The NHS Reforms: An Update
David Fisher examines the NHS reforms and, one year on, what's changed?
Twelve months ago, the Government embarked on a programme to reform the National Health Service. As part of the plan to jumpstart the stalled economy, £20 billion was sliced from the health budget. This money would be raised by abolishing financially inefficient primary care trusts. Their responsibility for purchasing patient services would be transferred to GPs. Not only would the arrangement save money by removing a tier of administration, it would hopefully lead to improved patient services and delivery of healthcare. A healthy injection of market competition amongst providers would drive efforts to engender greater patient satisfaction for lower prices. Principally, the proposals sounded auspicious but failure to quickly modify the Health and Social Care Bill following a barrage of complaints left the reforms tainted and with a damaged reputation. It is hard to recover once a dog has been given a bad name but in this case, the bad name is no longer deserved.
Initial concerns surfaced shortly after the proposals were floated. Doctors were concerned they were unqualified for resource management and would be caught in a conflict of interest if they balanced patient interests against profits. Other opponents felt it was unrealistic and irresponsible to manipulate an organisation the size of the NHS in an effort to tackle the deficit. Most problematic was the speed which the Government intended to implement the scheme.
A consensus emerged that believed the preparatory consultation had been inadequate and the time-frame to implement the reforms too narrow. Doctors felt particularly aggrieved that many of their concerns had been disregarded. This initial failure by the Government to invite cooperation from doctor’s groups and address their concerns before publicly presenting the reforms became highly significant.
The Government was effectively attacked for alienating the doctors by a barrage of vocal opposition from various groups. A recent survey by the Royal College of GPs recorded more than 70 percent of respondents want the Bill to be withdrawn. In March, at a Special Representative Meeting of the British Medical Association, Dr Hamish Meldrum, the chairman stated to rapturous applause, ‘I do not support this Bill. The BMA does not support this Bill. The profession does not support this Bill.’
In April, pressure mounted on the Government to significantly alter the Bill. A Health Select Committee of eleven MPs recommended tighter governance and accountability for service commissioning to ensure maximum quality of care. They suggested specialists should hold positions within consortia to reduce the risk of service fragmentation. Lay representation would aid public accountability. Decisions should be transparent and visible to the public, reducing the risk that conflicts of interest would develop. Buckling under pressure, the Health Secretary announced a three month pause which would serve as a listening period and opportunity to improve the reforms. A multidisciplinary group comprising health professionals and patient representatives formed the NHS Future Forum and was charged with overseeing the long overdue gathering of opinions.
June heralded numerous changes suggested by the Forum. Safeguards were introduced to prevent private companies ‘cherry-picking’ the most profitable services. Transparency of multi-disciplinary consortiums was assured and the time-frame for transfer of duties made more flexible. Competition for its own sake would no longer be the foundation stone supporting reform but would be used as a tool to improve choice and quality of services. Finally, the health secretary would remain responsible for the everyday running of the NHS, deviating from the original plan to delegate the responsibility.
The outlook for the reforms has appeared full of doom and gloom but glimmers of hope have been underreported. Policy Exchange, a think tank, published an analysis of the early implementation of the GP-led commissioning. The Government set up pathfinder groups of GPs to pioneer the reforms by commissioning services. Speaking with these GPs revealed blossoming enthusiasm. They warned that consortia decisions must have more input from patients and should be designed so patients may choose between competitive consortia. Alarm was sounded over the consequences of rushing the abolition of Primary Care Trusts and the potential for consortia to simply replace the existing structure with no innovation. These concerns have been reported in the media but the positive essence of the report has been missed. Many of the pathfinder groups are extremely promising. The report prophesises that careful implementation of the plans, taking into account current concerns, will benefit patient care. The pathfinder scheme is a unique test of the reforms and so these conclusions are extremely propitious. A survey by the British Medical Association highlighted the difference made by a practical understanding of the reforms. Asked whether reform would increase clinician decision making, only 39% of surveyed doctors agreed but this figure leapt to 73% among pathfinder GPs.
Still the reforms are unpalatable in the eyes of many doctors. In January this year, 92.8% of surveyed GPs believed the Royal College of GPs should call for the withdrawal of the Bill. In a letter to the health secretary they call for another confirmation that he will retain responsibility for the provision of care. They desire clarification that services will only be exposed to competitive market forces if evidence proves it in the patient’s best interests. Additionally, they seek safeguards on education and training. It is curious that even though these three concerns can be remedied, the college is still considering calling for the withdrawal of the Bill.
A year ago, the proposed NHS reforms were badly presented to doctors and to the public. Misplaced eagerness hoped to breeze through momentous structural reform and failed to act upon professional opinions and concerns. A bad start stained the Bill and polluted its noble objectives. Naturally, reform of this magnitude would be initially imperfect and require improvement, but the criticism from organisations was suffocating. The dog of reform was hounded.
The Government has taken several steps to address concerns and the preliminary testing of pathfinder schemes has revealed promising results. Further improvements are required but if managed carefully and embraced, these reforms have the potential to deliver improved healthcare at lower cost. Maybe it is time to give the dog a new name.
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