Has the government listened on NHS reform?

The government has responded to the listening exercise on the NHS reforms with a number of key pledges, but are they enough to satisfy the critics of the Bill? Two GPs who are speaking at the Commissioning 2011 conference, which starts in London on Wednesday, share their very different opinions.

Dr Johnny Marshall and Dr Ron Singer
Dr Johnny Marshall and Dr Ron Singer

Dr Ron Singer, president of the Medical Practitioners’ section of Unite: NO
Whatever warm words the prime minister and his ministers use, their pledges in response to the listening exercise and the NHS Future Forum report are an acknowledgement that the Bill is flawed.

Making Monitor responsible for integration as well as competition is a sticking plaster and really changes nothing because, in any given situation, it will be up to Monitor to decide which mechanism it prefers. The forced creation of foundation trusts only makes sense if a full-blown market in health care remains the goal. 

The promise to include hospital doctors and nurses in ‘clinical commissioning’ is simply a con to hide the real aim of the Bill behind the cuddly concept that ‘your GP, aided now by consultants and nurses, knows you well and can design services to suit you’.

With more than 100 types of nurse and myriad medical specialties how can a nurse or consultant on a commissioning board be there in anything other than an advisory capacity? In reality it changes nothing as the relevant specialists were always going to be part of the discussion.

Whatever their make-up, the consortia won’t have much impact on shaping services anyway. A&E and other emergency services will be commissioned at a higher level (around 750,000 population), specialist commissioning for low volume, highly specialised services like neurosurgery, will be commissioned nationally by the NHS Commissioning Board.  Elective care such as hip and knee replacements, will be via patient choice arrangements.

This will leave long-term conditions, where consortia may have some influence. But even this may not occur as providers package their own patient pathways and offer them to consortia.  This is called provider dominance and such packages of care will be fixed and not adaptable because tailoring the package would be complicated, costly and therefore bad for profits.

It will therefore be providers who adopt a leadership role, especially where acute trusts have merged with community providers. Providers may boss commissioners much as now and continue NHS commissioning ‘the wrong way round’.

The outlook for the NHS is therefore not good. The rigours of the market and the demand for shareholder dividends will change the shape of the NHS and how it does business. It will also change its ethos and compromise its ability to deliver quality, comprehensive care, free at the time of need.  I hope I am wrong.

Dr Johnny Marshall, chairman of the National Association of Primary Care: YES
There’s nothing in life more frustrating than seeing that something is wrong and not being able to fix it or seeing how something could be better and not being able to improve it.

So it is a relief to me, and many of my colleagues, that the government’s response to the listening exercise has underlined the key objectives of the reforms rather than undermined them. Because one thing is certain – the status quo isn’t working.

The problem with current arrangements is that you can come up with all the strategies in the world but if you can’t make them happen on the ground they are useless. Consider our local arrangements for physiotherapy, which we have struggled to change for years. It’s faster to get a patient into physiotherapy by referring him to a consultant than it is by referring direct – so guess what? Local GPs, myself included, clog up consultant waiting lists with patients who just need to see a physio. It’s madness but it’s been a problem for years and finding a solution has been like pulling teeth. Under new arrangements we’d just sort it.

It’s the kind of situation that needs a discussion, clinician to clinician, to find a more sensible arrangement – so it is sensible for the prime minister to make it clear that consultants and nurses will be involved in the process, not just GPs.

Broadening Monitor’s remit to encompass integration as well as competition is helpful too. It recognises the fact that competition won’t be required to improve the majority of services but that it needs to be available for those occasions when other routes fail. 

For all the fuss being made about it, you’d think competition was new. Actually it’s been driving progress for years. Some time ago my colleagues and I became aware of a new procedure for cataracts that seemed to offer advantages for at least some of our patients. It was available at a hospital some way away but not at our local trust. We talked to our local hospital but they were reluctant to offer it – at least in a reasonable time scale – and that was that as far as they we concerned.

So what did we do? Well, we started sending patients who were prepared to travel for the new procedure to the other hospital. Guess what? The local hospital noticed it was losing patients and quickly introduced it.

A lot has been made of the Bill’s apparent repealing of the secretary of state’s duty to provide a comprehensive health service. I have never interpreted it that way – I think it’s just trying to recognise that it is clinicians on the ground not politicians in Whitehall who make things happen. So for the prime minister to repeat his commitment to the comprehensive nature of the health service addresses a major area of concern for many.

But reform is crucial. The big problems within the health service just won’t be sorted unless clinicians take ownership of the service and engage with each other and social care professionals in a meaningful way.

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