The NHS is continuing to change even as opponents of the Health and Social Care Bill force delays to its timetable. Anna Dixon analyses some of the issues on the ground that should concern the public
Political debate is raging about whether the legislative changes proposed under the Health and Social Care Bill amount to privatisation or the end of the NHS as we know it.
Since the New Year, several Royal Colleges have followed the British Medical Association and come out in outright opposition to the Bill. As the draft legislation began its report stage in the House of Lords, the Opposition stepped up its attack, calling for the Bill to be dropped. However, away from Westminster, significant changes to both the commissioner and provider side of the NHS are already in full train.
When the health white paper was originally launched by health secretary Andrew Lansley it received a cautious welcome. Its aims – empowering clinicians and involving patients in their care – were laudable, but the means were not fully spelled out. The King’s Fund argued that many of the changes were possible without legislation by using a more evolutionary approach. We wanted to build on existing arrangements, ensure continuity of leadership, and encourage collaboration alongside competition.
However, the furore about the Health Bill risks obscuring the issues that matter most to patients and the public. These include the NHS finding £20bn of productivity improvements over the next three years; improving the quality of care for frail older people; developing a new funding settlement for social care; and transforming care in general practices and hospitals for those with complex needs. Small- and medium-sized hospitals must also be put on a clinically and financially sustainable footing. Addressing these issues will be the litmus test for the government and those with the task of implementation.
So how is implementation going? Unfortunately, the reorganisation of commissioning (yet again) and the way it is being done risks setting back the aim of increased clinical involvement. Local clinicians and managers who are engaged with clinical commissioning groups are focused on size and structures. Indeed, the relentless timetable for authorisation means there is little time for anything else. The real opportunity to bring general practices into a closer relationship with each other may be lost.
As the King’s Fund inquiry into general practice highlighted, CCGs could create an environment that is conducive to quality improvement, with GPs holding each other to account. But CCGs must also engage member practices in transforming primary care – the only way to deliver on the quality and productivity improvements required.
On the provider side, Strategic Health Authorities have been working with the Department of Health to enable all trusts to become foundation trusts by the official deadline of April 2014. But there is growing evidence that regulator Monitor has concerns about the finances of some trusts. The King’s Fund report on London suggests that many trusts are unlikely to achieve foundation status without some restructuring.
Solutions used to deal with ‘failing’ organisations, such as mergers with high-performing ones, don’t necessarily deliver benefits and can often have negative impacts on performance. Franchising to the private sector is being tried in one high-profile deal with private firm Circle managing heavily indebted Hinchingbrooke hospital, in Cambridgeshire. But it is not clear that there is a private sector appetite to take on other failing trusts. Instead, significant restructuring of hospital services, with some closing or moving off hospital sites altogether, is needed.
Local implementers have significant discretion to interpret policies – and often do more to shape what happens on the ground than radical plans dreamed up in Whitehall. It is vital that commissioners and providers work together to understand the challenges and agree a strategy for local health and care systems. They will need help from high quality data analysis, IT systems and financial and contracting support.
While there are important issues about the Health and Social Care Bill to be resolved, the continuing uncertainty over commissioning means that local clinicians and managers are wasting precious time, energy and resources that could be better spent fixing the NHS locally for the benefit of all.
See the March feature on health and social care
Anna Dixon is director of policy at the King’s Fund
This article is published in the March edition of Public Finance magazine