A chance to go back to basics on health and social care reform?

The government's decision to consult with stakeholders during this pause in the passage of the Health and Social Care Bill through parliament creates an opportunity to revisit the problems the Bill is intended to address.

In our response to the White Paper, published in October, we highlighted the many improvements in NHS performance that have occurred in the past decade. These include much shorter waiting times for treatment, gains in life expectancy and reductions in infant mortality, and falling rates of premature deaths from heart disease and cancer. We also noted evidence of increasing public satisfaction with the NHS and good performance in the international surveys conducted by the Commonwealth Fund.

At the same time, we drew attention to areas in which performance needs to be improved: increasing rates of obesity and alcohol-related hospital admissions, persistent inequalities in health, declining productivity, and slow progress in moving care out of hospitals and into the community. Our overall assessment was that while further reform was needed, ‘the means used need to be proportionate to the problems to be addressed'.

Six months later, we stand by this assessment. While there are no grounds for complacency, and many opportunities for the NHS to emulate levels of performance achieved in other countries, it is not self evident that root-and-branch changes of the kind now being implemented at high speed will deliver the improvements needed. Indeed, there is a major risk that the changes already under way will take time and attention away from the core business of improving patient care and delivering the £20-billion of efficiency savings that David Nicholson has called for.

What then should be done to avoid this risk and to tackle the problems that need to be addressed? As we argued in October, evolution rather than revolution is the best way forward. This includes building on successful examples of practice-based commissioning, encouraging partnerships between the NHS and local authorities on public health and other issues, and adopting a nuanced approach to regulation in which choice and competition in elective care goes hand in hand with collaboration among providers of emergency care and care for people with complex needs.

Our thinking on NHS reform has been influenced by the opportunity to work with senior medical leaders from high-performing systems across and outside the UK and with NHS colleagues during a programme of work on integrated care. One example is Kaiser Permanente, an organisation widely admired for its work on prevention and chronic disease management. On a recent visit, its leaders were perplexed by the perverse incentives in the NHS, especially the system of Payment by Results, under which hospitals are rewarded for the number of patients they treat.

Their advice was that the NHS should make serious efforts to develop aligned incentives to facilitate a shift from care in hospitals to care delivered in the community. To borrow a phrase from the health reform debate in the United States, 'accountable care systems' – that take responsibility for the care of the populations they serve within a fixed budget – offer a promising way to do this. These systems could evolve from the best of practice-based commissioning and the emerging general practice commissioning consortia if the right incentives are put in place to encourage GPs to work with specialists to improve performance.

The point about accountable care systems is that they offer a potential solution to a real problem facing the NHS – an over reliance on hospital care and a failure to make a reality of care closer to home. They will also support greater priority for prevention by rewarding spending now that reduces demand for treatment in the future. Moving in this direction would help to engage a wider range of clinicians and stakeholders and avoid the risks involved in big bang reform, by focusing on progressive improvement of existing arrangements.

David Cameron and Nick Clegg must go back to basics and ask if coalition plans will help the NHS tackle the problems that lie ahead. They should also seek reassurance that the plans are proportionate to the problems to be addressed. Only then should they proceed with legislation that as it stands represents the most fundamental change to the NHS since its inception.

This blog is also featured on the BMJ website

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#404 Anne Palmer

2. “The Bill contains provisions on a range of policies. It contains 281 clauses over twelve Parts, and has twenty-two Schedules. The Bill is intended to give effect to the policies requiring primary legislation that were set out in the White Paper Equity and Excellence: Liberating the NHS, which was published in July 2010”.

Provisions for delegated legislation
3. “The Bill is not in general an enabling or framework Bill. It places a large amount of core legislation about bodies on the face of the Bill. This is consistent with the vision of moving away from the current system – where the Secretary of State has wide powers to confer functions on various NHS bodies and wide-ranging powers of direction over their activity – to a more transparent system, with reduced scope for intervention from the centre. The Bill confers functions directly on those responsible for exercising them. This entails spelling out in more detail than in the past what the remaining role of the Secretary of State in relation to those bodies is”.

The Health and Social Care Bill” an important piece of Legislation the like of which, is so badly drafted, so ambiguous, I have never come across the like of such for a legal document in my life before. It of course could have been drafted in such a way for another that reason. When things happen which we do not like it could be said, “Ah well, it was all in the Bill” I simply do not know. One example here but many are the paragraphs like this.

Part 11 Miscellaneous. 853. Under this Part of the Bill, the Secretary of State would have the power to make schemes to transfer staff or property, rights and liabilities from one body to another as a result of bodies being abolished or created by this Bill. Schemes might make transfers of staff or property to a range of bodies, including for example local authorities, commissioning consortia, the NHS Commissioning Board, any public authority providing health services or a qualifying company11 . ( Far too ambiguous. “the Secretary of State would have the power to make schemes (what schemes? -some-thing that hasn’t been thought of yet?) to transfer staff or property? Which Staff? The rights and liabilities from one body to another? Which Body? The UK? To the EU? ETC, but you get the gist? And supposed they do not want to go? This Bill is a Minefield, it should be destroyed completely.

#406 Mary E Hoult

Nobody in all this seems to be taking account of the Patient Experience during this transition period,all this infighting does nothing for patients needing care.I do hope this latest pause does what it says "Hears the patients voice" not just the people with vested interests

#407 Stefanie

We should take note that this 'pause' would not have been possible without the intervention of the Lib Dems, as articulated at their recent party conference. This is a great example of the "checks and balances" a coalition government can provide, if it is fully functional (which arguably it is not, but both parties in government are learning fast about their respective power and its limits).

If we want to take the speed out of health reforms and to increase the controls on government policy-making we should be campaigning for the AV. This is not about Lib Dem politics or minor changes to the reform bill at all. The whole purpose of a change in electoral practices is to make more considered policies, to increase the controls on government, and to reduce the opportunities for individuals to push through reform ideas irrespective of substantial opposition once they find themselves in government.

#408 tim gilling
deputy executive director
centre for public scrutiny

Hopefully the 'pause' is an opportunity to revist some of the arguements we and others have been putting forward (through the Bill Committee and other means) about strengthening the Bill around 'transparency, involvement and accountability'.

These principles would seem to fit well with the concept of an 'accountable care system'. I don't know what evidence there is from the US on the effectiveness of patient and public influence - but a truley accountable system would see professionals, patients and communities co-producing solutions to difficult problems together, no matter what the structures are for commissioning and providing services.

#409 John Kapp

The real problem for the NHS is that its treatments (drugs) don't work to cure patients, and side effects make them worse. GPs know this better than anybody, and have the opportunity to commission NICE-recommended complementary treatments which do work, (Mindfulness Based Cognitive Therapy (MBCT) 8 week course, spinal manipulation for low back pain etc. These are not commissioned now because they are complementary. See www.sectco.org.

#411 Betty Driven

As a member of a small rural community I am more than aware of the problems my neighbours. A dear friend of mine has severe mental health problems as does another member of our community. Nick Cleggs promise has so far failed to materialise, cut backs have already started. The local CMHT is now reducing it's staff. It's a viscious circle for these poor individuals. As for Cognitive Therapy, do you really think six weeks is sufficient, or even 6 months. Mental illness is often long term and without the proper care and supervision lives will be lost!!

#412 Paul Kelly

The King's Fund is clearly against the NHS reforms as they stand.. I agree with them and also the suggestion that the reforms, as currently proposed, entail "major risk" of diversion away from improving patient care.
However, I do not understand why Kaiser Permanente was required to validate the existence of perverse incentives in the NHS or that incentives should be there to promote care in community settings rather than in hospitals. Most of the NHS workforce could probably say these things. I am also uncomfortable with the introduction of another set of words which when put together are branded and given their own independent definition, as in "world class commissioning" (RIP). The latest appears to be "accountable care systems". Now, if this just means care systems that are accountable, then I am fine with that. But if it means a collection of policies, strategies or ideology, or the latest idea marketed by business consultants then I am not. Give it a proper name. I am wholly behind the idea of spending on prevention to avoid spending later. The problem here, of course, is the time disparity between election intervals and the publication of the reaping of health benefits attributable to policies and strategies introduced in the election term. Overall I am just pleased that the King's Fund (and others) are not letting the politicians have a free reign.

#413 James Bunt
Interim (Commercial Tasks)
Gordian Management

Interesting points; integration has to be the way forward but is a challenge under PbR. However if you shift mindset a bit and call care outside hospitals "care off tariff" then secondary providers can be involved and benefit. They can shed low margin activities and focus on high margin ones such as elective surgery. If you crawl under the bonnet in secondary care perhaps there are win wins along these lines we just have to start thinking "off tariff".

#448 Nigel Starey
semi retired GP &PCT medical director

Much to agree with in this and the listening exercise paper - the twin imperitives of improving clinical efficiency and promoting integrated care to meet the Nicholson challenge - but I have one issue: Can a regional clinical cabinet/ outpost of the commissioning board really provide the system leadership which I agree is vital? Local health economies need that leadership and Regions will be too remote for most of the time - except for strategic reconfiguration or large population matters. I think there is going to be aneed for Local health economy Clinical cabinets to provide the system leadership, promote clinical efficiency and Integrated care across organisational and cultural boundaries.

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