The White Paper: Liberation or Evisceration?
19 July 2010
The recently published white paper, Health Secretary Andrew Lansley's plan to 'liberate' the NHS (or eviscerate it, depending on your point of view), is the topic on everyone's tongues...
The recently published white paper, Health Secretary Andrew Lansley's plan to 'liberate' the NHS (or eviscerate it, depending on your point of view), is the topic on everyone's tongues. Entitled 'Equity and Excellence: Liberating the NHS', the paper spearheads the Coalition Government's programme to streamline the management of the health service by cutting 'excessive bureaucracy' and 'top-down control' while expanding patient choice.
In a bid to attain health quality and outcomes that are comparable with 'the best in the world', power and responsibility will be devolved from central management to the front line via GP-led commissioning consortia, with PCTs and SHAs (and 60,000 plus jobs) ceasing to exist by 2013/2014. The consortia will have the bulk of the health budget (£80bn) with which to purchase care from hospitals or 'any willing provider', including those in the private sector, in what many are describing as a radical shake-up of the NHS.
Patients will be able to exercise more choice, says Lansley, by being able to decide which GP they register with, as well as pick from a variety of other service providers. NAPC and the NHS Alliance have welcomed the changes as an 'unique opportunity' to improve the quality of patient healthcare, while the BMA have asserted that doctors are 'ideally placed to help determine the needs of their local population'.
The plans form the sixth major health reform in twenty years, with Practice Managers positioned at the vanguard of change. In a seminar on world class commissioning (WCC) at The Royal Society on Thursday 15 July, Dr Mark Britnall, Head of health for UK and Europe at KPMG, championed the notion of 'disruptive innovation'; change can be a good thing if it's on your terms...
That may be so, but apart from the usual supporters, the White Paper has come up against criticism, scepticism and the old friend: apathy. Although supportive of the proposals in principle, RCGP, RCN, Nuffield Trust, The King's Fund and various think thanks have expressed concerns. A quick scan of articles and comments on broadsheet Web sites, GP Web sites (e.g. Pulse), or general medical, healthcare and primary care news providers such as HealthcareRepublic.com, shows that the White Paper begs more questions than it answers.
One concern is whether GPs will make good managers. Reports from Treasury, right-wing think tank Civitas, and Shadow Health Secretary Andy Burnham (in his vehement disapproval of Lansley's plans in the Commons on Monday 12 July) have all expressed concern that there is scare evidence that GPs make better managers than PCTs. After all, where will anyone find the time to do the job of the 60,000 plus managers 'who are to disappear overnight' as put by one commentator on GP blog The Jobbing Doctor. In a budget deficit of the UK's proportions, handing over £80bn to a group with little proven financial management skills and no piloting is risky business.
Not only do many see the 2013/2014 deadline as ambitious, there are wider issues to consider. The Guardian raises the point that some Labour leftwingers believe lack of commissioning expertise may lead GPs to resort to hiring private providers. The potential effects of this risk-sharing on real control of the NHS are tangible. Chief Executive General Secretary of the Royal College of Nurses, Dr Peter Carter, elucidates 'In economically challenging times there will be some difficult discussions with patients about their care and what is affordable, which has the potential to change the relationship patients have with nurses and doctors'.
Evidence that GPs will make good managers is not the only scarcity to consider. There seems to be no indication that GPs want to manage. 'GPs do not give a fig about commissioning', says Jobbing Doctor, '...the major issues are clinical. Government have a huge job to regain the trust of the GPs'. One comment on the site referred to government actions as 'dishonourable thuggish behaviour' and GPs 'being pushed around like children'.
The fact of the matter is that such a massive transition does not only apply to the health system architecture; it is also a change of culture. Former PG Director, Tony Plumridge, on Newsnight (Monday 12 July) emphasised the fact that there will be 'great difficulty involved in integrating doctors together', as they prefer to work alone or in small teams. During the WCC seminar, GP Paul Charlson also highlighted that different practice demographics mean that some part-time GPs will not be interested in their new role and that this will put pressure on others.
Theoretically, the White Paper has the potential to cut waste and improve quality, but comments suggest attempts should be made to put flesh on what is currently seen as a somewhat skeletal plan. For example, GPC Chairman, Dr Laurence Buckman, called the White Paper a 'really interesting package' but would welcome more detail on 'virtually everything'. Questions such as 'what will happen if quality gets worse?', 'what happens if money runs out?' and 'what happens if they overspend?' are circling the blogs and discussion forums. The Royal Society was awash with even more enquiries. Professor Gwyn Bevan at the London School of Economics, questioned the management of trade-off decisions between prioritisation and investment, and PCT Network Director, David Stout, highlighted the lack of clarity on how to hold the current system together while planning the new one and still encouraging people to stay focused. Commissioning OOH without OCTs is yet another point of confusion for many.
The prospect of abolishing PCTs and removing the middle-man seems welcome, but in a growing number of articles and comments, there is a mixture of dejection and contempt for meddling government and bureaucracy in general. BMJ have published online a highly critical report on the reorganisation of the NHS, claiming that there is very little evidence, both financially and in terms of service quality, to support restructuring the health service. Discussion forums expressing more or less the same thoughts on PCTs are essentially summed up thus: 'same people, different job titles, same round of reorganisations, same waste'. One blogger suggests that the bureaucracy stems chiefly from central government, with the PCTs simply 'suffering the fate of the messenger' and the new plans serving only as the 'first stirrings of a new epidemic'.
Among the ambivalence and somewhat mild discontent about the volume of unanswered questions, there also seems to linger a positive, if muted, response to this Paper. New practice managers express their excitement for the future and dedication to keeping an open mind to new possibilities, whilst others are briefing those who care to read. They go along the lines of 'Can we GPs manage effectively and simply, ensuring quality without getting sucked into the tedious layers of bloated protocols/policies/procedures/organisational self-centredness that have bedevilled us in the past? If not, private companies are waiting in the background and licking their lips'.
There is clearly a belief that those in primary care can do something groundbreaking and effective without auxiliaries numbering in the thousands, but the intensity of such feeling is hard to gauge when it is hardly detectable. Those in primary care must feed into this debate! If the White Paper is here to stay, one can attack it for lack of detail and evidence for only so long. This is not a hypothetical experiment for the purposes of ideological debate; real changes are taking place on the ground. These reforms have just been unveiled and need a thriving debate and discussion from those whom it affects most. And the sooner the better, for as one blogger put it: in a financial climate like ours 'unfortunately we won't have the luxury of time to sit around in indecisive meetings twiddling our thumbs'.
Dima Suleiman