The Health and Social Care Bill is in better shape now. There are still some gaps (failure and designated services being the biggest) but best for the politicians to pass it and turn their focus to more pressing issues in the NHS – achieving more value for money. That is our main assessment as outlined in our initial response to the Bill Committee: Memorandum to the Public Bill Committee for the Health and Social Care Bill.
We are left thinking that the whole policy-making process has been less than desirable. Perhaps an overambitious reform programme given the financial climate, key groups not enough involved or warmed up, and policies not fully developed because of the Bill’s wide scope. Hence the need for an eight week 'pause'.
The resulting Bill is now heavier in some places, such as in relation to the duties and requirements of the new clinical commissioning groups, but has also been left lighter in others.
The Government has had to withdraw clauses relating to the failure regime for providers and the protection of essential ('designated') services to do more work on them. And taken as a whole it is not always clear why some elements are in legislation (and thus clearer), while others left to secondary legislation, regulations, or indeed guidance (and thus as yet opaque).
But let's move on and tackle more immediate issues like achieving the efficiency gains needed to enable the NHS to continue offering high quality care. The focus must be on providers, which is not the primary focus of the Bill.
Worries about hospitals being unable to deliver QIPP plans has prompted much talk recently of the need for reconfigurations, and how decisions on service changes could be speeded up, even decoupled from the political process. The latter was tried in Canada during the severe economic downturn in the mid 1990s, with Ontario and Saskatchewan both making swift changes and where 'no sacred cows' held up the process. Watch our latest video interviews to see how they did it.
One sobering message was that if in dealing with an immediate financial squeeze, crafting reforms to ensure the medium term sustainability of the health system is lost, after the squeeze health care expendures just continue along the same upward trajectory.
But I am uncomfortable with tough talk about service closures if better management could prevent them. Have we earned the right to close?
Visiting Circle’s large independent sector treatment centre (ISTC) in Nottingham last month, I was struck by the engagement of the doctors and nurses in managing their services, as well as their use of cost and activity data. Clinicians were not alienated from management and seemed to solve problems from the bottom up.
This did not seem to be down to good commissioning, or competition, or for that matter integrated care, but fresh thinking about management and customer service from a new entrant to the NHS. Of course, I would like to see Circle's results next to the NHS on a range of metrics. But surely engagement of clinicians, especially doctors, is a critical first step to achieving better value care at lower cost?
As for the type of care ISTCs do not provide, we are working with The King's Fund and others to see how integrated care can best be encouraged to develop in England. For those who have recently asked me the question 'what exactly is integrated care?' see our new publication which provides the answers. The ingredients for success are also examined in a new set of international case studies in the Netherlands, US and Scotland (not the usual suspects) that we have published today.
Fledgling clinical commissioning groups might do well to take a look at Larry Casalino's pithy analysis of why some physician groups commissioning care in the US were successful, and why many failed over the last 15 years. Inadequate investment in management, and taking on inappropriate levels of financial risk were two of the biggest reasons for failure he cites. More on the latter subject from us next month.
Finally we hope you like the new website. It has taken months of hard work, but should give you better access to more debate and evidence, with video interviews with health leaders, interactive maps and bespoke data visualisations, and key slides – useful for pulling together presentations. Well worth a browse.
Dixon J (2011) ‘Let's move on and focus on the efficiency challenge’. Nuffield Trust comment, 7 July 2011. https://www.nuffieldtrust.org.uk/news-item/let-s-move-on-and-focus-on-the-efficiency-challenge