Editorials

The Future Forum proposes major changes to the government’s plans for NHS reform

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d3769 (Published 14 June 2011) Cite this as: BMJ 2011;342:d3769
  1. Chris Ham, chief executive
  1. 1King’s Fund, London W1G 0AN, UK
  1. c.ham{at}kingsfund.org.uk

Integrated care should be given priority, with less emphasis on competition

The report of the Future Forum, established by the government to lead the listening exercise on the proposed reforms of the NHS in England, has put forward a series of recommendations for modifying the direction of these reforms and the Health and Social Care Bill currently before parliament.1 Although it accepts the need for change, the forum has responded to the concerns of organisations representing patients, staff, and other stakeholders by reiterating the importance of the values contained in the NHS Constitution and urging caution about the role of competition in the NHS. It has stopped short of recommending that the Health and Social Care Bill should be abandoned, but the forum’s proposals nevertheless amount to far reaching modifications of the government’s plans.

The forum argues persuasively that care needs to be integrated around the needs of patients, noting that “concerns around integration came up time and time again” during the listening exercise. Citing examples of successful integration, including diabetes care in Bolton and care for older people in Torbay, it asserts that there is a need to move beyond arguing for integration to making it happen. Other recommendations in a short but wide ranging report include making patient choice a reality, allowing commissioning consortiums to take on their responsibilities only when they are ready to do so, and providing independent expert public health advice at all levels.

In advance of publication of the forum’s report, the prime minister gave a clear indication that he was “ready for turning,” to adapt Margaret Thatcher’s memorable phrase. His speech at the National Hospital for Neurology and Neurosurgery on 7 June emphasised that competition would be used as a means and not an end, and that much more emphasis would be given to collaboration between healthcare providers and the integration of care.2 He also argued that hospital doctors and nurses would be involved in advising on commissioning, anticipating one of the forum’s recommendations. The government has accepted all of the core recommendations as a demonstration of its sincerity in launching the listening exercise and its willingness to take account of stakeholders’ concerns.3

The fate of the reforms now hinges on coalition politics and the reaction of key groups of staff, especially general practitioners, as has been apparent since the reforms were first announced in the summer of 2010.4 Although the forum’s report provides a basis for the prime minister and the deputy prime minister to agree on changes to the Health and Social Care Bill and the general direction of reform, these changes have to be accepted by their supporters in parliament and the country. There are already signs of tension on this score as some Conservative members of parliament are unhappy at the reduced emphasis on the role of competition in healthcare. With Liberal Democrats claiming that the concessions they have negotiated amount to victory in the debate within government on reform, the future direction of health policy is not yet settled.

The reaction of general practitioners will also be important. The enthusiasm with which pathfinder commissioning consortiums have been established owes much to the willingness of a small proportion of general practitioners to pick up the gauntlet and lead their colleagues in taking on the responsibilities being offered to them. Proposed changes to the plans for consortiums, including the involvement of other clinicians and more formal requirements for governance, risk dissipating this enthusiasm if these general practitioners perceive that their freedoms and flexibilities are being fettered. It will be important to support consortiums that are able to take on responsibility for commissioning, so that they can do so as quickly as possible and avoid their commitment waning.

Equally important will be the ability of the NHS to absorb the increasing operational pressures it is facing while taking forward the much modified reforms. The prime minister’s recent speech was notable less for what he had to say about these reforms than his commitments to keep waiting times low and maintain NHS spending in real terms. The very fact that he thought it necessary to make these commitments signifies concern at the heart of government that the NHS is struggling to sustain improvements in patients’ access to care achieved under the last government. Seen in this context, the Liberal Democrats may have won only a pyrrhic victory on healthcare reform if the NHS is catapulted back into headlines as a result of declining performance.

Organisational changes and cuts in management costs made since the election have almost certainly contributed to the pressures facing the NHS, and their effects will continue to be felt even if the recommendations of the Future Forum are accepted. Modifying the pace of change in line with the forum’s sensible advice may help alleviate the impact of these pressures, but the NHS still faces the biggest financial challenge in its history, as the all party Health Services Committee has pointed out.5 In rising to this challenge, it is inevitable that changes will be made to how clinical services are organised, both to improve quality and patient safety and to release resources.

Politicians have been in denial since the election about the necessity for service reconfigurations, perhaps because of commitments made before the election and the well known difficulties of persuading the public to accept reduced geographical access to services, even if quality improves as a result. In an unscripted passage of his speech, the prime minister praised the improvements in stroke care brought about in London as a result of concentrating care in fewer hospitals, seemingly unaware that these improvements had resulted from the Healthcare for London programme that his government terminated soon after coming into office. The Future Forum makes only passing reference to service reconfigurations and yet they are crucial for the new model of care described in its report to be realised.

Notes

Cite this as: BMJ 2011;342:d3769

Footnotes

  • Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References