Reforming the NHS: accountability
Thomas Cawston 5:41pm
Last week, Reform published
its 2011 public service reform scorecard. It judged each major government department against the three criteria set out by David Cameron: accountability, flexibility and value for money. The report
finds the Home Office’s policing reforms succeeding on all three fronts, but inconsistency across other government departments. The Government’s health reforms are awarded grade D
overall, with an E for accountability, a D for flexibility and a D for value for money. Here's how the coalition can get its NHS reforms back on track.
The government has recognised the need for fundamental reform of the NHS. The proposals announced in the July 2010 White Paper are substantial. However, the government’s plans leave
accountability divided between patients, doctors and local authorities. Healthcare delivery continues to be centralised: Andrew Lansley has placed a moratorium on hospital closures, and the
government will maintain national direction of the workforce. The decision to ring-fence health spending means that health policy is based on increasing inputs and not value for money; significant
waste has been identified, but it should still be protected.
The government is reorganising the NHS’ commissioning structure. Clinicians will have to commission healthcare services from a plurality of providers and put patients at the heart of the NHS.
However, rather than consumer choice, the NHS White Paper sees professional empowerment and localisation as the key drivers of change. This has divided accountability: the reforms make GPs
responsible for commissioning medical services on behalf of patients; consortia are accountable to the Commissioning Board; local authorities will be responsible for public health, joining up
commissioned services and leading strategic needs assessment. Moreover, the Health Bill gives the
Commissioning Board significant powers over consortia. But it also gives the Secretary of State power to direct the Commissioning Board not only in what it does but in how it does it. Consequently,
accountability runs to the centre with “the Secretary of State…hold[ing] the NHS to account for improving healthcare outcomes.”
Sitting before the House of Commons Health Select Committee, Sir
David Nicholson stated that “we’ll have to centralise more power in the very short term to deliver benefits”. The Commissioning Board, which Sir David has been chosen to
chair, will be able to wrest funds from allocations to commissioners for the purpose of creating risk-sharing arrangements and to bail overspending consortia out – implying that surplus
generating consortia might not have their full underspends returned to them each year. This disincentivises success and indicates that the desired healthcare market may advance no further than it
did under the Primary Care Trust structure, which was subject to such top-slicing under the previous Government. In addition, having abolished targets, the Department of Health’s technical
guidance for the 2011-12 Operating Framework runs to 261 pages and contains more
than 100 indicators “against which the NHS will be held accountable”.
Existing proposals would see a new national workforce strategy for NHS employment. Despite a stated desire “to
empower healthcare providers, with clinical and professional leadership, to plan and develop their own workforce”, the proposed strategy calls for “sector-wide oversight of key aspects
of workforce planning, education and training” and “mechanisms that allow the NHS Commissioning Board to have strategic influence on the national picture for education and
training.”
Broadly speaking, the reforms aim to liberate the NHS from central control and create “the largest social market in the world”. However, providers’ freedoms continue to be
curtailed. The Secretary of State has imposed a penalty upon hospitals that continue to house patients in mixed sex wards. The government also acted immediately to stop NHS London’s proposed reorganisation of its healthcare services and introduced new tests for
redesigning hospital services.
If the government really wants to deliver a revolution in healthcare, it must make doctors and hospitals accountable to patients, not to multiple points within government. Doing so would create a
real market for health and the government must remove regulatory barriers to ease access for new entrants, while restrictions on how providers deliver their services must be lifted. Above all, the
ring-fenced budget must be scrapped to incentivise a real focus on value for money.
Thomas Cawston is a researcher at Reform
Previous
TrevorsDen
February 21st, 2011 6:40pm Report this comment'However, providers’ freedoms continue to be curtailed.'
It is still a NATIONAL health service and the electorate require the govt to set basic parameters.
TrevorsDen
February 21st, 2011 6:42pm Report this commentHow do you make hospitals accountable to patients?
Are patients competent?
It can only be via the GP and this is what is being proposed.
Magnolia
February 21st, 2011 8:30pm Report this commentA patient and GP orientated market system will not work unless the other parties (ie. the providers)are also allowed the freedom to work in a competitive employment market. This article recognises this. The reality will be that for much health care there will be no choice and no market at all. Will patients get a choice of cancer centre or of complicated radiotherapy treatment or complicated large specimen histopathology?
I can see how the education reforms will work because even I could set up a school in my spare bedroom with a blackboard but competition and choice in cancer treatment?
The NHS is not a great employer and there will be many staff that would love to have a choice of employer but there doesn't seem to me to be a way of providing this for the most demanding aspects of health care given what we are starting with.
A system that introduces competition may reduce health costs in some areas but this may be accompanied by increasing costs in the most complicated procedures and expertise as the market prices rarer talent at a higher value. The only way of keeping these costs down will be rationing and who is going to tell the customer/patient that there is no money for their choice?
The financial constraints put pressure on providers to say there is no need when the reality is there is no money. Who will say to the patient 'you need this procedure but there is no money for it'? Present day reality means that non urgent lumps that are sent for an MRI scan never get one because the pressure of demand is such that all the urgents continually displace the non-urgent cases. Who's going to tell the truth to the patient?
daniel maris
February 21st, 2011 10:12pm Report this commentCant, pure cant.
Sick people are in no position to act as managers.
The premise of the article is completely dodgy. Any organisation the size of NHS is not going to be efficient in all parts. But there is no evidence that localisation is more efficient and we certainly know that private insurance arrangements carry huge administrative costs.
I predict the move to GP commissioning will be an administrative and political disaster. A completely unnecessary one - just like the poll tax debacle.
2trueblue
February 21st, 2011 10:16pm Report this commentOne word missing from all of the above: Standards. There are basic standards of care that each person is entitled to and it is not rocket science to define them. We had 13 yrs. from Liebore promising that we would see the end of same sex wards and what exactly did Liebore do about it?
When I began nursing in 1967 there were fewer personel per patient, less of the great equipment, less drugs, less space in our wards. The care was better and our elderley were looked after better. Go on a ward today and what do you see? Lots of staff clustered round together. They are not having meetings, they are chatting. On nightduty staff use their mobiles to keep in touch with their friends whilst patients bells go unanswered.
Basic care. How can you place a meal in front of someone without ensuring that they are capable of reaching it and can actually feed themselves? That requires no training, it requires that you are a human being who cares. That is what is wrong with our society and becomes apparent when you visit a hospital today. There is no magic bullet that will cure the problem. It is called 'indifference'. If it is not written down , defined, we seem incapable of carrying out that task. It is just caring, simple. It is the thread that makes it all work. We are shamed by our lack.
Martyn
February 21st, 2011 10:39pm Report this commentMr Trevor Den identifies the problem with marketisation. Consumers cannot know. They can be trusted with broad generalities (which govnt to vote for) or with consumables (varieties of coffee), but thereafter voter choice can never be sufficiently informed as to match the voter's best interest. It is the same with a 'market' in higher education. Should the shape of higher education be determined by the choices of 17 year olds? Do they know what is best for them and, moreover, does this match with the 'national interest'? Some form of guided, informed choice is needed, and (importantly) an easy mechanism for providing this, before we embrace a comprehensive market formula.
Verity
February 22nd, 2011 1:49am Report this comment"the three criteria set out by David Cameron: accountability, flexibility and value for money".
What kind of lefty market-speak is that?
Why not, for example, "Service, effectiveness and accountability"?
Or, "Effectiveness, responsiveness and value for money"?
How about, "Executive effectiveness, stand-bye expertise and targetted facilities"?
Make up your own.
Cameron's either a knave or a fool.
The man's an ambulatory slogan.
To continue, the NHS shouldn't exist, except as a competitor in the marketplace. Employed individuals should be able to tick a box regarding where their "health insurance" contributions go - either the NHS or a private insurer.
Individuals who hadn't paid in to any scheme for three solid years should not be eligible for "free" help. (Although, in a free market, individual health insurance companies would set their own time limits.)
There should be no public assistance for visitors or "immigrants", documented or undocumented. They took a chance. They lost.
Do the casinos in Deauville insure me against being disappointed in a wrong bet?
Will J
February 22nd, 2011 8:03am Report this commentIn most European countries many hospitals are provided by local government. As they were in the UK before they were nationalised in 1948. That, supplemented by private and church provision, is what supplies the plurality.
The sheer size of hospitals prevents plural provision in most areas. In Coventry the biggest hospital was recently rebuilt even bigger, and the city's other hospital closed. How you are meant to have meaningful choice when a city of 300,000 people has a single provider is beyond me.
John Emsley
February 22nd, 2011 8:52am Report this commentI live in France,which operates its health cover on the onsurance model.
I am entitled to be reimbursed at various levels ,depending on the treatment. I have top-up insurance to bring the majority of my treatments into a 100% cover situation.
In other words-the money flows through me.
I can pick my doctor and together we pick out the best specialists/surgeons/clinics for my treatment.
Hence I am empowered,my Doctor is distributing his/my needs around a marketplace and quality of service and outcome lead the way-does that ring a bell?
Incidentally, there is a system here too for central records based on a smart card. Wherever I go they only have to swipe that to know the drugs I am on etc-this includes every pharmacy in France. When I look at the billion £ shambles of the UK attempts at this, I could weep.
Why is it that the UK must always go it alone rather than buying known,working solutions off the shelf????
(MOD please take note.......)
Perry
February 22nd, 2011 9:30am Report this commentAnother word missing from the above is 'clarity'. For instance,
Clear statements of intent, purpose and results.
All memos, 'initiatives', and reports to be in Plain English, devoid of PC bullsh*t and weird NooLayba words, and, as the Great Man insisted, on one side of one piece of paper.
That should be a very good start, and sort out the pen pushers from the purposeful people who might then be able to achieve something worthwhile.
Only a suggestion mind.
2trueblue
February 22nd, 2011 10:09am Report this commentJohn Emsley. Your last question is the rel one, why indeed? Because too many egos are allowed to be involved when the steering committees are set up to chose what will be included etc. There were 18 different Patient Admission Systems operating in the UK when I last worked on a project with the NHS. Each one was seperately contracted and negotiated! All down to ego. The waste was unbelievable. Admitting a person to hospital is a pretty straight forward business and I am mystified how it was allowed to happen. The whole thing was mind blowing.
David Bouvier
February 22nd, 2011 11:59am Report this commentMagnolia has gone to the critical question: Providers says there is no need, when really there is no money.
If the NHS defined what care it will pay for and some reasonable pricing, and the basic regulatory requirements to be allowed to treat patients, we would have accountability and quality.
Providers, whether public, private or charitable can develop services they think people will want, and complete to provide the service and quality that patients and doctors choose, within the tariff offered.
Healthcare financial crises are separate from the quality of care - only public changes to reimbursement make that link.
Result: quality of care, transparency of funding, public debate on the right public insurance coverage.
Variations on this cover most Western European countries, and work better than the NHS.
Mr L
February 22nd, 2011 5:40pm Report this commentMy GP is in favour of the new system: he says the existing structure is run by "a bunch of cretins" - and he should know.
These days airports give the impression of being shopping centres which happen to handle a few aeroplanes. The NHS, similarly, looks like a bureaucracy that happens to deal with a few patients.
Mary E Hoult
February 26th, 2011 1:23pm Report this commentI fully agree with trevordens comments
How can GPs ensure the system works?to give an example as patient.Today I have received an appointment for a scan arranged by my GP he did discuss choice with me and I asked to be refered to my local hospital,my appointment received is miles away and not the one I selected.To get there and back I will need to take 6 buses in total time about 3 hours.I have bad balance problems at the moment so where has the patient experience/choice been in all this?
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