Pause for Debt

Andrew Lansley’s one month pause to consider the 353-paged Health and Social Care Bill may at least give us the chance read it (12 pages a night is the maximum safe dose), but many appear to have made up their minds without bothering. 99% of delegates at the Royal College of Nursing conference gave him the thumbs down and now Nick Clegg has weighed in with ‘five key demands’ which are ‘non-negotiable’ 1. Competition should be driven by quality, not price. 2 GPs should not commission services alone. 3. GP consortia must not go ahead in 2013 if they are not ready. 4. The principles of the NHS constitution must be protected and 5. GPs must work local with councils.
If Clegg had digested the Bill and its hundred amendments, he’d know that these pledges have already been met, at least on paper. What happens in practice is anybody’s guess. Lansley’s original intent was to be ‘permissive’ and ‘local’. Strategic Health Authorities and Primary Care Trusts would go, leaving GP consortia free to decide their own size and make-up, and free to buy services from ‘any willing provider’ without too much in the way of accountability. After all, they were only being given £80 billion to spend.

The policy was openly questioned by NHS’s centrist chief executive David Nicholson. More surprising was his appointment – without competition – as head of the new NHS Commissioning Board. Nicholson is now busy centralizing what’s left of PCT’s in the hope of making £20 billion of savings. Non urgent GP referrals are being delayed across England, and lists of treatments that will no longer be available on the NHS have been drawn up (Eyes passim). The buck for these savings plans will then be passed onto the GP consortia. For example, in Birmingham and Solihull savings of £219 million will have to be made in 2011-2012 just to break even.

If GP consortia fail to make such massive savings, as many suspect they will, Nicholson will take back control and try to do it all from the centre, an approach that Labour tried with mixed success. The economic crisis makes management of the NHS in the next five years a near impossible task, particularly if you’ve kicked out the good managers along with the bad, and lost the expertise of some of the better PCTs.

GPs were chosen to kick-start commissioning because practices have defined lists of patients they can buy services for. But to do it well they have to join forces with hospital and social care staff, and allow patients to tell them which bits of the NHS work well and which bits are shit. The aim is for an integrated NHS where consultants would do clinics in the community, GPs would go on ward rounds and social workers would go everywhere, but many frontline staff are already doing two jobs, as those who leave and retire are not replaced. To prevent a future ‘Mid-Staffs’, the NHS needs to rediscover its humanity, and that simply won’t happen if the staff are burnt out.
Commissioning also has to be legal, and competition law is complex. All services have to go out to tender and any changes need public consultation. Whether consortia can achieve anything with a fraction of the management support of PCTs is debatable. With money so tight, commissioning better services can only happen if you decommission others, but no-one has figured out how to close anything in the NHS without a nasty, politicized, media frenzy.

Labour’s NHS was friendly if you toed the line but very intolerant of dissent, and many whistle-blowers had their careers destroyed and their concerns silenced. Getting rid of the SHAs may help, provided the bullies don’t all decamp to the Commissioning Board, but the bottom line is that the NHS is facing its toughest financial restrictions ever, services will close, waiting lists will rise and jobs will be cut. GPs are less likely to bully and more likely to tell it like it is, but they’re also more likely to shy away from commissioning if all it results in is unpopular rationing and negative press. It’s a tough time to be in charge of the NHS, which is why they gave the top job to Nicholson, the only willing provider. The new financial year has kicked in and the shit has hit the fan. All Lansley can do is sit tight and pray.

MD