Why the plans to reform the NHS may never be implemented
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c5032 (Published 14 September 2010) Cite this as: BMJ 2010;341:c5032
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Chris Ham does a good job of identifying the first big challenge to
the government's policy on health: making it happen. But even if they can
make it happen the self-contradiction inside the white paper seem likely
to undermine the ability of the NHS to deliver the declared objectives.
It is not necessarily a bad idea to allow consortia of GPs to control
the budget and to judge their success by the outcomes they achieve for
their populations. The White Paper seems to want to allow the consortia
freedom to decide how to achieve those outcomes. In principle this will
create several hundred experiments in how to spend the NHS budget better.
If we can judge who is doing well and incentivize the rest to follow, it
could lead to a dramatic increase in the rate of health improvement which
is what the country needs.
The self contradiction comes because, despite the stated objective of
devolving power to the new GP consortia, the white paper undermines that
freedom in two critical ways (and seems to do so for purely political
reasons).
The first problem is the legal form of the consortia which are
envisaged to be statutory organisations and not--as GPs themselves are--
private businesses. Paul Corrigan (ex special advisor to the last
government) points out that this amounts to nationalising the GPs (see his
blog www.pauldcorrigan.com) which is both a barrier to implementation and
a severe restriction on their freedom to operate. And their is no reason
to restrict their freedom this way.
The second problem is even more worrying. Instead of allowing the new
organisations complete freedom to decide how to improve their population's
health, the white paper proposes complete freedom to manage the budget as
long as the consortia don't spend much on management. So a group that
delivered substantial improvements in health outcomes and a budget surplus
would be regarded as a failure if it spent 2% of its budget on management
instead of the target of <1%. There appears to be no reason for this
central target except a visceral loathing of "management" and a desire to
generate cheap positive headlines (defending managers is about as popular
as defending rich bankers or priestly paedophiles in the world of tabloid
headlines). If we trust a consortium of GPs to deploy hundreds of
millions of pounds of NHS money, we should trust them to decide how much
they need to spend on deciding how to deploy the money well and tracking
that the money has been well spent. If the consortium that spends 5% on
management gets better health outcomes than the one that only spends 1%,
then we have learned something useful about the difficulty of allocating
money well in the NHS.
In short unless the government stays committed to its own principles
and allows the new consortia the freedom to operate, they will cripple an
expectation that the reforms won't have been yet another great upheaval
for not gain at all.
Competing interests: No competing interests
Because professionals and professional organisations want status quo.
Competing interests: No competing interests
Re: Why the plans to reform the NHS may never be implemented
The Health & Social Bill has had a chequered passage since it was announced as proposed legislation for England on 19th January 2011. The Secretary of State for Health (England) proposes wide-ranging changes to the delivery of health care and how it is commissioned. The Bill will ensure a complete overhaul of the NHS structures at the same time, on a scale never previously seen. The Bill creates an illusion of commissioning by GPs, and makes scant mention of consultants in its first iteration.
The reforms, if implemented, will increase the stake of private companies in the NHS, so that instead of GP led primary care and consultant delivered hospital services we will witness ‘Any Willing Providers’ picking up the most lucrative operations, with the NHS left to provide complex, costly care. A market-based competitive spirit will ensure that only the fittest survive. Vitally, the Health Secretary will no longer be able to intervene as he would have abdicated from responsibility to oversee the provision of universal health care.The destruction of the NHS will be engraved on the coalition’s political gravestone and it will have a significant adverse effect on future generations.
Earlier, the Prime Minister’s parliamentary speech suggesting that the reforms are well supported by the Royal Colleges and health workers would not stand to scrutiny. The BMA has openly asked the Bill to be withdrawn, the RCN has passed a vote of no confidence in Andrew Lansley, a large number of scholars have written openly in the national papers for the Bill to be withdrawn, and the Bill has been dubbed 'Dr Lansley's Monster' by the BMJ. It is worth reminding ourselves that there is no mandate from the public or either party in the coalition to this reform.
We ask that professionals and the public join us in stopping the Bill in its tracks. You can view the e-petition at: http://epetitions.direct.gov.uk/petitions/22670
Competing interests: Both authors work in the NHS, and have affiliations with the BMA.