The debate, held at a breakfast session in Dorking, Surrey, was chaired by Fiona Godlee, BMJ editor in chief. The attendants were Nigel Edwards of the King’s Fund and KPMG; Judith Smith, head of policy, Nuffield Trust; Gareth Goodier, a doctor and chief executive of Cambridge University Hospitals NHS Foundation Trust; David Bennett, head of the NHS trust regulator Monitor; Helen Thomas, medical director of Sentinel Commissioning Group in Plymouth; Penny Dash, a doctor and partner, McKinsey and Company; James Morrow, a general practitioner in Cambridgeshire; Clare Gerada, chair of the Royal College of General Practitioners; Simon Stevens, former adviser to Tony Blair and president of the global health division at UnitedHealth Group; Alastair McLellan, editor of the Health Service Journal, and Paul Corrigan who worked with Tony Blair and is now a management consultant and blogger.
Fiona Godlee: Welcome. This session is intended to look at what life will be like after the bill. Do you think it will be very different?
David Bennett: I shouldn’t think there will be huge changes. In many ways it’s about taking things that are being done today—whether you’re talking about pricing or the principles and rules of cooperation and competition—and putting them on a more statutory footing. In particular, putting them into Monitor or the [NHS] Commissioning Board.
Helen Thomas: I think after the bill it will be exciting to get a move on because we feel like we’ve been stalling, waiting for edicts to come down from the Department of Health that don’t come, or they do but we try to fight them. I think once we’ve got a line in the sand it will be useful to get on and do it. We’re particularly looking forward to working with our secondary care colleagues. And the only thing that engages my clinicians locally is talking about patient care and improving it.
Gareth Goodier: I think that the budget challenges are having a far greater impact. While I’m not in favour of GP commissioning because of the conflict of interest, I am for clinically led commissioning. And the changes going on in Cambridgeshire are very positive because we found the discussions with the GPs much more fruitful and sensible than with our previous commissioners. I wish this was speeded up because we’re in limbo.
James Morrow: I think the dangers from the bill are that the increased tiers of bureaucracy, central control, and regulation may stifle some of the innovation. The danger of regulating for the peripheries is that you stifle the majority in the middle—that tight regulation for the poor performers is a barrier to the majority getting on and doing things well. That’s where it’s going to require intelligent interpretation from Monitor among other bodies.
Penny Dash: The key challenges are going to remain. Those are three things: the need to redesign the system to better look after people with long term conditions and older people—largely outside hospitals; secondly, to improve quality of care to ensure that every provider is as good as the best, and to improve beyond that; and, thirdly, to have more efficient services.
Clare Gerada: I think the positive bit of all this is that it has catalysed GPs to re-engage with planning services for their patients and talking across professional groups. A figure came to me today, which is that the top 10 activity costs account for £34bn (€41bn, $54bn) [of the total NHS spend]. A lot of that isn’t due to the ageing population. It’s due to boring things—accidents, smoking, obesity, and alcohol. We’ve got to start getting the message correct. We’ve got to start investing in community services, public health, general practice, because that is the only way of reducing [the £34bn]. This is about preventing that activity from having to happen in the first place.
Judith Smith: The devil is, for me, in implementation. I was a health manager, and my sense is that what the service needs now is certainty. The managerial and the clinical leadership communities need assurance that the direction is set so they can get on with the serious business of implementation.
Alastair McLellan: Everyone has asked for certainty. It ain’t arriving any time soon just because the bill has passed. There is a huge swathe of secondary legislation. There is a huge range of guidelines to roll out. There is as much uncertainty in front of us as behind us.
Nobody has talked about commissioning support. That is going to be as important as CCGs [clinical commissioning groups]. I believe the best of CCGs will have an impact, but it won’t be felt in a major way until the other side of the election. That’s how long it takes to have an impact on a system as complex as the health system. And one final thing: after the bill, Francis. The Robert Francis report into the public inquiry into the Mid Staffordshire NHS Foundation Trust care failings will be published, and organisational and possibly legislative and personal consequences might follow from that.
Paul Corrigan: The original bill was a localising bill, and then after the pause it became a centralising bill. So it is now both a localising and a centralising bill—and there will be two sets of implementations. Let’s face it, the people who are going to be doing the centralising implementation are pretty good at power, and so they’re going to be rolling out—and they are already rolling out—a lot of centralised power. This is the biggest nationalisation of commissioning we’ve seen. Then localisation will be going on, and in many of those areas where localisation is well organised there will be substantial impacts.
Nigel Edwards: The passing of the bill is just an event. It’s probably not that important in the sense that we are already doing a substantial amount of it. And many of the problems that we’re facing don’t seem to immediately map back to things in the bill. I was struck yesterday listening to Andrew Lansley [the health secretary] giving his explanation of what the problems we face are, and was trying to then track back those problems to the policy instruments that he’s developing. I must confess that I was struggling. People are dealing with a whole set of problems that don’t relate to the bill. We’ve got more hospitals that are struggling and are in trouble. The money is an issue. And the Francis report is a big deal. That might change vast amounts much more quickly than the bill.
Our experience with this sort of cataclysmic reform is that it only looks cataclysmic when you look back 10 years afterwards because in the first couple of years, generally, it doesn’t appear that much is happening. There is not a lot of space for new entrants in the market. Many of the bits of machinery aren’t yet in place. We don’t even know how many of the CCGs will be fully authorised at the end of this process.
Simon Stevens: The NHS has been “reformed” many times. The NHS loves to put itself on a couch. And when we do that it’s easy to forget that the NHS has got a lot going for it. It’s got a lot of fundamental design advantages. Net public satisfaction is at an all time high. And over the past decade there have been huge improvements in the responsiveness of care to patients. Waiting times are at an all time low, though there are clearly pressures there. There have been massive improvements in population health. All of that said, the challenge now is to think about what it will take to “future proof” the NHS for the phase ahead, and that will be done during a period of the deepest and most sustained budget crunch that the NHS has had since 1948.
Will changing some of the intermediate tiers of management have a profound impact on that? Possibly, but I think there are some more fundamental challenges. The Mid Staffs inquiry might be a pivot point for a conversation about the care of the majority of patients the NHS is dealing with who are older, frailer, with multiple morbidities.
Effect of competition
FG: How will competition impact on the structure of services reconfiguration, and will hospital trusts, and indeed CCGs, be allowed to fail, and how that will play out over the next few years?
GG: In many ways hospitals are already in a form of competition. I’d like to see a bit more competition in the community. And by definition, to have competition you’ve got to have a slight excess of supply. At the moment there is no hope of having that excess of supply. I mean, it’s not easy to have a different provider of palliative care and so on. There is virtually no competition in the community provision.
PD: We tend to use the word competition as a bland word, but you might want to use it differently for different services, and that is sometimes forgotten. It would be hard to envisage how you could introduce competition to things like ambulance services or complex cardiothoracic surgery. Places that are more amenable to competition are out of hospital care, where there are more providers and it’s more of a local service, and so on. The challenge is, ‘how do we support that in a way that ensures continuity of service, ensures high quality care, but uses competition to continue to drive high quality care and efficiencies?’ And that ought to be where our collective focus is.
CG: We’re not against competition, but at the provider side. The college’s policy is around federations of practices, which are groups of practices drawing in the third sector and the private sector to start dealing with some of the big issues that are facing us such as end of life care, out of hours care, and pre-hospital care. And that’s where we see the real change.
We need sensible commissioning, supporting providers to reform so we can have competition. But with respect to GPs—I mean I’ve said this before—GPs are heaving under the workload at the moment and it’s not because we’re all off playing golf at lunchtime. I think there has been an explosion of demand for healthcare that has been translated into every aspect of our health service.
JM: We’ve preserved the primary-secondary divide in aspic. That is anachronistic. That is not the way healthcare should be delivered and needed. A GP from the 1930s would recognise the system of today. And that cannot be right. My concern about CCGs is that it is cementing this relationship further—that primary care is a separate entity from secondary care. And by failing to deal with competition among GPs, by the bill bottling free competition by not abolishing practice boundaries, we’re missing a trick. I think we should have competition at the front end—the consumer facing, consumer experience bit—and that, I think, is where liberation, freedom, innovation, and competition should be placed.
GG: I would liken the reform in the community to being moved from corner shops to supermarkets and having a blend of both. So, we are planning to move chemotherapy out into three general practices. Now, you can’t do that to all practices, and what we’re finding is that [in] the coalition of GPs commissioning, there tends to be some jealousy because necessarily we will put diagnostics, chemotherapy, and so on in a few ambulatory care centres. But there is a resistance when the coalition of GP commissioners sees that some of them are going to be winners and some of them are going to be losers. And that, to me, is the big issue.
Can I also say that not all community provision is general practice. And I think this country is hung up on the issue of this locality basing. We’ve got groups like Macmillan nurses who do a fantastic job, and I’d almost see that patients should have the choice—sort of red cross, blue cross, green cross nurses, to do their provision. In other words, national organisations but in your locality that are often NGOs [non-governmental organisations], charitable based organisations.
Capacity of commissioning groups
FG: One of the problems with the CCGs expressed to me is they won’t be able to do anything strategic at the national or regional level. So, for example, stroke reconfiguration, which I think people feel has been a great success, would not have been possible. Does anyone have thoughts on that?
PC: I don’t think the secretary of state believes in planning. I think he believes that these patterns of services will emerge, and he’s mistaken, I’m afraid. Somehow the CCGs will need to come together to work out how to do these. Let’s hope they’re better at collaboration than PCTs [primary care trusts] turned out to be. There will be a temptation to be parochial.
JS: I think what will light [GPs’] candles will be developing some of the integrated care, the services we’ve been talking about for frail, older people, and so on, and possibly in a competitive manner in due course. But I don’t think that the majority of GPs want to make those major strategic planning decisions. Indeed I don’t think it’s fair to expect that of them. [Instead] I’d put my money on some sort of outpost of the NHS Commissioning Board because the kind of regional SHA [strategic health authority] tier has always persisted in the 60 year history of the NHS.
Role of regulator
David Bennett: You were talking about the secondary care sector and the impact of competition. I think the biggest impact on that sector over the coming years is not going to be competition. It’s there and it will continue to be there. The general squeeze on funding which often, especially at the moment, ends up at the door of the secondary sector will continue to be a huge pressure. The changing way commissioning is happening—how that plays out is unclear, but I think it will continue to put pressure on the sector. Simple things, like moving demand out of secondary into primary care, are going to have a big impact on the secondary sector. And then, thirdly, I think something that is often missed is the government’s ambition to turn all the non-foundation trusts into foundation trusts. That’s going to, if it’s successful in its ambition, produce huge amounts of change among those trusts.
PC: If we are to come back to the financial problem—the mismatch between resources and demand, and the fact that people want to do that around integration. I think what we will get is competition between integrators. We will have new integrators coming through the system who will have the capacity and power to bring together this discredited primary and secondary care into an organisation. And they will slash into the existing organisational forms. If that were to take off then it would be a profound competitive intervention.
NE: But what we haven’t got, and the bill doesn’t deal with, is bundled payment currencies to enable us to do that. We’ve got the GMS contract, which means that some of the money that you’d want to put in the pot is locked away in the Quality and Outcomes Framework.
What about population based healthcare?
FG: One of the jewels in the NHS crown was that we had this population base on which we could do public health and provide primary care.
NE: I think there is a danger that if you just use practice populations you potentially lose the denominator that allows you to do area based health planning. So the job for the health and wellbeing boards and the job of public health is to reconstruct that sort of local epidemiological picture. I’m struck by the fact that the GPs in Stafford missed what was happening because the signals were weak. You don’t see them at the level of 1500 patients. It’s not that they did it wrong. It’s just it wasn’t visible. To spot you’ve got a problem someone has to put the epidemiology back together, and we need good public health supporting the GPs and the CCGs to reconstruct that picture. Losing that would be a disaster.
PC: It’s like a lot of the rest of the bill: there are some places where I think this will be a big advance, and other places that won’t be able to do that for a variety of capacity reasons, and where I think public health may well disintegrate.
FG: Do we see a situation where a foundation trust, such as Addenbrooke’s perhaps, will begin to take on a kind of Mayo, Cleveland Clinic, Kaiser-type approach and start becoming an integrator?
GG: I can see that as one favourable model, particularly in a rural area. I think it’s more complex in a city like London. James and his practice, Sawston, and ourselves have been talking for years about a model that’s like an accountable care organisation. But we’ve found any number of impediments in the current structures and the future structures because if you want to have one practice that offers almost 24/7 primary care, takes on the out of hours service, does the urgent care where the nurses are centred around that practice to do the community work, and so on, it upsets a lot of smaller, single handed GPs, and so on, which is why I think GP commissioning is a flawed concept.
HT: This is where I think it’s interesting to have competition among GPs because I’m looking forward to the intelligent patient, not the intelligent commissioner. I want them [patients] to walk away from that practice that’s crap, and the PCTs [primary care trusts] in my area have spent a fortune holding it up and putting in extra resources. And you think, “I wouldn’t send my dog there.” So, you know, I think it’s time that we let that happen and the good, big practices to thrive.
FG: And that would be easier after the bill, in your mind?
HT: I think so. I think CCGs might be quite tough on one another. And once we get some transparency and see where you fit in the bell curve, I think you’re going to want to move up.
JM: When I have been talking to CCGs several of them have worked out that the first step they need to take is not to sort out their acute provider, but to deal with some of their colleagues. So maybe this is as much about improving primary care as it is about improving commissioning.
Looking for joy
FG: Don Berwick [former chief executive officer, Institute for Healthcare Improvement and and former administrator, Centers for Medicare and Medicaid Services] yesterday talked about joy, and I think a lot of us were struck by his ability to find hope for the future in sometimes dark times. Could people give their thoughts on how we could see more joy in the delivery of healthcare on the policy side, in primary/secondary care, and the new integrated future. Any thoughts from anyone on joy?
PD: I am joyful and optimistic for the future of the population of England. We are starting to see a bit of a wake-up call. For whatever reason,[quality data] have been hidden in files for the past 10 years. Things like stroke audit data have been there, but people haven’t looked at them, whereas now they are starting to. People are becoming aware of some of other data around things like acute cardiac services and vascular services and are starting to ask questions about that and do something with that, either as individuals or as relatives or as GPs and as GP commissioners.
We’re starting to see a step change in the way in which people think about quality of care.
AMcL: So it’s a straw in the wind at the moment, but increasing transparency of health services does give me cause for optimism. It’s interesting, we’re just recruiting a new reporter at the moment, and we mostly recruit our reporters from the local press. Time after time they were showing us clippings from lead stories that they’d generated from CQC data or various other things. It’s happening out there in the local paper. People are taking their local newspaper reports, they’re taking that local data and putting them out into their communities. So these things tend to sneak in the back door, but it is happening.
Cite this as: BMJ 2012;344:e1661