NHS reforms II

About a year ago I tried to summarise my understanding of the then new-ish UK coalition government’s health plans— see here.

So with news that some of the government’s own cabinet ministers have serious reservations about these very same— their own— plans, maybe it’s a good time to revisit the topic.

The main elements of the plans I identified back then were:

  • Scrapping PCTs and replacing them with commissioning consortia [and I could have added- scrapping the strategic health authorities, SHAs, the next tier up of health service management)
  • Downgrading the regulatory powers of NICE
  • Moving responsibility for public health from PCTs (ie from the health service) into local authorities (ie into local government)
  • Scrapping the health protection agency (HPA) and absorbing its functions— sorting out communicable disease epidemics and chemical spills and the like— into a new body responsible to the Department of Health, which we now know will be called ‘Public Health England’, and which— it turns out— will also do some of the health improvement and health service planning and delivery roles formerly done in the to-be abolished PCTs and SHAs.
  • An NHS commissioning board to oversee the process at the national level.
  • Some noble aims:  putting patients at the centre of decision making; empowering health professionals; devolving decisions to local level and making services more responsive; focusing on clinical outcomes rather than processes; and (ha!) reducing health inequalities.

If this all seems rather dull and complicated to normal people (ie those not closely following UK health policy)… well, it is. But sadly, dullness does not equate to unimportance.

At the time there were some elements of these plans that seemed reasonable, but also a good deal that was unclear and/or slightly worrying. Nor was I sure that my understanding, as summarised above, was correct. But the biggest proposed reorganisation of the NHS since 1948 was clearly going to be complicated and difficult. There were some positives there and I didn’t want to be too negative while the bulk of the detail was still to come.

After all, Something Needs To Be Done with the poor old ailing NHS. Difficult economic situation, ageing population, increasingly complex interventions, and all that.

Naturally I hoped ‘they’ (AL and advisors) had worked out some of the thornier issues in advance, and would introduce any changes at a sensible pace and with plenty of reasoned discussion along the way.

Surely, over the next year things would become clearer. As a practising GP and student of public health, I was well placed to keep abreast of the upcoming changes, and had a keen personal interest in doing so. I would attend local meetings on subjects such as GP commissioning. I would follow how the plans developed in the medical and non-medical press. I would pick the brains of the public health people I came into contact with, hoping that they could explain what was going on.

And— I’ve tried to do all those things. I’ve attended a couple of talks on commissioning (local and RCGP) and kept abreast of national developments as best I could. Alas, with a busy life in the real world I’ve been unable to read every revision and amendment as the different versions of the Health and Social Care Bill shuttle between Houses, Colleges, Faculties, and newsrooms. Every now and then I’d hear something new: GP commissioning becomes ‘clinical commissioning’, ‘any willing provider’ becomes ‘any qualified provider’, local talking shops called ‘Health and Wellbeing Boards’ suddenly pop onto the discussion, and so on.

And the laudable (if not always compatible) aims of local responsiveness, patient choice, health professional empowerment, and reduced inequalities get lost in a welter of confusing detail. Some dim patterns are discernible in all this: a lot of big structural changes, tiers of bureaucracy scrapped, new bodies springing up to take on orphaned roles… As the enormity and proposed rapidity of the changes becomes clear, issues such as the exact role of NICE or exactly who gets to do health protection— hardly  unworthy of attention— begin to seem almost trivial in comparison to the scale of the proposed wider reconfigurations.

Let’s use a straightforward medical analogy: the patient is not going to get a routine over 65 health review and prescribed a new statin and antihypertensive, but is instead destined for combined open heart surgery, spinal cord microsurgery, AAA repair, bilateral knee and hip replacements— and a slew of distracting cosmetic procedures— all to take place in the same afternoon theatre slot.

And there is growing criticism from health professionals, growing concern in the press, and building opposition from politicians— it now seems— of all hues. Now my thinking goes something like this:

  • Is all this really going to save money?
  • Hold on: the biggest changes in over fifty years to what is surely one of the most complex organisations— and certainly the largest employer— in Europe, and they want it all in place by 2013? Next year? Isn’t that a little, well, hasty?
  • If this was all so well thought out, why all the revisions and amendments?
  • And a not unrelated question: why does it still seem so complicated? It was supposed to become clearer over time, not cloudier. Interestingly, this is also the opinion of one of the UK’s leading public health researchers.

Here we get to the nub of it. Maybe it really is that complicated— in which case, it seems we are expected to believe that even if experts in health system research and frontline public health people and clinicians don’t understand it, at least Andy and friends have all the angles covered.

Or the more likely story: they are finding that as they unravel the threads of a devilishly complex interdependent system, unexpected holes keep appearing. Some of them are big enough that people notice. Cue panicky on-the-hoof policymaking to patch them up.

[Or, for the conspiracy theorists, there is a Hidden Privatisation Agenda. As my disquiet grows I find myself increasingly thinking like a conspiracy theorist.]

In short: I no longer have any confidence in the coalition government’s health plans. None whatsoever. There may have been some good ideas in there somewhere a while back, but they are now irretrievably lost in the mess of the current Health and Social Care Bill.

It needs to be scrapped. The government needs to start again from a clean sheet.

Primum non nocere.

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