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Rapid Responses: Rapid Responses published:
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Commissioning must change
- Andrew N Bamji (7 May 2008)
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West of Offa's Dyke
- Richard Bartley (8 May 2008)
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Re: West of Offa's Dyke: Rhetoric versus Reality
- L Sam Lewis (9 May 2008)
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Andrew N Bamji, Consultant rheumatologist Queen Mary's Hospital, Sidcup, Kent DA14 6LT
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Chris Ham's dissection of the problems of NHS commissioning is welcome to me as it shows I am not the lone voice crying in the wilderness that I feared I was. It is the providers who have the face-to-face contact with patients. Doctors (and their families) can also be patients. Is it therefore too arrogant to suggest that they might have additional expertise in deciding on service planning and commissioning? Is it unreasonable to suppose that commissioners might need some direction in planning? It is odd that they often fail to take specialist advice and then wonder why they confront opposition post hoc. I am convinced further that the current system of commissioning has lost touch with the reality of patient care. Commissioners have become obsessed with saving money and have started playing games to achieve this. Secondary care services are (largely) paid for through the Payment by Results (PbR) tariff but increasingly we are seeing attempts to commission cheaper services by finding ways around paying tariff rates. In my own area a consultant service in rheumatology has been established within a GP practice, so not subject to PbR. It costs less than half the PbR tariff rate which I, as an acute Trust employee, cannot match. Can my own service go off tariff? Actually it appears that it can - by establishing clinics that call themselves something else (for example, a medical musculoskeletal service). Using such a title I can tender my services at a newly competitive rate and win back some lost business (about 50% of my non-inflammatory joint disease caseload). My Trust will make less of a profit, but it gets some money instead of none. It is, of course, unfair for a service to be forbidden to set its own price. At least that's what I think, but I can't get anyone to test this; the Competition Commission. the Office of Fair Trading and the Trust lawyers refuse to act and I cannot afford to mount a judicial review myself. In Hillingdon the PCT put out a tender for the entire musculoskeletal service which, I understand, was awarded to a private company. The PCT set charges that were between two-thirds and three-quarters of the PbR tariff. I have been told that the acute Trust's lawyers advised that it could not tender below tariff and was thus excluded from applying to do its own work. The knock-on effects of removing an entire service from a hospital are worrying indeed; elsewhere this was recognised (the Lancashire/Cumbria musculoskeletal ICATS proposal was abandoned partly for this reason. So how has Hillingdon got away with this? Did it consult the patients? Would they have agreed? From my own experience I doubt it. If we are to avoid such absurd perversities and the need to play games it is essential for all barriers to fair competition to be removed. However the risks to existing systems from such competition must be factored into any financial analysis. But to adopt this common-sense approach requires the abolition of PbR; if it persists, yet independent organisations are free to undercut it with impunity, then secondary care as we know it will collapse. Maybe it will anyway - but if that were to happen it should be for sound clinical reasons and not for the sake of saving a few thousand quid here and there. The joint College's concept of "Teams without Walls" becomes increasingly attractive. This can, of course, be instantly achieved by putting all hospitals back into PCT management. This allows them to set their own tariffs and at a stroke restores care to the community without disturbing a thing. That we are reinventing the Health Authority system by doing this further demonstrates the folly of the purchaser-provider split which has done nothing but increase bureaucracy and led to war between primary and secondary care. Competing interests: None declared |
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Richard Bartley, Physiotherapist Denbigh, Wales LL16 3ES
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The Welsh Assembly Government (WAG) is looking carefully at what is happening in England and I am sure learning valuable lessons. WAG claims it wishes to remove the internal market in Wales and is currently circulating a policy discussion document on the future remodelling of the Welsh NHS (1), even though on close inspection it doesn’t seem to be aiming to remove the internal market in its entirety. An internal market will obviously only work if private and state- funded providers compete on a level playing field. The obstacles described by Professor Ham are the very issues that prevent true competition. To hope that a commissioning system will be fair and efficient under these conditions is pure folly. However, I cannot see how the Kaiser Permanente model can offer anything better, given that many parts of Wales cannot financially sustain or justify multiple integrated ‘total’ providers. I don’t anticipate any change in England with the present micro- management obsessed government in power, but I hope the WAG will put an end to this internal market nonsense in Wales. 1. http://new.wales.gov.uk/consultations/currentconsultation/healandsoccarecurrcons/nhswales/?lang=en Competing interests: None declared |
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L Sam Lewis, GP Surgery, Newport, pembrokeshire , SA42 0TJ
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Not only is the supposed internal market unlikely to work in Wales, it frankly does not exist (much). Sure , there was a purchaser / provider split under Thatcherite 'New Public management', whereby Health needs for populations were to be determined, and then as a distinct and separate step, commissioning /purchasing was supposed to hire the necessary providers... But it was more of a structural dream than a truly working model.. Nowadays, Labour and Plaid want to see the back of all things Thatcherite in Wales. Fair enough - that's what the people of Wales appeared to vote for, and they are the shareholders. But it won't change much of the reality - whereby Trust Providers dominate 'market-share', and no Local Health Board Commissioner in Wales has made the slightest practical effort to re-shape it. Interestingly, the Wales, Scotland, and NorthernIreland health systems increasingly match to Ham's theoretical 'integrated models', with inherited market-dominance. I hear that English border constituencies are forming an orderly queue in applying to cross the Dyke or the Tweed. I am wholly in favour of population empowerment, representative and local democracy, and celebration of diversity. But what will actually make a difference to EFFICIENCY or EFFECTIVENESS in today's health environment ?? Competing interests: an Internationally-minded English-born GP working 25 years in West Wales. |
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