Wake up in Wakefield

Last week, MD chaired a clinical commissioning meeting in Wakefield where Dr James Kingsland gave a blunt summary of the NHS reforms: ‘It’s simply about making clinical staff financially as well as clinically accountable.  Every clinician has to question every decision he or she makes to ensure it’s the best use of NHS resources. We have to make £20 billion in efficiency savings. There is no plan B.’

Kingsland is a senior GP partner and the ‘national clinical commissioning network lead’ at the Department of Health. He’s in a consortium covering 7 GP practices and 40,000 patients, and told of his frustration that one of his patients had gone straight to hospital with cellulitis, where he was admitted for nine days on intravenous antibiotics at a cost of £5000. The infection could have been treated equally effectively – and far more pleasantly – at home with tablets. ‘There are 8,300 GP practices in England and if we all stopped someone like that going to hospital every week, that’s £2.5 billion saved.’

It’s a fair point but you don’t need a Health and Social Care Bill of bewildering complexity just to ensure patients don’t go to, or stay in, hospital unless they absolutely have to. Labour tried to promote Healthcare Closer to Home but hospitals – particularly those with unserviceable PFI debts – were so desperate for business that they sucked as many patients in as possible and GPs didn’t put up much of a fight. Now GPs are being forced to limit referrals and it’s having an effect. Hospital admission and referral rates are down, hospitals are no longer paid for patients who are readmitted within 30 days for the same problem, and savings are being made. On the downside, by Andrew Lansley’s admission, 60 hospitals run by 22 PFI funded trusts are now in the brink of financial collapse.

This was always going to happen given the recession and flat-line funding (Eyes passim). In the past Labour threw money at indebted hospitals but it’s rich of Lansley to finger PFI given its Tory roots. The income of hospitals is set to take a further hammering when ‘any qualified providers’ (AQPs) enter the market offering, say, dermatology and ENT outpatient services at the same cost as the NHS but in nicer buildings with easier parking and real coffee. Hospitals that relied on block contracts to survive will be fighting for every single patient.

The task of coming up with a tariff for every single episode of care in the NHS so it can be put out to tender is down to the economic regulator Monitor. Whether it has the expertise to strip down psychiatry into component parts in any meaningful way remains to be seen, but tariffs don’t work when they fail to differentiate between patients, some of whom require far more complex and expensive detoxification or hip surgery than others. And if the coding is done on the cheap by those with no clinical experience, bills and outcome measures become littered with errors.

The best bit of the health reforms is encouraging clinical staff to get involved in figuring out better ways of treating patients. Clinical staff should also be ensuring that diseases and treatments are accurately coded to save money and lives. The Mid Staffs inquiry has heard allegations of managers flipping diagnoses to avoid scrutiny of poor mortality rates, and the regulators failing to spot this. The NHS needs peer review spot poor care, but a Care Quality Commission spreadsheet of all job adverts for the last year reveals none require any medical or nursing qualification. The posts of “Deputy Director of Operations”, “Registration Assessor” and “Senior Analyst” all say in the qualifications column ‘none required’ (see www.medicalharm.org )

Lansley is paving the way for hospital closures and will try to pass the buck onto PFI, Labour, the financial crisis, clinical commissioning or even patients choosing not to go there. But health secretaries are always held accountable for the state of the NHS on their watch. Lansley needs to make friends with NHS managers and get clinicians involved not just in commissioning, but regulating and inspecting to make sure the services they buy aren’t all done at high risk ‘on the cheap’, and actually improve the lives of patients.