The Health and Social Care Bill gets a second opinion

When the NHS White Paper was published a year ago, it diagnosed three main pathologies for which major reform was the prescribed solution: weak commissioning; insufficient competition and choice; and excessive micro-management from the political centre. 

The prescription set out an array of medicines to deal with these ailments including: GP commissioning ‘consortia’ in place of primary care trusts; an economic regulator to promote competition among ‘any qualified provider’ of NHS-funded services; and a new more strategic role for the Secretary of State, with more power and responsibility vested in an independent NHS Commissioning Board (now NHS England) and local health and wellbeing boards.

The patient and its carers were not however universally impressed with this prescription despite some agreement about the actual diagnosis.  A stream of very public protest and criticism followed, but it was only when senior Liberal Democracts began to make threatening noises that the Government was compelled to act, announcing an unprecedented two-month ‘pause’ in the legislative process, during which it committed to listening to these concerns and reconsidering the prescription for change. 

And this they did – the Future Forum reported what it had heard, and the government announced what appeared to be a surprising amount of concessions.

GP commissioning is to become ‘clinical commissioning’ and involve a wider range of professionals through clinical senates and networks, and with specialists and nurses formally part of consortia boards.  Monitor will have a duty to promote the integration of services and to focus on preventing anti-competitive behaviour, rather than promoting competition as ‘an end in itself.’  The role of the Secretary of State also remains as described in the 1946 NHS Act, with primary care trust (PCT) clusters looking set to become outposts of the NHS Commissioning Board and the new intermediate tier of the NHS. 

But how different is this prescription for the NHS?  Is this a case of replacing branded with (in effect the same) generic medicines, or does it represent a truly different therapeutic approach?  

On commissioning, the move to a more inclusive approach with specialists working closely with GPs may offer the potential for local providers to work together in new ways to develop forms of integrated care like those explored in two new Nuffield Trust publications: Integration in action: four international case studies and What is integrated care?. If so, we may see a strong focus by GPs and specialists on the provision, rather than necessarily the commissioning, of new services in areas such as chronic disease and urgent care.  

Another reading of the latest approach to clinical commissioning would be that in its desire to increase the local accountability of GP commissioners, it has prescribed a range of checks and balances that risk stifling the initiative and enthusiasm of the very people it was supposed to ‘liberate’.  This fine balance of risks and incentives in GP-led commissioning is explored in a challenging new Viewpoint by Larry Casalino: GP commissioning in the NHS in England: ten suggestions from the United States. 

On competition and choice, the devil will surely be in the detail of how the policy proposals are implemented, and the way in which the new NHS Commissioning Board and Monitor interpret their role and decide how far to encourage commissioners to offer a wider range of services and care pathways at a local level.

The lingering ambiguity about these issues is examined in our response to the proposed amendments to the Health and Social Care Bill, where we call for greater clarity, in particular about how far the NHS will be subject to EU competition law or not. Finally, on the issue of micro-management of the NHS by the political centre, one has to think hard about the primary challenge facing the NHS, this being not commissioning, competition, or control, but a need to make unprecedented efficiency savings of 4 per cent per year for the next five years.  

Whilst local commissioning will clearly go some way towards developing the very different forms of care needed to address the health needs of an ageing population with ever more complex needs, it will struggle to make the very difficult and unpopular decisions needed to extract major efficiencies.  In Managing the transition we set out the scale of this challenge for managers in the NHS, and warned of the importance of keeping the NHS safe from both a financial and, most importantly, patient service, point of view.

The government has listened and responded.  What we do not yet know is whether the response is sufficient to address the primary diagnosis of financial challenge, a diagnosis that is likely to require major surgery for some parts of the NHS, in the form of service reconfiguration.  

Only when this has been confronted will the other remedies of commissioning and competition be able to take effect.

This piece was was also posted on the Public Finance blog.