Passing the Buck

Andrew Lansley’s vision of an NHS Commissioning Board, independent of the Secretary of State, sounds superficially convincing. The constant political meddling of his predecessors as they tried to micromanage the NHS from the centre was generally counter-productive. But in divorcing himself from the Board, Lansley must not divorce himself from accountability for the state of the NHS and the effect his Health and Social Care Bill has on it.

Lansley admitted on BBC1’s Question Time that ‘all government Bills are incomprehensible’. We simply have to trust in him that it will do what he claims it will. Lansley is publically certain that the NHS will improve with free market competition, that clinical commissioning groups headed by GPs will have the expertise and resources to deliver the toughest multi-billion pound challenge the NHS has ever known and that European competition law won’t stand in their way.

But no reforms can flourish without winning over the staff and patients, who are culturally very resistant to the idea of health as a commodity and need to see evidence that Lansley’s approach will work. There are no randomised controlled trials of health reforms but no reason why NICE shouldn’t provide independent analysis on which strategies are most likely to work and give value for money. The NHS is desperately short of cash and having to make £20 billion savings. Before Lansley throws all his cards up in the air and spends another small fortune on structural reorganisation, redundancy and rehiring, NICE should tell us if this represents a good use of resources.

Experts are at least voicing their concerns. Stanford University Professor Donald Light  has studied the NHS and other European health care systems for 25 years: ‘The reforms simply will not work. They rely on inexperienced clinical commissioners who lack any expertise or experience in contracting for millions of pounds of specialty care, even though they understand the clinical issues better than most managers. As has happened in every reform since 1990, the commissioners will be kept poorer, paid less, and under-equipped compared to the executive teams of hospitals.  Inequities are likely to sharply increase as are dislocations in service. Competition is about losing: only a few win a competition and everyone else loses. Why take the NHS down that road?’

‘The Dutch and German health care systems are being much more careful to establish rules of fairness in competition, and have set up elaborate, careful and worried watchdogs. Even with all that, competition has not produced any clear benefits. The NHS proposals are, by comparison, loose-cannon competition.’ UK health economist Professor Alan Maynard concurs that ‘competitive commissioning requires very high levels of complex regulation to design, implement and performance manage the system.’ Based on an on an international study of commissioning, Professor Chris Ham from the King’s Fund concluded ‘there is little substantive evidence that any commissioning approach has had a significant strategic impact on secondary care services.’ Lansley knows the NHS is running more hospitals than it can afford. But instead of making the case for hospital closures bravely and openly, he is hoping GP commissioners will do the dirty work for him. Clare Gerada, chair of the Royal College of GPs, is adamant this should not happen. ‘Big decisions –like whether to close hospitals – should be the responsibility of governments, not GPs. It’s the government’s job to decide how much we invest in healthcare – and what services the NHS should provide. ’

The Nuffield Trust is researching how the NHS can learn from other countries in times of austerity. A key conclusion is that  ‘it requires skilful political leadership and honesty with the public about the need for cuts.’ Instead, Lansley has devolved his responsibilities to GP commissioners who will be starved of the expertise and resources to do the job properly and a Commissioning Board run by a former communist party civil servant who doesn’t believe the reforms will work but can’t go public about his concerns. Lansley needs to take over the reins, be honest about hospital closures and start speaking the language of compassion, not commodity. He also needs a chairman of the Board with a deep and expert knowledge of the NHS. Step forward Professor Malcolm Grant, novice health commissioner, who’ll do the £60k job part time while continuing as £378k Vice Chancellor of UCL. As Chairman Mal puts it: ‘I have to say that the Bill is completely unintelligible.’

For more thoughts of Chairman Mal, go to http://www.healthpolicyinsight.com/?q=node/1268