Don't oversimplify the debate on NHS reform

Passions are running high in the debate about the NHS reforms. At The King's Fund, we are passionate about the NHS and the principles that underpin it – universal, comprehensive and equitable health care for all – while recognising the need for further improvements in performance, building on the major achievements of the last decade.

The government has undoubtedly made a major strategic error in deciding to enact its reforms through a lengthy and complex piece of legislation, but some of its critics have undermined their case by claiming that the Health and Social Care Bill heralds the end of the NHS as we know it.

Discussion about the reforms has become unhelpfully polarised around a debate about whether or not the Bill should be dropped. Our view at the Fund is that the complexity and importance of the issues at stake cannot be reduced to the simple question, are you for or against the Bill? This is because the Bill and associated reforms offer opportunities as well as risks, and our role as a think tank is to analyse, inform and seek to influence policy, rather than to adopt a campaigning stance that takes sides in an increasingly acrimonious debate.

We take encouragement from the amendments made to the Bill following the work of the NHS Future Forum as well as those that seem likely to be introduced following pressure from members of the House of Lords. As a result of these amendments, there is now explicit acknowledgement that the emphasis on competition needs to be joined with support for integrated care where it will bring benefits, and – assuming agreement can be reached, as now seems likely in the House of Lords – greater clarity about the role of the Secretary of State. At the same time, we remain concerned by the further reductions in management costs and posts that will be made following the release of papers on the role of the NHS Commissioning Board last week, and the loss of organisational memory and experienced managers that will inevitably occur.

One of our most important concerns is the impact of major organisational changes on the ability of NHS leaders to focus on the core business of improving patient care and maintaining recent improvements in performance. At a time when the NHS faces the biggest financial squeeze in its history, the priority has to be rising to the Nicholson Challenge and releasing resources to invest in service priorities such as the care and dignity of older people and improving care for people with dementia. Much work also needs to be done to tackle variations in quality and patient safety, often involving difficult but necessary decisions on concentrating specialist services in fewer hospitals able to deliver better results.

We made clear in our October 2010 response to the white paper which launched the reforms that the government would have been better advised to pursue its aims by building on existing arrangements rather than embarking on further major change. Almost 18 months on, the changes already made in anticipation of the Bill becoming law make turning back very difficult. This week's joint editorial by the editors of the BMJ, HSJ and Nursing Times argued that the result of the government's action is 'an unholy mess' but it is not at all clear that the mess would be avoided in the unlikely event that the Bill were to be dropped.

One of the roles of think tanks is to go beyond commentary and critique to set out alternative options. The Fund has sought to do that, not only by arguing the case for evolution instead of revolution, but also by proposing that integrated care should be given much greater attention. The policy tide is now running clearly in this direction and we shall continue to propose ways in which clinical commissioning groups and health and wellbeing boards can use their powers to make a reality of integrated care in practice. We have elaborated on our ''Plan B' – Where next for the NHS reforms? – through a series of contributions to the debate and continue to believe that there is no inherent contradiction between integration and competition.

In 2010 I wrote an article for The Times in which I argued that the choice was not between stability and change but between reforms that are well designed and deliver benefits for patients and those that are poorly planned and undermine NHS performance. While passions will surely continue to run high on an issue that matters deeply to the British people and to staff working in the NHS, now is the time for cool heads and rational discussion of how to make sure that the reforms really do work for patients and that the risks they represent are managed and minimised. A service already performing well can do even better if the energies and intelligence of all who have the best interests of the NHS at heart can work together to secure its long term future.

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#695 mark driver

How about asking all 58 million citizens whether they want to keep it? And if so how much they think is is worth to them? In terms of weekly direct taxation.
Lets NOT assume that we all think the NHS is wonderful. It was ground breaking in 1947 but it sure isn't now.

#696 Malcolm Kendrick
Salaried G.P.
Intermediate care CECPCT

My primary objection to the bill is that it will drive a further wedge between primary and secondary care. GPs, as purchasers, will try to negotiate the best financial deal with providers - and no doubt some of them will go bankrupt as they try to undercut the competition.

On the other hand the 'providers' will do all they can to maximise income from every patient contact. Negotiating, conrolling and policing the various contracts and services will use up billions, and will reinforce a 'them and us' culture.

We already see that consultant to consultant referrals are banned - with the patient being told to see their GP for another referral back to the same hospital - to see a consultant who may well work next door. This maximises income for the provider. But it uses up GP resources, and time, and is highly inconvenient for the patient.

This is not integration of the service. It is disintegration, and it can only get worse under the new bill.

We have to look at ways to design the service round patient needs. This will not happen by grafting a quasi-market system onto a tax-payer funded service.

#697 John Kapp
patient rep and director

There is an alternative health service which is patient-centred, and whose treatments are NICE-recommended and clinically appropriate for 2/3 patients (Mincfulness Based Cognitive Therapy 8 week course, and spinal manipulation and acupuncture for low back pain. The waiting time on the NHS is thousands of years, but could be below 18 weeks if commissioners paid the therapists with vouchers prescribed by GPs. This would improve public health, reduce inequalities, and meet the Nicholson challenge. See our website for details.

#698 john cornell

I agree that things have gone too far to think we can go back to the PCTs and then actually build on what we had. I agree that we are likely to be in an "unholy mess" whichever way we go. However, "unholy messes" can be rescued if the stakeholders can sit down and have a mature debate around the real vision of where we want the NHS to be and how the current situation can be refined to enable us to get there. The problem seems to me is that as the professionals try to logically debate what we see as the difficulties in doing that, the government are on a parallel track because their real agenda is different. Thus, all reasonable argument seems to fall on deaf ears, as we are not on the same wave length, even though there is much agreement about many of the elements of the vision - choice, clinical leadership, quality, service redesign etc. However, being on parallel lines is leading to increasing frustration and unless government is willing to honestly engage, I don't really see any orderly solution. Clearly the NHS will continue and adjust to all the new demands placed on it but I doubt whether this will lead us to the promised land and I fear that something will ultimately give and tip it into more than a financial crisis.

#700 Gordon Read
former Chief Probation Officer
Patients' Participation Group

I tend to agree with Malcolm Kendrick (above) in the sense that a market is already developing between Primary and Secondary care in such a way as GPs are now required to find reasons not to use their neighbouring acute hospitals. Those hospitals, once starved of patients, will have to market themselves elsewhere to survive resulting in other costs to patients like travel and accommodation and further congestion on our roads.

As to your contributors, while Professor Field is probably correct about the importance of Health England, the 'internal' marketing system now developing would also further undermine integration.

Shirley Williams spoke with most of the integrity and less of the rhetoric about what, for the most part, will be an illusory choice for most patients who would need GP guidance in any case. She also emphasised something one might have expected independent think tank members to have pointed out, that the NHS is one of the best national systems in the world (see the Commonwealth Fund 2011 Reports: "Multinational Comparisons of Health Systems Data" & " International Health Policy Survey of Sicker Adults in Eleven Countries").

My concern is that our brilliant English barristers will use EU Competition Law to drive coaches and horses through the puny safeguards currently proposed in amendments to this Bill in the same way they opened up weaknesses in our licencing laws in the '80s and '90s to extend the use of alcohol to the health scourge it is today.

#701 Daniel Steenstra
RAEng Visiting Professor in Medical Innovation
Cranfield University

I fully agree with Prof Ham’s observations and analysis; the situation the NHS is in is one of mind-boggling and unprecedented complexity. Whilst having to cope with short-term productivity and efficiency challenges at the same time as having to develop and implement structural reforms for the medium and long term in itself is something that other organisations have to cope with too. But how many large companies get this right? The sheer number of staff involved in NHS and Social Services; the fact that the same people have to deal with the short and long term challenges; the geographical spread; the diversity of disciplines and structures, and the potential disastrous impact any change could have on patients; contributes to this huge complexity. Stopping the Bill is far too simplistic. The recognition that we are dealing with complexity means that we should look for practical solutions in complexity management and whole-system innovation.

#702 Mike Nicholls

I will not hold my breath. In my 20 years as a county councillor I was chair of social care, for much of that time and the member responsible for working across social care and the NHS. I cannot remember the number of reorganisation that the NHS went through in that time; all of which were false dawns. What the NHS has lacked is a period of stability in order to bed in a management system, rather than yet another reorganisation.

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