Health Matters | Paul Corrigan's blog

In the last few months, during the political tussle that took place before the final passage of what is now the Health and Social Care Act, some very strange claims were made about the power of various Royal Colleges to reverse government policy.

There was a strong belief amongst medical opponents of the Bill that if all the Royal Colleges called for its withdrawal this would have stopped the Bill. I commented at the time that this was an odd view of political power, but was understandable coming from people who were rarely involved in the politics of legislation. Read the rest of this entry »

Whilst the content of my posts rarely stray far from the NHS there are occasions when other page 1 news on strays into the NHS.

This one starts with a process which was the hallmark of the NHS, the Government trying to implement one policy by going against its own policy in another area. Read the rest of this entry »

The Health and Social Care Bill has become an Act. This was only possible because the Prime Minister supported changes from the moment he put his name to the White Paper, through to the moment he changed his mind in April 2010, and all the way to the end of the process. It all adds up to the simple political truth that Prime Ministers get the legislation that they want through Parliament.

I suspect that if he were asked what the Bill was for he could give the ‘top line’ answer – that it gives more power to doctors and nurses. But if, over a kitchen supper, you asked him to explain how Monitor would both set prices and performance manage existing FTs, I suspect he couldn’t really give you an answer.

That wouldn’t matter so much if someone else could give an answer, but never mind – for the moment the Bill is an Act.  We know that he was in favour of something that didn’t really matter.

But what I am not clear on is where the Prime Minister stands on change in the NHS that really does matter.

Across the country there is a growing recognition that most hospitals are going to have to change the way that they deliver services, and how they are organised. The best ones are going to have to take over the worst, and as a consequence nearly all of them are going to have to change.

For example, last Friday the London Evening Standard published a page full of likely changes that will be necessary in west London over the next year or two. It involved closing A&Es and many other departments. Some local politicians were shocked at the level of these changes, but what was even more significant was an editorial supporting the changes.

This is going on all over the country.

Long term readers of my blog will remember that when the Coalition Government was formed I said that I suspected that what had been one of the major tensions within modern conservatism would play a role in the development of NHS policy. Since 1979 modern conservatism has believed both in the power of markets to improve efficiency and outcomes, and the importance of conserving institutions.

Of course these two drivers are in tension. In the Conservative-led Government of 1979-1997 markets ran through British society bringing substantial change. Whilst not many Conservatives noticed the closure of the steel and mining industries in their towns and villages, they did notice the closure of the local offices of banks, post offices and shops. All of these closures were the result of market decisions for efficiency that were at the core of the Government’s drive to change society.

Then these same Conservatives would launch campaigns against the closure of these local facilities, because not only do they believe in markets – but yes they believe in conserving as their name suggests. In the 1980s and 90s most of these campaigns, launched against the impact of their own policies, failed. Their market ‘side’ beat their conservative ‘side’.

How does this relate to the Prime Minister and his current policy toward the NHS?

At various stages in the last 18 months the Prime Minister has argued strongly that the NHS needs to change radically and that bits of markets might help bring this about. He will probably see clinically-led commissioning as something that will drive greater efficiency in the health service than the previous PCTs. He recognises that the NHS needs new drivers for efficiency.

But I wonder if he understands how that efficiency is going to hit the way the local district general hospital operates? After all as we saw in the 1980s and 90s driving efficiencies into organisations brings about changes and in many parts of the country those efficiencies meant that services were changed forever.

The consequence of greater efficiency in the NHS will be radical changes to the District General Hospital (DGH).

I think this may mean that the first half of this Parliament will see the Government arguing for greater efficiency in the NHS and the second half will see them defending the DGH against it.

But if he doesn’t make these efficiency savings, the Prime Minister will have to find more billions for the NHS to fund the inefficiency that his conservatism demands.

Last week I spent some time in Boston as a member of a British Consulate delegation. We were there to discuss health systems with various people carrying out health care innovation in the USA.

I fell to thinking about how readers of this blog would react to that last sentence. To some it will be a red white and blue rag to a bull.

During the last year I must have been in a dozen meetings about NHS reform where most of those present would hiss at the possibility of ever learning anything from the US. Within our NHS reform debate there are groups of people who say that it would be morally wrong to learn anything at all from the US about health care – because they have such a bad system.

I’m afraid I don’t find this a very mature reaction.

In truth, in the last year I have found much of the ‘little Englander’ and ‘little NHS’ emotion which necessitates rejecting the possibility of  learning anything from the biggest economy in the world a bit sick making.

The US health system is an expensive, broken system where nearly all the incentives are moving this non-system in the wrong direction. It would be mad for any country in the world to learn anything systemic from that. The interesting thing is that every single person I have met in my three visits to the US to discuss health care over the last 4 years agrees with that. They feel that their system is an expensive generator of inefficiency and inequality, and all spend a lot of time trying to do something about it rather than accept it as a national ‘given’.

So within a very bad system there are hundreds of thousands of doctors and nurses doing very good things – and there are hundreds, if not thousands, of organisations that are developing interesting and important innovations in care.

For those that understand more about religion than I do there seems to be a sort of ‘original sin’ argument here. If you – or any of your ideas – are connected with the US health care system – then by associating with this ‘original sin’ you are irredeemably lost.

As I say, I think that sort of thinking is immature. More so it treats the NHS as if it were a fragile flower (do you remember David Cameron’s analogy of May 2011 – that it is like carrying a precious glass vase across a slippery floor?). I didn’t believe that then and I still don’t. I think it is a very, very strong institution and because of that can learn from different countries with very different traditions.

So over the next few months I will be challenging this simple anti Americanism by sharing through the blog aspects of US innovation that I think the NHS can learn from. Ideas and practices that can provide better services for patients within the principle of equal access for all, paid for out of general taxation, free at the point of delivery.

I very rarely blog about non-health issues but the petrol crisis created by ministers last week made me think about how Andrew Lansley’s communication skills seem to have become part of the way in which other cabinet members now  talk to the public. Read the rest of this entry »

One of the main issues for implementing reforms that create new roles is that it is wise to ensure that the people who have to carry out these new roles have the capacity and the skills to succeed.

Just because people were good at doing one thing in the past, doesn’t mean that they will be good at doing something very different in the future. Read the rest of this entry »

The phrase “developing the NHS during the long age of austerity” was one that I first used in December 2011. It’s one to which I will return frequently over the next few months. Read the rest of this entry »

One of the really interesting tussles taking place over the next few months concerns who is actually implementing the Bill. This may sound like an odd issue to bring up because one might think that the constitutional process is obvious. The Government manages to get a Bill passed by Parliament, the Queen signs it, and the Government implements it.

But as the Bill becomes an Act the people that will carry out its implementation will be very different.

One of the things we learned last week was that both political parties in Government – who have been voting for this Bill at regular intervals for the last 15 months – are simply delighted that it has at last left Parliament. For them, the actors and actresses in the theatre of parliament, the show is over.

The Cabinet banged the table with glee that it had gone (Did they ever do that at your school? – No they never did in mine either.). There is huge relief in Parliament. The Bill has passed and outside the Select Committee no-one will give much thought to what happens next.

It isn’t this part of Government that does the implementing.

Insofar as politicians continue to be involved it is the job of Ministers to oversee implementation.

Now, I am now going to say something that may startle you. I know it may not have looked like it for the last 18 months, but this group of Ministers have had previous experience with Parliamentary legislation. Admittedly it was in opposition, but before this Bill they did know how to argue amendment and move legislation through.

(I know, I know, but I am not saying that this group of Ministers had learnt to do it well - just that they had some experience of doing it).

None of these Ministers have any experience of implementing a Bill in Government.

But the people who run the National Commissioning Board have been implementing legislation since before the Cabinet learnt to bang their desks when given a half day off at school.

So if you had to put money on who will be most effective in implementing this Bill I would not put much on the Ministers.

This partly explains the numbers in yesterday’s post. The accountable officers in 6 out of 10 PCTs are similar to the accountable officers that existed under the PCT system. The old system will reproduce itself in the new where it can. But the old system will where it can use implementation to grab more power than it had before.

So if Ministers are not really capable of implementing the Act and the NCB writes its own rules for implementation, then surely the field is open to just one sort of implementers? The National Commissioning Board.

But on the ground there is in fact another group of implementers – the GPs in Clinical Commissioning Groups. If they don’t implement this Act then not a lot that is new will happen. (If GPs – as accountable officers – decide to walk away, not a lot that is new will be implemented).

And within a few hours of the Bill’s passage the combination of the National Association of Primary Care and the NHS Alliance sent out the following letter to their members who are and will be some of the main implementers of the Act.

“The passage of the Bill has been nothing if not controversial. The NHS Clinical Commissioning Coalition of NAPC and NHS Alliance has been a strong advocate of Clinical Commissioners throughout, while working hard “behind the scenes” to ensure that we are given the necessary powers to match our new responsibilities. As clinicians, we now have a real opportunity to

transform local services and health.

The last few months have seen a sometimes polarised debate of strong political and professional opinions, which have led to passionate and public disagreement. In retrospect, we can all think of ways in which engagement could have been improved. We have also learnt some important lessons

around managing our relationships at a time of significant turmoil.

But now the parliamentary stage is over, it is vital for our patients and our populations that the profession and primary care reunites and finds ways of making the new NHS structures and arrangements work. As the NHS Clinical Commissioning Coalition, both NHS Alliance and NAPC are committed to helping you meet the challenges ahead. We must demonstrate quickly to our

patients, colleagues and the country that these changes have not been just some bureaucratic shift of organisational structure but that they will have a real and meaningful impact on the health and the health care of all NHS patients.

The NHS Clinical Commissioning Coalition is keen to support you in this process. We shall be publishing a monthly newsletter which will update you on everything that is going on and provide examples of the innovations, advances and improvements in patient care that you, as CCGs, are driving. Please let us know of any early wins as well as the challenges you face in your CCG so that

together, we can continue to win the argument for GPs being at the very heart of the reform programme.

Meanwhile, we must ensure nationally and locally that the new arrangements are allowed to work. That is why both of us are meeting regularly with the Secretary of State, ministers, Department of Health, leaders of the National Commissioning Board (NCB), Monitor and many others. We now

have an urgent mission and we are endeavouring our utmost to ensure that CCGs and their leaders are masters of their own destiny.

On April 24th we have organised a first meeting of CCG leaders following the passing of the Health and Social Bill. This represents a unique opportunity for us for us all to determine our own future April 24^th will also be a crucial opportunity for us discuss progress and concerns and to put the results

of those discussions to the Secretary of State, Chairs of National Commissioning Board and Monitor as well as others. . Please also let us know of any way in which we can help you to make clinical commissioning a success in your area.”

It’s important not to underestimate the potential of this letter. These two GPs organisations plan to short-circuit the relationship between what is talked about nationally as policy and what happens to GPs in practice.

They plan to use the April 24 meeting to bring the experience of the actual implementation on the ground to the Secretary of State and present him with different implementation solutions at both a policy and a practice level.

This means that one of the answers to the question “who is going to implement the Act?” could be the people who are going to carry it out.

The next few months will show whether GPs will be the implementers of the Act or will have it implemented upon them.

A few weeks ago I asked this question of the Prime Minister’s rationale for the Health and Social Care Bill in response to his assertion that “… our Bill gives power to doctors and nurses”. Now that the Bill has been passed and issues of implementation begin to arise I will return to this question throughout this week.

As I have often said it may have been true that the intention of the July 2010 White Paper had been to give power to GPs. At that time it was drafted it intended that GPs would form their own organisations to control the commissioning of most NHS care across the country.

But during the first 6 months of 2011 the Government failed to make the case for this radical devolution. They became frightened of the backlash – and since June 2011 the Bill has been amended again and again with central diktats and national organisations to hedge around the power that doctors will have over commissioning.

Whilst the Bill was moving in the direction of greater centralisation the Prime Minister, in despair of his Secretary of State actually explaining what was going on, was searching for a way of explaining the Bill to the public. The post-June 2011 amendments would be best explained as creating greater central accountability for the NHS to the National Commissioning Board – but in truth that isn’t really a very catchy storyline.

So the Prime Minister went back to the original version of the white paper and claimed that “first our Bill gives power to doctors and nurses”.

Now that the Bill has passed we will, over the next year, get an increasingly clearer idea of the extent to which this explanation of the reforms will hold true. We will be able to judge the Prime Minister’s success in constructing a reform process in line with his intentions.

This will also provide us with a better understanding of how good the Prime Minister is at actually governing. 

Changing the world – rather than just talking about it.

Under the previous system the people in the localities that had power over most NHS commissioning were the Primary Care Trusts. All of these had GPs on their boards – most of them having GPs as medical directors.

But the Prime Minister felt this did not give sufficient power to doctors and so he introduced an enormous Bill to change the legislation to give them more.

The way in which the spending of public money is held accountable in this country is through a chain of accountable officers. Under the old system this chain went from the Department of Health to the Primary Care Trusts where all 150 of them would have a designated officer to be accountable for the money.

This is where real power lies. If you have spent any time in the NHS you will recognise that the expectation laid upon the accountable officer in the organisation is far greater than on anyone else. There will be lots of different people in the local organisation with some power, but at the top of the pile is the accountable officer.

So one way we can judge the efficacy of the Prime Minister’s intention to give more power to doctors through clinical commissioning is to see how many of the accountable officers are, or will be, GPs. Obviously as of the end of March 2012 this picture is still forming so over the coming year this blog will keep a running score of how things are progressing.

Luckily the HSJ has already carried out a survey asking this very question.

They asked, “Is the accountable officer of your Clinical Commissioning Group a GP or a manager?”, and they have found that 38% of the CCGs do have a GP as the accountable officer.

They have also found that 62% do not.

Admittedly this is only one yardstick of power, but it is one that the whole Bill and the reform programme has concentrated on. The Bill has been trying to change who had the power over the finances of commissioning – and at the moment it looks like it will fail in just over 60% of the country.

What does this tell us about the Prime Minister’s ability to govern?

He chose his method of reform – which was to have a very large Bill (with 1000 amendments) to bring about these changes.

Through this mechanism of government he has achieved what he wanted in nearly two fifths of the country.

He could have chosen to keep PCTs and through the change process of secondary legislation said that the accountable officer within the PCT must be a registered GP.

That would have covered 100% of the country rather than 38%.

He could then have said that there needs to be a majority of GPs on every PCT board. Again that would have covered the whole of the country not just those parts that will have authorised CCGs in the next few months.

So to recap.

The Prime Minister had a policy intention that stated that “our Bill gives power to doctors and nurses”

He chose as a form of intervention a large Bill with 1000 amendments in both Houses where the coalition have significant majorities – with the result that his policy intention will be carried out in nearly 40% of the country.

Whatever you think about GP-led commissioning the link between the Prime Minister’s intention and the outcome in the country is not very efficient.

As the Health and Social Care Bill was clearing its final hurdle in the House of Commons – just after 10 o’clock on Tuesday evening – I was on the Radio 4 programme “The World Tonight” talking about the Bill.

I mentioned recently that it’s fun talking to journalists about the Health and Social Care Bill because they, as a matter of professional pride, expect to be able to explain very complex things very simply. Yet they are all to a person defeated by the experience of trying to do that with this Bill. Read the rest of this entry »