New Year priorities for NHS under the microscope

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The King's Fund chief economist, Professor John Appleby, examines the New Year priorities for the NHS outlined in last week's Operating Framework for 2008/09 and urges PCTs to rise to the challenge and exercise their freedom to improve care for local communities.

The devolution of around three-quarters of the NHS budget to primary care trusts (PCTs) has for some time been cited as proof that the centre has effectively jettisoned its command and control tendencies. But as PCTs know, being given the money is not necessarily synonymous with being truly in control of how it is spent.

In one sense the Department of Health's Operating Framework for next year, published last week, implicitly recognises this. Its headline message appears to be: we have opened the doors of the cage, please, please go out and exploit your purchasing freedoms for the benefit of your populations.

PCTs may feel aggrieved at the accusation that they are too timid, that – psychologically almost – they cannot seem to escape the chains and shackles of the 'old' way of doing things. The accusation is not – even PCTs may admit – totally without foundation. Too often too many PCTs continue to look upwards towards government rather than out into their local communities.

But there is a distinct lack of recognition of the constraints that NHS commissioners have had to work within. A key constraint has been the need for PCTs' commissioning plans to satisfy nationally set policy goals. Targets are not necessarily bad things, and to some extent they reflect what PCTs should be prioritising anyway. But they can conflict with locally determined priorities, reduce the scope for local manoeuvre and leave little management time to focus on local priorities.

It may seem unfair to point this out, but although the Framework presents a pyramid, the small apex of which is labelled 'national priorities' and the much wider base 'local action', it then goes on to devote 10 pages to detailing said national priorities (with 29 instances of the phrase 'we expect') and only one paragraph on priorities determined locally.

Having said that, and as an aside, one of the new national requirements is particularly welcome and is a start in improving the information PCTs need to improve their purchasing. Overdue by around 150 years – ever since Florence Nightingale classified patients as relieved, unrelieved or dead – is the requirement from April 2009 in the standard NHS contract that every patient receiving treatment for knee, hip, hernia or varicose veins routinely record their health status. The NHS in England will be the first health care system in the world routinely to collect information on the very reason for the existence of health care services – to improve health.

Although there is not much said about local priorities, the list of five key priority areas – which includes reducing health care associated infections, waiting times and health inequalities, as well as improving access to GP services at evenings and weekends – become significant when looked at in more detail.

And of course there are still 'must do' tasks from previous years. Even the scope for locally set priorities seems somewhat curtailed: 'There are issues that some PCTs will need to ensure are covered as part of their local priority setting process….'

Add in the fact that a significant chunk of PCTs' budgets will be spoken for as a result of the choices patients make, and that most decisions about resource commitment are actually in the hands of providers, it is easy to see the local control implied by holding 75 per cent of the NHS budget draining away.

But if, for whatever reasons, PCTs have failed so far to meet the core tasks set out in their job description – to maximise health bang per buck and minimise inequalities in access and health – then the return to the notion of an internal market has failed to deliver what was expected too, so far at least.

This could be taken to be a damning statement. But the truth is inevitably more complex. And part of this complexity is the dawning realisation that setting the rules of engagement in a quasi-market, balancing and defining local freedoms and national responsibilities (a phrase familiar to those who recall that eponymous Departmental guide from the early 1990s on the limits to competition and the scope for co-operation) is difficult and involved.

The 2008/09 Operating Framework is a step in the right direction as it sets out 10 principles of competition and co-operation. But it has taken more than seven years since the (re)separation of purchasers and providers to get to what surely should have been the first step on this policy journey.

With the support implied by the rhetoric of world-class commissioning, PCTs now need to seize the opportunity to exercise their freedom to improve care for their populations, to become truly active purchasers.

This article was originally published in Insight, The King's Fund bi-monthly update, December 2007