domingo, março 06, 2011


Reforms mobilise doctors

The UK Government's planned shake-up of the health service has caused concern among doctors' leaders, who are calling for changes to the legislation. John House reports.
When the coalition government came to power in Britain in May, 2010, few people had any idea of the momentous upheaval that was about to ensue for the country's health services. 2 months into their term of office the Conservative-Liberal alliance started to make public proposals for a root and branch reorganisation of health-service provision in England. The government is now trying to pass legislation to facilitate the biggest reform of the National Health Service (NHS) since its inception in 1948.
Doctors believe that the reforms involve too much unnecessary reorganisation in too short a period of time. NHS managers and health-care commentators share these concerns. The reforms have prompted an unprecedented level of political activity from the medical profession. The British Medical Association (BMA) is lobbying Members of Parliament (MPs) and the Royal College of General Practitioners (RCGP) is calling on the government to hold a public debate about the future of the NHS.

What the reforms involve

The government says that comprehensive reorganisation is the only way to make the country's health services match up to the best in Europe. The reforms have three broad objectives: to give doctors greater control over designing services and over deciding how money will be spent; to give patients greater choice and more involvement in their care; to overturn the previous government's emphasis on targets and make quality of care and clinical outcomes the benchmark for setting service standards.
At the moment the NHS in England is organised into Primary Care Trusts (PCTs), Acute Trusts (ATs), and Strategic Health Authorities (SHAs). PCTs are at the centre of the service and between them manage 80% of the health budget. They are the local government authorities that are responsible for strategic, financial, and organisational functions. Each AT runs several hospitals in a region, and SHAs aim to promote regional cooperation and oversight.
General practitioners (GPs) work in independent partnerships that look after a population in a fixed geographical region. The local PCT hires their services. From 2004, the Labour Government allowed some hospitals to become Foundation Trusts with greater operational and strategic freedom.
The PCT is allocated a budget for its geographical area and it funds local primary and secondary care through an internal market where services are commissioned. All services—consultation, investigation, procedure, hospital stay—have a fixed price or tariff. This system is supposed to encourage competition on efficiency, but not on price.
The coalition government wants to wipe the slate clean. The reforms will abolish PCTs, ATs, and SHAs, and require general practices to organise themselves into consortia. Consortia will take over the financial, administrative, and strategic role of the PCT at the same time as continuing to run general practice surgeries. Like the PCTs, the new consortia will each receive a share of 80% of the health budget and will commission primary and secondary care services. 20% of the budget will be retained for central planning—the details of this are still not clear. All hospitals will have to become Foundation Trusts. There will be an oversight body, the Health Commissioning Board, and a financial regulator, Monitor.
The government wants the bulk of the transition to be complete by 2014. The draft legislation for enacting the reforms is set out in the Health and Social Care Bill. Among other things the bill will frame one of the most radical aspects of the reforms—the introduction of price competition and a level playing field for both state and private providers of health services. It makes Monitor responsible for setting a cap on tariffs, rather than a fixed cost, so providers will be able to lower prices. The bill will also allow “any willing provider” to compete. So-called pathfinder consortia (panel) that will test GP commissioning before national roll-out have already been set up all over the country.

A consortium prepares for its commissioning role
General practitioner (GP) Mike Ingram, saw the reforms as an opportunity, and pushed for his practice to become one of the pathfinder consortia. The Red House Practice in Radlett, outside London, is no longer just responsible for 19 000 patients. It has become the Red House Group Consortium and is now tasked with beginning the process of implementing National Health Service (NHS) reforms in Hertfordshire.
The Red House Group was among the first 52 pathfinder consortia to be announced by the government in December, 2010, and is unique among the pathfinders in that it consists of only one practice. But like most other pathfinders, Ingram's practice has been involved in practice-based commissioning (PCB) for the past 3 years. PBC was introduced in 2005 under the Labour Government and is the forerunner of the new system. General practices were given virtual budgets to buy services for their patients with the funds and transactions being managed by the Primary Care Trust (PCT).
Ingram believes that the new system will allow him to organise better services for his patients. “Take a patient who needs a hearing aid. At the moment I have to refer that patient to an ENT [ear, nose, and throat] surgeon before they can see an audiologist”, says Ingram. “If I've already established the cause of hearing loss and I know a hearing aid is indicated, I should be able to save my patient unnecessary appointments and delay.”
However, Ingram says that GPs cannot design services alone. In the coming months, the Red House Group will need to establish a system for facilitating consistent input from hospital doctors. Ingram also points out that some tertiary services, such as cardiology, will have to be commissioned on a national basis. “We don't want to get into a situation where we're operating outside our scope of confidence.”
Ingram disagrees with the government's assertion that the NHS is failing patients: “It has its problems, but on the whole we have an excellent health service.” However, he and his colleagues came to the conclusion that the reforms were inevitable and the only way to safeguard their patients' interests was to become leaders in the new system. “If you are not going to be involved you have to accept that decisions will be made on your behalf. If you are going to fight it you will be disruptive. So even if it's against your ethos, you have to get involved.”
Ingram adds, “the privatisation agenda is what people are worried about”. The Red House Group has already been approached by accountancy and consulting firms such as KPMG and Pricewaterhouse Coopers who are offering administrative and finance outsourcing services for consortia. Ingram anticipates that private health companies will also be looking for new business. He says that although the private sector has a part to play, “if you listen to patients and doctors, what everyone wants is a comprehensive, efficient service in their local NHS hospital”.
At the end of January, 2011, doctors and managerial staff from all of the pathfinder consortia were invited to Downing Street where they met the Prime Minister David Cameron and the Secretary of State for Health Andrew Lansley. It is clear that there is a lot riding on the reforms.
But Ingram has already found out that there is a gap between how the consortium was supposed to be rolled out and the reality on the ground. The pathfinder consortia are supposed to receive support from their local PCTs in the form of seconded staff. Ingram is still waiting for his, and he says that it is not surprising as the PCT is already overstretched. At the end of February, Ingram was still waiting to find out how much money he will be allocated. Based on the data for the practice's commissioning activities in previous years the PCT has told them that they could face a funding shortfall of £1•5 million in the next financial year. Ingram could have his work cut out for him.

Unnecessary upheaval

The medical profession has welcomed the objectives of the reforms, not least the aim of giving decision-making powers to doctors. “Let's make this clear”, says Hamish Meldrum, BMA council chairman, “we are not saying that we disagree with everything that has been proposed, no one would argue about the basic principles”. However, doctors, health-service managers, and health commentators question the validity of the government's strategy. Andrew Lansley, Secretary of State for Health, has said publicly that the country's health outcomes are among the poorest in Europe. The King's Fund, the UK's leading health service think-tank, disputes this claim. It says that the government's conclusions are based on a very selective reading of the data.
Andrew Goddard, Royal College of Physicians (RCP) workforce director, says that it is not clear why a fundamental reorganisation is necessary: “The RCP thinks the reform's objectives could be achieved with what we already have.” Doctors and managers alike feel that the reforms are too ambitious to be achieved in 3 years. They are also concerned the implementation process threatens interim service provision. “It is clear they have not thought through the implications of what they are trying to do”, says Meldrum.
The Department of Health (DH) told The Lancet: “We cannot simply keep the status quo while the world is changing—the NHS needs to respond to…an ageing population and rising costs of new drugs and treatments.” A spokesperson said, “we do not agree that the implementation of these plans will be rushed”, explaining that the new organisations will be given over 2 years to develop. “We are confident that this gives the system sufficient time to prepare prior to taking on its statutory responsibilities.”

Flawed strategy?

But the doubters are not convinced. “The organisation's most difficult financial situation in decades will coincide with the most disruptive 3 years it has ever faced”, says Nigel Edwards, policy director at NHS Confederation, the organisation that represents health-service managers. Like the rest of the world, the UK is recovering from a recession and with the national debt more than £1 trillion and rising, the government has raised VAT and is making hefty cuts in public service spending. The NHS is not exempt. The King's Fund says the NHS has been tasked with making savings of £20 billion.
Edwards says that having the new system running in parallel with the existing systems will result in duplication and double running costs. The DH argues that the reforms will release £1•7 billion savings every year, helping the NHS to meet its efficiency target. But Edwards says that regardless of the financial outcome the reforms could create an impossible work load for PCT staff—who are expected to assist fledgling GP consortia in addition to running existing services.
The decision to put GPs in the driving seat has also been questioned by professional organisations and the NHS Confederation. RCGP chair, Clare Gerada, says “commissioning is a very complex task”. She points out that NHS managers have generally done a good job of commissioning, but says, as practising doctors, GPs will be closer to clinical reality than lay managers. Nevertheless, GPs cannot do the job alone and she says if they are to have any chance at success, consortia will need substantial involvement from hospital physicians, public health, specialists, and lay people.
Meldrum says that price competition will be damaging, pushing providers to deliver services at the lowest cost instead of maintaining quality standards. “They mistakenly believe that price competition will drive efficiency”, says Meldrum. “That's alright if you're selling groceries but it's no good for patients if most of the services at their local hospital have been forced to close by a more successful provider elsewhere.” But the DH says that there will be safeguards against this: “Monitor, will ensure that competition works in the interests of patients and taxpayers. The NHS Commissioning Board will work with Monitor to regulate prices and strengthen incentives for providers to improve quality and efficiency.”

Active listening

Draft proposals for the reforms were put out for public consultation in September, 2010. The professional organisations say that this consultation period was inadequate and that few of their responses were listened to. The DH says that it listened to the responses and made changes as a result. But doctors say that the government is pushing ahead despite the concerns that have been raised: pathfinder consortia are already tasked with implementing the new system, and the draft legislation for enacting the reforms has begun its passage through the House of Commons. “We're in a situation where the consultation is happening while the bill is being read”, says Goddard, adding that “you can't help but wonder if any of the consultation will be acted upon”.
The Prime Minister David Cameron and the Secretary of State for Health Andrew Lansley have defended the reforms by saying they are a natural development of existing systems. However, doctors' leaders and the NHS confederation say that the reforms took the health service by surprise. “During the election we were promised that there would be no more top-down reorganisations of the NHS”, says Meldrum.
While the Conservative Party was in opposition, Andrew Lansley was the shadow health secretary for 7 years. The RCP and the RCGP maintain that he never consulted with the professional organisations on his ideas for the NHS. While Meldrum says that Lansley “spoke to the BMA about developing practice-based commissioning and something that sounded like GP fund holding, but never anything on this scale”.
Lansley made great efforts during his years in opposition to travel up and down the country to canvass the views of people in the health service, says Gerada. But she says that his fact-finding missions gave him a skewed view. “Cumbria was able to make a success out of practice-based commissioning because of cooperation from the PCT”, says Gerada, “and Cumbria is demographically very different to Lambeth in London, for example”.

Hidden agenda?

Many doctors are suspicious about ulterior motives for the reforms. “For those who are concerned about privatisation, there is little to reassure them”, says Meldrum. He points out that price competition and a level playing field would have the potential to shift the cost of health services from the state to the private sector. In their public statements, Cameron and Lansley have made few references to these aspects of the reforms, says Meldrum, “but if you read the bill it's full of it”. Goddard says that regardless of whether the reforms are an agenda for privatisation, “I really need to be convinced that this is not just decentralisation to save money”.
A spokesperson for the DH told The Lancet: “We will never privatise the NHS…The government is committed to the principles of the NHS as set out in the NHS Constitution, and all organisations will be required by law to have regard to it when carrying out their NHS functions.”
The DH also told The Lancet: “These plans are not about rapid cuts to spending—this government has delivered on its commitment to increase health spending, which will grow by more than 10% in cash terms over the spending review period.”
Both Meldrum and Gerada say that they would prefer an approach to NHS reform that seeks to strengthen integration and cut out wastage. They point to the work of the semi-autonomous, or devolved, governments in Scotland and Wales. In Wales, for example, the internal market has been abolished and replaced with more efficient financial control. Gerada says that, if necessary, she would be prepared to accept a form of means-tested health insurance to address funding shortfalls. Meldrum and Gerada say that they made these opinions known to the government early on in the consultation process.

Time for action

As of March 1, 2011, the Health and Social Care Bill had reached the Public Bill Committee, where a committee of MPs heard evidence from experts, and interest groups. The BMA, the Royal Colleges, and the NHS Confederation gave evidence before the committee.
However, doctors' leaders are going further. The BMA is calling for a halt to further implementation of the reforms before the legislation is passed. It is also lobbying ministers to alter the bill and challenge the reforms. Meldrum explains, “if we can persuade enough MPs, maybe there will be flexibility”. The RCP wants the bill to be amended to provide for mandatory specialist involvement in commissioning. This change would ensure that hospital physicians are involved in consortia.
Gerada told The Lancet that she is calling on the government to hold a public debate about the future of the NHS. She says that the NHS is in need of reform, not because it is failing patients, but because the service everyone expects is no longer financially sustainable. “We need an affordable NHS”, she says, “it's not broken, but we've got an aging population and we spend more on our health services than any country in the world”. So far, says Gerada, neither the Labour Government nor the current coalition government has been prepared to address this publicly. According to Gerada, politicians shy away from publicly confronting this issue because of the perceived sacrosanct nature of the NHS in the minds of the British electorate. “It's time to let the population decide”, says Gerada.
However, professional organisations accept that they can only do so much to alter the government's strategy. “It's a democratically elected government and GPs are pragmatic—we will put our patients first”, says Gerada. As Edwards puts it: “this is it, there is no plan B”. In light of this situation, doctors and managers are trying to ensure a smooth transition to the new system. After all, the government is putting doctors in a position to design and run services. Meldrum says that as well as campaigning “we also need to educate our members to take advantage of this and do their best to mitigate any disruption in service provision”. The RCGP has set up a Centre for Commissioning, a specific service to support GPs in adapting to the reforms
Meldrum says that it is essential that doctors engage with the process. Not least because over the past decade the profession has criticised government and NHS managers for cutting doctors out of the decision-making process and deprofessionalising their role in the health service. In fact, the RCP is calling on GPs and hospital doctors to seize the moment and use the reforms as an opportunity to address the fundamental problems that weaken the NHS and the medical profession. “We have become a very target driven culture, we practise conveyor-belt medicine, the patient is more like a product than a patient”, says Goddard. “As a profession we've become more divided than ever—this could be what brings us closer together.”

John House, The Lancet, Volume 377, Issue 9768, Pages 797 - 800, 5 March 2011