Health policy debate
4 to 15 November 2005
Public and patient involvement
Patient and public involvement forums not consulted on proposals to change PCT structures
Fewer than half of patient and public involvement forums have been consulted, according to a survey from The Commission for Patient and Public Involvement. Of the 39% that were, only 22% felt it was meaningful.
CPPIH chair, Sharon Grant, said the results showed not enough PCTs were consulting on the changes. “It is shocking that so little meaningful consultation appears to be taking place” [go to note 21].
The future of democracy
Patricia Hewitt told the 1000 people that gathered for the final Your Health, Your Care, Your Say that this event is ‘the future of democracy’.
Reports suggest that the debate was often focused. People talked about, for example, the need for stronger social care instead of ‘people taking up beds for no reason’. Bother other contributions were not so focused. On one table, an elderly man talking about policies for youths, talked about young people having ‘no respect’. He advocated ‘sending them to the navy…or that society should sterilise them…They should be locked up if they don’t do as their told’ [go to note 22].
The challenge for the health secretary is maintaining consultation and discussion with the public as reforms unfold.
In an article on primary care reform (of which, more later), Richard Lewis, Senior Fellow at the King’s Fund, says there should be a re-examination of public accountability. ‘The rights of patients as consumers are not a satisfactory substitute for the right to be engaged in design, delivery and monitoring of services’.
He goes onto say that, ‘the divestment of community health services by PCTs offers an opportunity to develop new ‘mutual’ organisations, with a formal stake offered to staff and patients. Arguably there is a more compelling case for foundation-style principles in primary care than there is in hospitals’ [go to note 23].
Out of hospital care
An HSJ survey of chief executives supported the view that government policy on primary care provision became ‘fatally flawed’ because of poor handling. Subsequent clarifications from the secretary of state may have cooled the political temperature, but only just over-half 51% thought Patricia Hewitt’s ‘clarifications’ had given them only ‘a little more flexibility’, 13% ‘much more flexibility’, while 36% felt the announcements made no difference’. 36% percent expected PCTs to only provide 10% of current services by 2008 (the largest group) while 43% (also the largest) wished to retain more than 70% [go to
note 24].
Tensions unleashed by the July 28th letter have caused so many problems that the publication of the white paper will now come after Christmas, though, as the Guardian’s Michael White noted, the official reason for the delay will be because ‘her consultation process has thrown up so many good ideas’ [go to note 25].
Hewitt’s speech hints at the detail of the white paper
Some details of the white paper can be gleaned from the secretary of state’s speech to the NHS Alliance.
She said that PCTs as commissioners must challenge acute trusts and also support them, which sounds a difficult balance. She said she wanted GPs to be able to compare their referral patterns to others.
She noted that the general public is satisfied with GPs, but frustrated by poor access to them. Patients want better integrated care. She said she would like to see a service that is “something between” a GP appointment and A&E. She also pledged, “we are not going to change the basic principle of registration”, though people will be able to have dual registration.
On long-term conditions, she said: ‘We will give every GP a strong incentive to improve support for people living with long-term conditions.’ She said that 27% of this group did not have a clear care plan and said she wanted to see strengthened multi-disciplinary care teams [go to note 26].
Competition between professionals?
The news that nurse practitioners and pharmacists were to have greater prescribing powers is important context of widening primary care access.
A leader in the Independent said, ‘the outcry by the BMA over the prescribing issue…suggests that doctors’ reluctance to embrace this and other changes reflects a concern not just about cost, but about what they see as the erosion of their closed shop’ [go to note 27].
John Carvel, writing in the Guardian, called the changes a ‘huge boost for the clinical status of nurses’, which ‘smashed the demarcation barrier between doctors and nurses’. He predicts that changes will lead to fierce battles between the professions [go to note 28].
According to the HSJ, the DoH is ‘lining up nurse practitioners who could conduct appointments at more convenient times for the public’. It could be the case that in the future nurses will work with pharmacists and run services that compete for patients.
At the Your Health, Your Care, Your Say event in Birmingham, participants were asked whether they would be happy to attend appointments with trained nurses. While most people wanted to see their GP, 20 per cent said they would be happy to meet a highly trained nurse. The idea was more popular than allowing dual registration [go to note 29].
A debate on reforms needed for primary care
The King’s Fund’s Richard Lewis and Judith Smith of the Health Services Management Centre in Birmingham each penned a piece for the HSJ on reform in primary care.
Lewis argues that it is important not to throw out the baby with the bathwater. ‘It could be argued that the fundamentals of primary care are in pretty good shape and reformers should be mindful to ensure that the medicine is not worse than the disease.
Smith says that reforms are needed to improve access. ‘As well as needing an injection of courage, they need to develop a wider range of incentives for practices and other providers. This might mean using current contract flexibilities more imaginatively, extending the GP contract to cover a more exacting range of non-clinical indicators of quality, and developing specific payments for new services.
There are three aims, according to Lewis: improve quality, commissioning and pursue clinical integration.
One strategy is to increase ‘contestability’, but Lewis points out that PMS has enabled PCTs to introduce new types of providers for years, but they have not pursued this option. There is scope for to extend competition. Another strategy is ‘to put stronger incentives behind practice-based commissioning. It is not terribly clear where practices responsibilities for an ‘indicative budget’ end and the PCT’s begin. Moreover, the benefits of practice-based commissioning may not look compelling to a practice: uncertain management support, savings off-set against overspends three years into the future, and restrictions over what savings might be spent on’.
‘If practice-based commissioning is to have bite, it must involve the transfer of financial risk. In return, practices must feel they receive a proper reward. There is no reason for that not to include higher personal incomes for those involved, providing their commissioning is successful and effectively coded. Of course, the converse should also be true’.
‘Many practices will group together for commissioning, and will need high-quality management. Spending money on managing –practice-based commissioning is not shameful, although this has been implied’. He calls on support for PCTs to ‘benchmark the performance of commissioners’ [go to note 30].
Judith Smith is positive about opportunities ‘to use skill-mix differently, extending existing services, increase income, and use resources released form secondary care. She is aware of risks. ‘A wider range of providers could mean fragmentation and duplication of care for patients unless secure and effective information flows can be assured. Similarly, care co-ordination could suffer unless commissioners are able to purchase effective pathways of care and incentivise strong partnerships – something that has provided difficult even in a relatively managed system.
Developing clinical collaboration in a market
Lewis says some interesting things about the potential for clinical collaboration. He talks of ‘developing community-based multi-specialty organisations’.
‘Such organisations could be ‘virtual’, based on collaborative agreements between hospitals and primary care about innovative ways of dividing their labour. However, there is no reason why they could be real organisations where specialists and generalists work jointly to manage care within a global budget. Some have begun to explore this, and more should follow now that practice-based commissioning and payment by results are combining to offer powerful incentives’.
While advocating reform he says, ‘we should also be clear about what should be left alone. Tinkering with our patient registration system would be fraught with difficulty’.
Developing care pathways in Scotland
The Scottish Executive published its response to the Kerr report, Delivering for health. Although many of its aims are similar to that expressed in English documents; the approach taken is very different.
“We will deliver our plans through the continuing development of the NHS as an integrated service, so that patients experience a smooth and quick ‘journey of care’ wherever and however they may access services. The emphasis on integrating care will require multi-disciplinary team working. It will require collaboration and co-ordination between professionals and across organisational boundaries – in fact, a partnership approach at all levels to achieve continual improvement in quality and value for money. It requires the NHS to deliver public health improvements by engaging with other public authorities for services such as transport, housing, education and leisure”.
Scotland has dissolved trusts and moved toward single system working, meaning that all providers work with pooled resources. Delivering for Health specifically details mechanisms for integrated working, such as Community Health Partnerships, which support the development of pathways and the provision of care in community settings.
Comparing Delivering for Health with English policy provides evidence that under devolution, the policy of different countries is diverging. A paper comparing English and Scottish policy in the light of Delivering for Health is available from HPERU.
Row over the IT programme in England
Various newspapers report the fallout from a spat between NHS IT supremo, Richard Granger and Head of access and patient choice, Margaret Edwards. Sir Nigel Crisp will reportedly be sending Granger a ‘stiff note’ as a consequence.
Last week, Granger gave an interview to Computing magazine, in which he said changes to specifications were threatening effective rollout.
Grangers’ outburst was triggered by an email from Margaret Edwards marked, “Restricted – Policy”, which began, “we have a problem”. The email explained that patients and GPs still cannot book treatment at any of the country’s foundation hospitals by computer because they are not on the choice menu.
Email exchanges between Granger and Edwards were subsequently leaked. In one, Granger says Edwards’ “consistently late requests” for changes in specifications were “in grave danger of derailing (not just destabilising) a £6.2bn programme”. Granger told Edwards, “unfortunately, your consistently late requests will not enable us to rescue the missed opportunities and targets” [go to note 31].
Department officials told the Guardian that Mr Granger’s behaviour was “puzzling”. “Why is he breaking protocol? He seems to be defending himself against charges that were never levelled against him” [go to note 32].