning model. Many will recall that the principal opposition to the GP fundholding model (and the reason why it was scrapped by Labour) was that it created a two-tier service with patients of fundholding GPs receiving fast-track treatment at the expense of others.

For these reforms to see the light of day, the Health & Social Care Bill will need to pass through Parliament. Although there is political support at the highest level – the White Paper, Liberating the NHS, is signed by both the Prime Minister and Deputy Prime Minister – there might be some resistance in the House of Lords where the crossbenchers have considerable expertise and numbers. However, the smart money says that MPs will not sink the coalition government when there are no ideological difficulties with the NHS reforms, just concerns about the implementation.

Ultimately, the Bill will go through, but the politics of healthcare are also working against the Secretary of State in another way. To help secure a second term in office for the Conservatives, Andrew Lansley needs to ensure that his White Paper reforms are starting to yield dividends by the time of the next general election. With this in mind it is interesting to consider the likely policy priorities in the next 12 months.

Implementing the reforms and reducing costs
This is the really tricky bit. Everyone knows that, even with small increases in funding, the NHS will have to find major efficiency savings but no-one is quite sure how, especially while there are major structural changes being planned. The Spending Review 2010 announced the Quality, Innovation, Productivity and Prevention (QIPP) programme as being the answer to the NHS efficiency challenge, but just who believes that QIPP can deliver the scale of savings required?

Critics claim that NHS waiting times will grow. In an ideal world – one without funding constraints – everyone would be treated as soon as possible. But since not all conditions are clinical emergencies, some operations and procedures can wait a bit longer than others. Doctors practiced clinical triage long before NHS targets and micro-management dictated that everyone should be treated within 18 weeks.

Moreover, a blind focus on waiting times and not considering the actual number of people waiting for an operation would be a mistake not to be repeated. In March 2005, the number of patients waiting under the three month waiting time target for complex operations – such as neurosurgery and cardiothoracic surgery – was higher than when the Government began its war on NHS waiting in 1997. Patients with more serious conditions were being pushed to the back of the queue as other less complex operations were prioritised ahead of them.  That these complex specialities account for 97 per cent of all hospital deaths is a story yet to be told.

Ensuring uniform uptake
At the time of its abolition in 1999 only about 50 per cent of GP practices had adopted the fundholding model. This meant that all the benefits applied only to patients of fundholders, which in turn had implications for health inequality as patients of fundholding GPs jumped long waiting times of 18 months or more. Who knows how many would have become fundholders in the long run, but given that reducing health inequalities is now part of Coalition health policy there is huge political risk in having a two-tier NHS at the time of the next General Election.

In contrast to other areas of Conservative policy the strategy in the NHS is to compel GPs to join GP commissioning consortia. While there are clearly some enthusiasts for Lansley's policy, evidenced by the first wave of pathfinders, there will be a core rump of GPs – perhaps up to 30 per cent – that do not wish to engage. A percentage of them will reluctantly join their local consortia comforted by the fact that at least their colleagues are in charge, but a challenging question is what to do with those that don't? And should these pockets of resistance coalesce to cover discrete geographic areas, then even greater problems arise.

It is interesting to speculate, therefore, whether the Government resorts to parachuting in private companies to run the consortia where take up is low in much the same way that independent sector treatment centres (ISTC) were deployed to exert competitive pressures for acute hospitals to improve. This, of course, would be politically difficult leading to further accusations that the Conservatives (or perhaps the Coalition) are privatising great swathes of the NHS. But that is to misunderstand the current private sector status of GPs. As long as the NHS remains free at point of use and the right checks and balances are in place, how many patients would rather belong to a bad GP-led commissioning consortium rather than a good corporate-led one?   

Ensuring the GP-led consortia do not fail
At the time of writing (on the eve of publication of the Health & Social Care Bill) it is not certain what the financial oversight mechanisms for the new GP-led consortia will be. Monitor is going to be the economic super regulator ensuring system-wide financial stability and setting NHS tariffs, but will it still be directly accountable to Parliament rather than the Department of Health – a finer point missed by all but the uninitiated.

Irrespective of where the accountability lies, Monitor will be a mission critical organisation for the new NHS and will need the return of strong leadership just as it had when Foundation Trusts were being rolled out across the country. The risk is that new consortia will be being governed by a new regulator: both finding their feet in a period of intense financial pressure. By April 2014 – 12 months before the next general election – GP consortia will be just closing their first year's accounts with up to £80bn of NHS funds.   

Implementing GP-led commissioning     
Since most experts accept that aligning clinical and financial decision making is the right thing to do, the Coalition has a responsibility to ensure that GP-led commissioning is implemented permanently. The cycle of restructuring under Labour – the creation and subsequent abolition of 100 health authorities, 481 primary care groups and 303 primary care trusts – in an attempt to re-create the efficiencies of the GP fundholding model cannot be repeated since each re-organisation costs the health service 18 months as everyone struggles with implementing change rather than improving services.

The creation of an Independent NHS Board is an attempt to insulate the NHS with a layer of political neutrality, but a key question is how can costly re-organisations be avoided in future?

The King's Fund says Andrew Lansley's proposals are, "the most radical restructuring of the NHS since its inception" but that is to overlook the creation of the purchaser-provider split in 1991 which was much more radical. And to miss the blunder that was the scrapping of GP fundholding in 1999. As tempting as it is to gaze into the navel of these White Paper reforms, we should remember that reorganisations do not make patients better; medicines and clinicians do.

The Author
Henry Featherstone is a senior policy advisor in the Public Affairs & Corporate Communications team at Fleishman-Hillard London, and author of the Policy Exchange report Which Doctor? Putting patients in control of primary care.

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