Provider reform: will anything be different this time round?

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Plus ça change was the observation offered by Robert Naylor at our breakfast seminar on provider reform last week. Current debates about the future of hospitals and bringing care closer to home echo those of the 1970s. So will anything be different this time round?

Naylor’s answer to this question was unequivocal. The current configuration of hospitals in London is unsustainable and changes are urgently needed. More care needs to migrate to specialist hospitals, district general hospitals will have to change their role, and services should be delivered through integrated care organisations combining responsibility for primary care, community services and hospitals.

In his view, this might mean the development of around a dozen Foundation Trusts running a range of services. These integrated care organisations would replace the patchwork quilt of current providers and would lead the development of new models of care appropriate to the needs of an ageing population and the increased prevalence of chronic disease. Critically, financial incentives would need to change to stop rewarding hospitals for treating more patients and to support more care to be delivered in the community.

Moving in this direction would require a comprehensive programme of mergers and acquisitions to reduce the number of organisations providing care, and to overcome fragmentation between services. Naylor made a strong case for mergers arguing that they could produce benefits if well managed and were given time to work. He also challenged the view that PFI (private finance initiative) is a major cause of provider failure, citing the experience of University College London Hospitals (UCLH) as an example of how the environment of care can be improved at an affordable cost.

What chances are there that major reconfigurations will happen? In her contribution to the seminar, Candace Imison argued that the financial pressures on the NHS made it more likely that reconfigurations would occur, despite likely public and political opposition. Robert Naylor went further to suggest that the NHS has the opportunity to use its current financial surpluses to make once in a lifetime changes in how care is delivered, although he was sceptical about the likelihood of major changes happening this side of the election.

The challenge is who will lead these changes when strategic health authorities (SHAs) are being abolished and clinical commissioning groups (CCGs) are still finding their feet? This is exactly the question raised by the Fund in its analysis of the challenges facing the NHS in London. Although Naylor was doubtful about the ability of CCGs to fill the vacuum left by SHAs, recent experience in North West London where CCGs have been instrumental in leading debate about service configuration suggests it would be premature to conclude that they cannot take on this role.

The other unanswered question is whether regulators will be willing to sanction mergers that result in the emergence of integrated care organisations. The view advanced by Naylor that integration and collaboration, rather than competition, should drive health care reform runs counter to the direction of policy, and may well fall foul of the Co-operation and Competition Panel. Catherine Davies from the Panel explained at the seminar that each proposed merger would be considered on its merits with the Office of Fair Trading and the Competition Commission being involved where appropriate.

The elephant in the room was the future of primary care provision. Many GPs who recognise the need to strengthen primary care are fearful of being subsumed into large integrated care organisations led by experienced hospital managers. The challenge this throws down is whether integrated care can be built from a foundation in general practices, for example through federations of practices developing stronger links with community health services and social care, as well as with hospital-based specialists.

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Vickie Ferns

Comment date
13 July 2012
As I have stated in an earlier post I have considerable experience of both the Uk and NZ health systems. New Zealand has had community based care for 15 years. Unlike the Uk it was not reported in our newspapers that our health system was going down this path. I have been extensively researching this over the last 8 months and although there were articles in a middle class magazine "the Listener" with various articles on cost cutting, there was no big debate as your country has done here. A lot of people in New Zealand are unaware of just how bad the 'care' has become with many doctors resigning and going private through being unable to buy the latest equipment, long hours which ruin marriages and not being able to give the world class care that our citizens deserve. I'm told that parts of NZ have world class care and parts do not.The on line 'Doctor' magazine has many articles on cutbacks ,shortage of staff etc. Currently Pharmac are looking at cutting out any choice in diabetic equipment and buying one product only which is reported to be of poor standard in a bid to save $10 million. At least the oppurtunity for submissions have been made on this proposal.
G.P's are often sent letters asking them not to send patients to hospital, not that they need reminding.10 years ago I saw 4 different doctors who failed to diagnose septicima. I was very ill yet no one thought to take a blood test let alone send me to hospital. I think one took my blood pressure and remarked it was high because of how much pain I was in. I was lucky that because of my health problem I was on permanent antibiotics which I increased and added in the anti inflammatories which I also had at home, as I suspected it might be septicima due to a root canal -- a year earlier I had been told to go to a private dentist because the hospital dentist could not find the 4th root, it was to cost $1000 which I did not have so I thought it would be okay as I was on permanent ciprofloxin. My liver specalist later confirmed it was highly likely I had had septicima. The nerves were so badly effected I had severe neuralgia for 6 months which was also misdiagnosed by a G.P as some dreadful bone disease. I believe the G.P's in our country are under immense pressure to keep people out of hospital and that is why mistakes like this can happen.
In the 12 years before I went to the Uk to live with my daughter ,I would have times when I was in so much pain I could barely walk for two months at a time and I would be told I could not go to hospital as I would be sent home. I could only get morphine injections once a day, no night time or weekend cover and I couldn't afford 2 months worth anyway.
I was promised a PTC exam for years and I finally wrote to Auckland asking for help. A year later they found two hepatic ducts had narrowed. Still I was in severe pain with no one actively looking for a reason why and left to poor community care. When you change over to this so called better more intergrated care there has to be safe guards and G.P's must not be put under so much pressure to save the country money they make serious mistakes.
My current G.P who constantly worries about the cost to the hospital for my care wanted to give me steriods, he has tried to in the past. This would be dangerous for me and luckly I have a thorough understanding of my complex condition --a far better understanding than he does. I wouldn't take them until I saw my specialist as I was concerned. Turns out it could cause an infection for me. I have high blood pressure due to the amount of pain I am in but did not get medication until I went to Britain.
A Scottish doctor lived in Wellington for 5 years trying to get a department for stroke patients to enhance better outcomes , in the end he gave up and went home.
An MS patient who had moved into our street said he regularly saw a specalist down in Dunedin but has only seen one once in the 18 months he has lived here, his G.P looks after his care. He has been in a wheelchair for the last 10 years as he is deteriorating.
Our G.P's were wanting to micro manage our care so much that I was once told if I had chest pains to drive down to the office to see if I needed to go to hospital. Something must have happened as now on the phone they have a message asking people to go to hospital in an emergency.
We have Accident Compensation in NZ which replaces private insurance. Recently it came out that they get a bonus for getting 'clients' off the books to the cheaper sickness benefit or work. I hope G.P's are not payed for keeping patients out of hospital.
A survey needs to be done of the community care we have, it would be interesting to see the results.

Celia Davies

Comment date
09 July 2012
It was certainly a very thought-provoking session - but I came away feeling that things were the wrong way round. In these days when what it means to provide a public service and what that service is going to look like is still in the melting pot, commissioning seemed the proper place to start. It's not just a case of form follows function as we used to say.Starting this way would have put questions about why we are here, what we are trying to achieve, and where the patient fits into it all much more firmly at the centre. So roll on session 2.

An average patient

Comment date
09 July 2012
What happens under this approach if your local HMO (for that is what is being advocated) is not very good at treating your condition? At least now you can choose to go elsewhere - as I was forced to do to sort out my LTC. Instead, this is proposing to concentrate monopoly power in the hands of the current managers / clinicians who tend to run the NHS in their own interests, rather than that of patients - and deliver worse patient experiences and outcomes than most other Western countries.

Without competition, all you end up with is the worst kind of monopoly - just look at the level of adverse outcomes from key maternity services in east and south-east London to look at what happens.

Integration is important, but can be achieved through better IT, driven bottom-up rather than the kind of top-down mess that NHSPfIT delivered. And experience from other sectors suggests that innovation in doing so is much more likely to come from new
entrants than monopolies (both providers and doctors).

Mick Smith

West Suffolk NHS Foundation Trust
Comment date
06 July 2012
As a new governor at a new FT this sort of issue is close to my heart. My first comment is this item seems way too London biased. There are other parts of the NHS than London.

Other than that, this issue of competition must be brought into play if the private sector is to be successful in taking over our health services so proper collaboration, mergers and so forth that will genuinely increase the quality AND QUANTITY of health service provison in a properly integrated way will not be allowed to happen as that will not give the edge to the private sector.

Tess Harris

Comment date
05 July 2012
As an LTC PKD patient of 31 years since diagnosis, I predict the NHS will be as disjointed in 10 years as it is now.

calum paton

Prof. of Public Policy,
Keele Univ.
Comment date
05 July 2012
The late Prof. Roger Dyson worked with Tory Ministers and the Cabinet Office in the 1980s and 90s. He interpreted the 90s' 'internal market' as an attempt to achieve a hospital 'plan' by the backdoor.

The same question can be asked today, but I suspect Ministers do not know if an affordable reconfigured hospital system will allow the luxury of competition or not.

One thing I do know: with the CCP, Monitor,the DoH, the NCB's regional offices, CCGs, the OFT and the CC all jostling for a piece of the action, we will have the Oliver Hardy theory of health reform validated ("another fine mess you've got me into, Lansley.....I mean, Laurel")

Oh,and by the way, when is Bob Naylor going to realise that boasting about advising Alan Milburn is something that is better done in private amongst consenting adults?!

John Chater

Comment date
05 July 2012
Robert also said that UCLH was in the throes of a cancer services in exchange for cardio services NHS swapsies deal with Barts. No mention of an invitation to tender or consultation on the best deal for patients, the paying public or the NHS, just the usual scenario of established NHS providers reconfiguring the NHS landscape seemingly at will (and exactly the kind of thing that the Health Act may well determine to now be illegal).

In response to a question about the possible effect of competition on such arrangements he blithely added: "Well, I've been doing business like this for over 25 years you know."

Plus ça change, plus c'est la même chose indeed.

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