Health Service Focus

Clinical commissioning and the NHS reforms

Some of the biggest issues in healthcare were debated at the party conferences, including a session hosted by 2020health on what clinical commissioning will actually look like in practice. The speakers were David Worskett of the NHS Partners Network; Debbie Abrahams, Labour MP and PPS to shadow health secretary Andy Burnham; Dr Linda Patterson, clinical vice president of the Royal College of Physicians; and Dr Clive Peedell of the BMA and NHS Consultants’ Association, who has since co-founded the new National Health Action political party. The meeting was chaired by 2020health’s own chair, Dame Helena Shovelton.

'What will doctors do now they are meant to be running the NHS?’ was the provocative title of a Labour party conference fringe session held at Manchester Town Hall on October 2, hosted by 2020health and attended by NHE.

Dr Clive Peedell spoke first, and unsurprisingly was very hostile to the NHS reforms, having been a key opposition activist. He said that doctors had “overwhelmingly rejected” the provisions of the Health and Social Care Act during its long gestation, and that the final legislation will lead to the increasing privatisation of the NHS.

He quoted former health secretary Andrew Lansley as saying that competition was the “primary objective” of the reforms – though that quote was from a 2005 speech. Dr Peedell said Lansley obviously misunderstood the NHS and doctors, who preferred to work collaboratively to improve patient care, and to refer locally.

Moving from the ‘trust’ model of care to the ‘market’ model of care was a mistake, he said: “We’ve stopped trusting the professionals.”

The NHS reforms are “doomed to fail” without clinical leadership, he said, while the massive efficiency savings needed under the QIPP initiative meant that CCGs will have to act as rationing bodies. That will fundamentally change the doctor-patient relationship, he said.

David Worskett, director of the NHS Partners Network, which represents the private sector companies within the NHS Confederation that deliver acute and primary care for the NHS, had different concerns.

Despite the view among campaigners and the medical profession that many of the reforms have been aimed at giving the private sector easier access to the NHS, in fact most independent providers “aren’t terribly keen” on the new structure.

The fundamental point is, he said, that in practical terms doctors won’t really be running the NHS, despite all the rhetoric from day one. “The vast majority of doctors will be getting on with treating their patients,” he said. “They won’t want to run this arcane and bureaucratic new system,” which actually requires very different skills, he said. Medical school does not concentrate on procurement, health economics and contract negotiation, he joked.

He said a minority will be energised by that challenge and take on the new roles, which will make them more like other professionals such as lawyers and engineers.

He said local, clinically-led commissioning would imply, by its very nature, local variation – but that recent history has shown us that the media and public tend to be very unforgiving of such variation in practice. There is a dislike of Whitehall-led micro-management and targetsetting, but equally people hate the idea of a ‘postcode lottery’ where care might differ based on what CCG serves you. It is a “huge problem”, Worskett said, predicting that many CCGs will struggle, at least at first, despite the support of the CSUs. There will be an inevitable “retreat” to more centralisation – which some argue has already been happening as the NCB beds in – and then more consolidation among CCGs, pushing us further and further away from the original aims of the reforms.

He warned of “stand-offs” with hospitals, and implied CCGs were not going to be able to lead on necessary service reconfiguration.

He concluded by quoting Bevan’s speech on the second reading of the NHS Bill on 30 April 1946, where he said: “There ought to be nothing to prevent anyone having advice from another doctor other than his own. Hon. Members know what happens in this field sometimes.

“An individual hears that a particular doctor in some place is good at this, that or the other thing, and wants to go along for a consultation and pays a fee for it. If the other doctor is better than his own all he will need to do is to transfer to him and he gets him free…the same principle applies to the hospitals.”

Worskett said: “That doesn’t sound to me like the founding father of the NHS being vehemently opposed to patient choice.”

Debbie Abrahams MP spoke next, with the audience keen to hear her thoughts as she is PPS to Andy Burnham, shadow health secretary.

She warned that much too often, ‘choice’ is equated with ‘personalised care’, when the reality is much more complex. She said she backed the principle of clinically-driven, evidence-based decision making and noted that in her locality, Oldham, there are six GPs who are voting members on the CCG, and seven associate members – out of 100 GPs.

She echoed Dr Peedell’s argument that the evidence base for competition increasing quality of care was “very poor”, and said there was pressure on CCGs to work with the private sector.

She spoke of the importance of public health, and worried it was being downgraded, as was the importance and weight given to NICE guidance by commissioners because of the pressures of funding. It “can’t be seen as an optional extra”, she said.

She reiterated that Labour plans to repeal the Act if it regains power at the next election – but said that would not be about more top-down reorganisation, but instead an integrated and holistic healthcare system.

The final speaker was Dr Linda Patterson, of the Royal College of Physicians, who made the point that the changes to commissioning at least were less radical than some suggested – since many doctors and consultants have had roles in decision-making and policy-making in recent years. “Clinical leadership is to be welcomed," she said, noting that quality of care is ultimately based on professional values.

The key is integration, she said – joined-up care between GPs, community services, acute services and social care. The current system is not good enough, and it is not clear whether the reforms will help or hinder the process of integrating care.

The Royal College of Physicians opposed the Bill, she said, but said the amendments it helped get passed improved it. But “it hasn’t been a happy two years”, she said. “We have to try to make this work: it’s the way it is,” she said.

But she said the rules around who can sit on CCGs were “bonkers” and “completely daft”, in that while the amended legislation ensured a nurse and a consultant should sit on CCGs, concerns about confl ict of interest have led to a situation where physicians can only sit on CCGs outside of their own locality or if they are retired. Many CCGs have struggled to recruit effectively because of this, she said.

She spoke next about ‘Hospitals on the edge’, the influential RCP report released in September that suggested acute care needs a complete redesign if it is to avoid ‘collapse’. That report highlighted a lack of continuity of care as a big concern, with older patients sometimes being subjected to several moves during a hospital stay, with no handover between staff. Staff are also often under the impression that older patients “shouldn’t be there”, the research showed, harming the quality of care as well as building attitudes of resentment. A redesigned service to improve access to primary and community care could involve consolidation of hospital services and lead to hospital closures, the RCP confirmed.

She said media outlets worldwide had picked up on the report, and she had spoken to journalists from Sweden, Germany and the US: but she also reiterated Worskett’s point that responsibility for service redesign in a locality was unclear.

She warned that the new structures will “fail miserably” unless commissioners engage with these big issues.

In a Q&A session afterwards, the panel answered questions from an audience primarily made up of people from the worlds of public health, local government and the anti-reforms ‘Save the NHS’ campaign.

On fragmentation, Worskett noted that commissioners have huge powers to promote integration if only they’d choose to commission services that way, rather than as fragmented ‘silos’.

He made clear that although he represents the independent sector, obviously NHS providers will often be the best choice to provide a service.

Dr Peedell spoke about the problems with data collection and analysis, especially in more complex fields, and Dr Patterson agreed that with more patients suffering with multiple conditions, measuring outcomes in a meaningful way is getting more and more difficult.

Panel chair Dame Helena suggested that the fact that the NHS in England is going down such a different path to the health service in the other UK nations means in the long term, comparisons will be possible between the different systems, to judge the broad effects of the reforms.