The Department of Health has been engaged in what it calls a listening exercise to take account of public opinion while its plans for modernising the NHS are on hold. I’ve taken part in the exercise and I’ve been listened to.
It’s not clear what the listening exercise was really intended to achieve, but it’s clear that it has not elicited clearly-defined improvements in the plans. Rather, it has exposed deeper faults in the NHS, suggesting that perhaps the plans do not go far enough.
The listening exercise has several parts to it, including meetings around the country, a committee (the NHS Future Forum) of invited representatives, and a website, Modernisation of health and care. I would have attended a meeting if I could, but instead I only took part through the website.
The website asked for comments on some specific questions, but the people who contributed comments mostly ignored the questions and gave their opinions on other issues. Conversations then developed around these other issues. Thus, the major themes expressed in the comments do not relate directly to the present plans for modernising the NHS.
The plans are designed to make some changes in the way the NHS is managed, without directly affecting patient care. The plans build on and extend changes made by previous governments, including the last Labour government. Their ultimate goal is to improve patient care indirectly by reducing the proportion of the NHS budget spent on management, and by giving clinicians and patients a greater say in how the NHS is run at a local level, liberating the NHS from some central planning and bureaucracy.
The plans are not a radical rethink of the entire NHS, only a simplification and opening up to public scrutiny of NHS management. Curiously, many of the opinions expressed in the listening exercise in effect called for a truly radical rethink.
Many of these radical opinions, however, did not seem to be based on sound knowledge of how the NHS already works, sound knowledge of the plans for modernising it, or actual experience of NHS treatment. It seems possible that many of them were not genuine opinions about healthcare, but merely political positions.
Many people contributed comments saying they did not want to have choice in healthcare. Sometimes they gave no reason. Sometimes they said that choice implies some treatments are worse than others, and that by banning choice all treatments would become equally good. Sometimes they said that patients do not have the knowledge to make the right choices.
For example, from Robert Irving:
I do not want choice or competition. I want one good hospital, dentist, GP close at hand so that I don’t have to travel…
Removing choice from the NHS would require a radical rethink. Certainly in my lifetime, and probably from the very start of the NHS, people have had a choice of GP, dentist, optician and pharmacist, and we have had the right to change our minds about them at any time. It has always been illegal for NHS staff to treat people against their will (except in very unusual circumstances). Choice has always been a key principle of NHS healthcare.
The previous government started to introduce greater emphasis on choice, naming the main public NHS website NHS Choices in 2007. At the same time, in recent years the clinical guidelines from NICE have all emphasized the need for patients to be involved in decisions about their care, and to be helped to make informed decisions when there are alternatives to be considered. The plans for modernising the NHS support this long tradition of choice in the NHS by making it more explicit and by making provision for patients to be better informed.
The listening exercise seems to show, however, that there are some people who do not want choice at all. They want NHS staff to make decisions for them. Unless this is merely political posturing, there may be value in having an opt-out for such people, even though this would be a radical departure for the NHS. Perhaps there could be a simple mechanism for delegating all one’s healthcare choices to a relative or advocate.
Many people contributed comments saying they did not want there to be any competition between healthcare providers. Sometimes they reasoned that providers who were in competition with each other would not be able to cooperate to provide integrated treatment. Sometimes they reasoned that competition implies duplication and waste of resources. Sometimes they reasoned that competition would result in cheap but low-quality care. Sometimes they confused the last government’s slogan, “any willing provider” (from 2006 or before), with the present government’s plans for the future.
For example, from David R Reed:
We do not want competition in the NHS, we want enforced standards of care decided at national level…
Removing competition from the NHS would require a radical rethink, and then some. When there is more than one way to treat a condition and it is not clear which is better, there is bound to be competition between supporters of each treatment. This happens whether the treatments differ in their medical approach, differ in location, or differ in some other way. Even if every detail of the NHS were centrally planned from a single room in Whitehall, there would be constant competition inside that room.
At present, much of the competition that occurs in the NHS is hidden inside primary care trusts (PCTs), which make decisions about which care providers get which kinds of work. Decisions of this kind have always been made in the NHS, and often behind closed doors. This might have created the illusion that there is little competition in the NHS at present.
The plans for modernising the NHS contain only minor changes to the way competition works. It will be somewhat more transparent, because decisions that are now being made in relative secrecy by PCTs will in future be made more publicly by consortia. This will tend to dispel the illusion, making competition between providers more obvious, but it will not introduce any extra competition.
The plans would give local GPs as a group the ultimate responsibility for choosing between competing providers locally, and it seems unlikely that GPs or patients would put up with failure to provide integrated treatment. Competing providers don’t refuse to cooperate in integrated treatment at present, and they would only lose out if they ever did start to refuse.
There are so many examples showing that competitive environments are more efficient in their use of resources than monopolies, that it should no longer need saying. The public superstition that monopolies are benign in the NHS reflects a failure of the NHS to explain in a straightforward and honest way how healthcare really works.
The plans specify that providers will not be allowed to compete simply by being cheap, but will have to compete by providing high quality care, with consortia having a legal duty to improve the quality of care. The existing tariff structure, initiated years ago, will help to maintain the focus on quality and not price.
The listening exercise seems to show that there are some people who do not want to know about the inevitability of competition. They presumably want it to occur in greater secrecy so as to strengthen the illusion that the NHS is a benign monopoly. Unless this is merely political posturing, such people are demanding to be lied to, and that is a difficult demand to meet.
Perhaps a degree of spin might provide a temporary solution, replacing the word “competition” with some other word that causes less of a negative reaction. For example, many aspects of competition could be expressed instead in terms of diversity of provision. Commissioners would then be said to allocate care provision from amongst diverse providers instead of choosing between competing providers.
Many responses to the Department of Health’s questions about accountability and patients changed the subject to discuss GPs and commissioning instead. Some people contributed comments saying they did not want GPs to be involved in commissioning. Sometimes they reasoned that GPs do not know enough. Sometimes they reasoned that GPs are too busy. Sometimes they reasoned that GPs have a conflict of interest because they also treat the same patients. Sometimes they reasoned that not only GPs but also all kinds of other health professionals should be responsible for commissioning. Sometimes they confused the present plans with a return to the old idea of GP fundholding.
For example, from Anon:
GPs are ‘jacks/jills of all trades’. They know a little about some things. They cannot possibly know or be aware of the minute details of service provision in primary or secondary care. What we actually need is representation of all services, professions, patients, relatives and carers, academics and managers on health boards.
The NHS has always used a model of healthcare with two (or more) levels. There are some healthcare services, like GPs, dentists, pharmacists, A&E etc. that you can use directly. There are other services, like consultants and other specialists, that you can only use if you are referred.
The plans for modernising the NHS build on this distinction to place the overall management and funding of local services in the control of GPs, because GPs are best placed to understand the broad healthcare needs of the local population. This is a big change from the present system, in which managers in PCTs can make decisions about which services to fund, independently of the medical consensus in the local area.
Those commenters who thought that GPs do not know enough, would be too busy, would have conflicts of interest, or would become fundholders, seemed to be unaware of what the plans for modernising the NHS actually propose. The plans include safeguards against all those imagined drawbacks. Many GPs are already involved in setting up the consortia that will take over commissioning from their PCTs, and they have not reported any of the problems that these commenters imagine.
Those commenters who thought that other professionals in addition to GPs should also be involved, seemed to be unaware that those other professionals would mostly be employees of providers seeking to have their services commissioned. In their own areas of expertise those other professionals would have a conflict of interest, and beyond their own area of expertise they would have little of value to contribute.
The listening exercise seems to show that there is widespread confusion about how commissioning works at present, which is perhaps only to be expected given the secretive way the PCTs have generally gone about it. It might be helpful for local HealthWatch to have a duty to monitor consortia and ensure that the public are well informed about the reasoning behind every commissioning decision, naming the GPs responsible, so that this confusion gradually fades.
Many people contributed comments saying they did not want private companies to provide healthcare. Some of them reasoned that private companies would cherry-pick the most profitable services, leaving less money for NHS providers.
For example, from J Salisbury:
If private companies are allowed to take on sections of healthcare provision they will be looking to make profit and not to necessarily provide the best possible treatment journey.
These commenters generally avoided explaining what they mean by the word “private”. They seemed to have in mind privately owned companies that are run for the individual profit of their owners, but there are probably few of those of any great size in the healthcare sector. It is not clear that their owners really make more in profit than, say, senior managers of NHS trusts make in salary, bonuses and benefits.
Some commenters mentioned shareholders, without acknowledging that shareholders are lenders. Shareholders should be compared to other lenders, such as those who might lend money to NHS foundation trusts.
It is, of course, confusing that public companies (PLCs) and social enterprises are included along with sole traders in the “private” sector, while PLCs and social enterprises that have charitable status for tax purposes are regarded as being in a “third” sector. NHS foundation trusts operate according to almost exactly the same financial principles as PLCs and charitable companies, but commenters did not generally seem to understand this.
Commenters who worry about cherry-picking seem unaware what the plans for modernising the NHS actually propose — namely, clinically-led commissioning and competition based on quality. Although some PCTs might very possibly have allowed cherry-picking in the past when they commissioned services based on price, it is not clear how that could happen in the proposed new system. Also, if there are any cherries to be had, it seems just as likely that NHS trusts might cherry-pick. Indeed, for all anyone knows GP consortia might turn out to have a bias towards NHS trusts as providers.
The listening exercise seems to show that there is concern about taxpayers’ money allocated for healthcare but then going into the pockets of certain undeserving people, even though it is not very clear who these undeserving people really are. Unless this is merely political posturing, it suggests that it might be helpful for local HealthWatch to provide the public with information on the financial status of local care providers, whether NHS, “private” or “third” sector, making it clear where the money is going and who the fat cats are.
Many people contributed to the Department of Health’s question about clinical leadership by changing the subject to representation. They suggested ways for clinicians to be represented, rather than directly and individually involved. For example, they suggested that representatives of professions other than GPs should be involved in commissioning, or they suggested that representatives of unions or professional bodies should be involved.
For example, from james:
The answer is to listen to the views of professional organisations that represent staff when they suggest that these top down changes are not in the interests of patients, staff, the wider NHS or the future of the NHS.
Over many years the NHS has increased the amount it spends on managers and management relative to the amount it spends on providing healthcare. It has become less efficient. Many healthcare professionals now feel unimportant in relation to managers. Having a representative of your profession, or a union employee, on some committee does not address this.
The plans for modernising the NHS do not meddle directly in the workings of NHS trusts and other providers, which is where most clinical leadership would naturally occur. It is difficult for the public to grasp that the emphasis on quality of outcomes in the plans will drive a corresponding emphasis on clinical involvement within the NHS trusts. Those trusts that do not respect and involve their clinicians will find themselves unable to compete on quality.
This is another area where local HealthWatch could contribute, by monitoring and publicizing the extent of local clinical leadership in improving the quality of services, naming the local clinicians responsible.
I have not attempted a comprehensive review of the listening exercise. These few points are just the ones that struck me most as I read through some of the three thousand or so comments. They suggest some ways in which the plans for modernising the NHS might be enhanced:
- Provide a way for people who do not want to have to make choices about their care to opt out.
- Replace the word “competition” with a different word that avoids the suggestion of “cut-price”. Perhaps “diversity” would be better.
They also suggest some ways in which the role of local HealthWatch might be specified in more detail, to ensure that in future the public are better informed about:
- The reasoning and expertise behind local commissioning decisions
- The financial status of local care providers, their highest-earning personnel and their shareholders
- The extent to which local clinical leadership is improving the quality of services