Climate change: everyone has got a view on it. But what of the NHS environment? New Labour’s healthcare equivalent of the carbon footprint is its sustained and unprecedented bout of NHS reform. Will it work? Will the NICE-caps melt the NHS? Gordon Blackwell examines the BMA view of the current climate.
IT IS EASY to write a list of reasons why NHS reform is going wrong and the BMA provides the following:
• a stream of initiatives not well aligned
• reform is driven by ideology not evidence
• the NHS has been forced through several cycles of wide-ranging change, without a clear direction
• reform has not proved value for money
• it is destabilising the NHS
• the system of care is becoming more fragmented
• there has been a failure to engage either
professionals or the public in a meaningful way. Admitting that doctors are often seen by government as dinosaurs that are opposed to anything that means changing their practice, the BMA has attempted to counter that perception by publishing proposals for what it calls “A rational way forward for the NHS in England.”
Its basic motivation is made evident by the view that: “reform over a number of years has reduced the space for a professional view, which has come to be understood as at odds with organisational aims and in conflict with the philosophy of NHS management. The current reform programme is further marginalising health professionals. The lack of partnership working means that reform is developed in a managerial way, in isolation of a much needed professional perspective.”
It wishes to see a “fundamental change in manager-doctor relationships, moving away from disempowering professionals and towards working in partnership with them, playing a supportive role.” It is, therefore, interesting to see how the NHS would change if the medical profession had its way.
The radical document claims to provide an alternative approach requiring “political clarity about the services and standards that are provided, professional leadership in the operation and development of the NHS, and improved accountability at a local level.”
It wants an NHS constitution as an agreement between the government, the NHS and the public, which sets out:
a) The core values of the NHS – containing its founding values and adding new ones such as the provision of integrated care pathways, a commitment to supporting world-class research and education, and a focus on health as well as illness.
b) A charter explaining what the public can expect from the NHS as patients and carers and what the NHS expects from them.
c) The arrangements in place to determine the range of core services that are nationally available on the NHS with nationally agreed standards.
It acknowledges that without expanding the budget to cope, some level of rationing is inevitable and it makes the point that efficiencies can only account for relatively small savings. Therefore, it is up to society to decide whether to fund cost increases by paying higher taxes or accept some rationing beyond agreed services. This will require a significantly higher level of transparency than we have been used to and needs an admission from the Government and politicians across the board about the real limitations of the service. But the BMA does not make clear how society would have the ability to decide on how much should be spent and how.
It tries to make the distinction between priority setting, which acts at the level of allocating resources to particular services, and rationing, which acts at a lower level in the allocation of resources to individual patients at the point of service delivery. However, this appears to dodge the issue. With ever expanding technological capability and new expensive drugs, society should be given the opportunity to agree nationally what it wants to afford and therefore what should be rationed. To call central decisions “priority setting” is a cop-out.
Over and above core services, it thinks that local health economies should agree what additional care should be available, funded from their needs-weighted allocations.
The proposals acknowledge that national politics have a role to play in setting priorities and budgets but argues that politics in the day-to-day running of the NHS should be reduced. It proposes:
• an independent board of governors, appointed by and accountable to Parliament, responsible for ensuring compliance with the constitution
• an executive management board, appointed by and accountable to the governors, responsible for “guiding the performance and national operations of the NHS,” with a chief medical officer, the NHS chief executive, the NHS directors of finance, human resources, research and development as well as the chief executives of SHAs.
The primary concern of the Secretary of State should be ”health and the wider context of healthcare, and to represent public health at cabinet level with a remit to lead on health across government, in a way that genuinely joins up policy across departments.” SHAs will “support collaborative relationships across the health and social care systems” as an important tier between the NHS executive management board and local health economies.
Local health economies will take decisions about the shape and delivery of services, but their structure would vary by moving away from the current PCT structure in an evolutionary way, being “clinically led.” “Innovation should not be driven from on high, but by local professionals working to improve services for patients,” with greater autonomy for health professionals and managers to shape local services. The BMA does not wish to recommend structural change to reinforce integration.
Integrated care systems
It sees a more mature approach to commissioning, which would diminish the need for a purchaserprovider split. Commissioning should be clinically led in the public sector, based upon collaborative relationships between primary and secondary care, seeking to develop integrated care systems.
This could be facilitated by the establishment of health economy foundation trusts (HEFTs), with provider and commissioner representation from hospitals, general practice, community providers and public health representatives on their boards.
HEFTs would plan and deliver healthcare across a local health economy and could “revolutionise relationships between local health systems and communities.” Local citizens would register with the organisation and have the opportunity to directly influence decisions in their area. The document is clear that private sector provision should only be commissioned where there is no NHS capacity to provide the service.
It then focuses on the need for medical education and the development of integrated services through clinical networks. Clinical networks are the “means by which healthcare professionals jointly agree, implement and monitor provision of care for their patients.”
• The formation of local health councils to provide a link between the community and health professionals/managers who are shaping local services, particularly in the context of consultation on plans for service change and reconfiguration.
• A much stronger relationship between health and local authorities. In advance of legislation that will mandate a ‘joint strategic needs assessment’ for the populations they share responsibility for, these bodies should set out arrangements for future closer working.
• Commissioners must be given freedom to make investments without showing a return within the financial year; a three-year budgetary cycle, even if only for part of the budget, would better support joint strategic planning.
• A much greater onus on clinical leadership.
All of which makes interesting reading and a few things for Gordon Brown to consider, but you can’t help thinking that if physicians really want a greater input into service redesign and the chance to innovate, why are they not steaming ahead with practice-based commissioning?