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The NHS White Paper

20/07/2010
by Rob Findlay

The White Paper was like diving into a British lake: a cold shock, a rush of blood, a feeling of disorientation, and yet all somehow very invigorating and healthy.

The SHAs are being abolished, and they will not be missed. I hope that now all the stories of bullying, extra-legal activity, and jobs for the boys will come out. The SHAs filled a gap in the organisational chart of top-down control, but in practice they neither insulated Ministers enough for Ministerial comfort, nor showed enough willingness to place Government policy above local issues to be genuinely useful to them. Soon they’ll be gone.

The abolition of PCTs has been deftly done. Now that so many PCTs are coterminous with local authorities, many people expected functions to transfer over. Health improvement is a natural transfer. So is the join with social care. Handing commissioning to GPs is also natural; in fact GPs have always done the commissioning because they refer the patients. What’s left? An untidy bag of statutory duties will need sorting out, but they are not enough to justify the PCTs’ existence. So off they go.

What emerges at local level is very different from the longstanding model of monopoly hospital toughing it out with monopsony commissioner. In its place we will have something more like a normal market, with many independent commissioners (the GP consortia) buying care from a much smaller number of hospitals. This is very much to be welcomed.

So what could go wrong? Plenty of course, and it will.

Quality will inevitably become much more variable around the country. So expect a lot of complaints about health inequalities and postcode lotteries, even as overall quality improves.

There also will be complaints about the funding formula, because as it is applied more locally, funding will become more variable. The strength of the assumptions being fed into the formula will start to look shakier on close local scrutiny, and the most likely result will be a simplification of the formula and a reduction in funding variation, amid loud complaints from the biggest losers.

Some hospitals will struggle to achieve Foundation status, and some Foundation trusts will flounder (as is happening already). As noted in an earlier post, many hospitals would work better if their monolithic structures were broken up, to separate the different clinical, operating and property functions within them. As with GP commissioning, this would be no more than a reflection of reality: consultants have always been clinically autonomous, and so it would make sense to rediscover their heritage and become organisationally and economically autonomous again too.

Some GPs will struggle with commissioning, especially in the early stages. But a penumbra of independent-sector services will emerge to provide the specialised services they need. This penumbra will not necessarily be big companies from overseas; their chances were better when they had big government to talk to. No, the GP consortia will be much smaller outfits, and will deal easily with boutique companies (like gooroo) providing very well-targeted expertise for the local situation, with each GP consortium remaining in control as customer.

The separation of GPs’ personal fortunes and their commissioning budgets will be crucial, and difficult. GPs will be establishing out-of-hospital services for conditions like diabetes, COPD, and cardiology, referring patients to those services, and profiting from providing them. It will appear that they are pocketing their commissioning budgets in the process, and there will be sufficient wriggle room in the application of the tariff to blunt protestations that they are simply competing on a level playing field. Handling this blurring of boundaries between commissioning and providing will probably be the commissioning regulator’s biggest challenge.

The regulators will face constant temptation to extend their powers and intervene more. Every scandal and every failure will bring calls for Ministers and the regulators to “do something”. These temptations to recreate SHA-style powers through the regulators will need to be firmly resisted if GP Commissioning is to flourish and providers are to become more responsive. The heavier the hand of regulation, the more everyone will look to the regulator instead of to the patient.

As the feelings of disorientation wear off, and as the detail of these changes becomes clearer, it will start to feel as if there are more problems than solutions in these changes. However, a decade from now, I think we will all look back and wonder how we ever tried to run the NHS as a management hierarchy, defying the reality that doctors were autonomous all the time.

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