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Public Services for All > Published by Trevor Cheeseman, July 13th 2010 at 10:30 am

The NHS turned upside down

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David Cameron has made no secret of his desire to roll back the state – but was careful in opposition to try and reassure voters that the NHS would be safe in his charge. The Coalition document even promised “no top down reorganisations” for the NHS. Instead, two months on Andrew Lansley’s new White Paper ‘Equity and Excellence: Liberating the NHS’ is being described as “the NHS turned upside down” by a leading health commentator.

Andrew-Lansley-NHS-shake-upThe main proposal is to make GP “consortia” take over budgets for NHS services from local Primary Care Trusts (PCTs). £80 billion of public money is to be given to GPs from primary care trusts to commission NHS services from 2012 – by assessing local need, setting contracts for local health providers and monitoring those standards. This builds on the Tories’ GP fundholding of the early 1990s which had high transaction costs and led to differential service standards between GP practices.

There are some fundamental conflicts of interest in giving GPs the final say over real funding streams: GPs are independent contractors, running businesses seeking to maximize income; they will also now hold massive budgets which they may choose to spend much of on services they run themselves.

Yet there is a more fundamental problem: most GPs do not want the hassle of strategic planning, negotiating multi-million pound budgets and making unpopular decisions about NHS service organisation and costs. In fact, clinical commissioning as an idea is nothing new – for the last five years Labour ran Practice-Based Commissioning (PBC), a voluntary scheme that allowed GPs considerable influence on how services are commissioned, but with PCTs having the final say.

By any objective measure, progress has been challenging: the Department of Health’s recent survey results highlight a decline in interest in PBC and a consistent minority of GPs who actively oppose the principle of GPs getting involved, such that the DH’s  lead GP referred last autumn to PBC as “a corpse”.

Yet the White Paper is thin on detail, with key points unclear. Will GP consortia be allowed to retain budget underspends; and what will happen if they overspend their budget? Not insignificant questions given this proposal coincides with what even Nick Clegg admitted at the weekend was “an extraordinarily tight settlement for the NHS”. How will regulation be undertaken? Again, the detail is absent.

Could this White Paper mark the beginning of the end of the NHS, or is it hyperbole to suggest as much? Certainly the principle of a service based on needs, and free at the point of use remains. Standby, however, for rows during  this Parliament – on the “postcode lottery” of differential service standards now likely to develop, and on health top-ups, such as for expensive drugs or faster access to services.

And not forgetting the prospect of those private sector companies required to “support” GP commissioning consortia being allowed to refer to their own (or arms’ length) providers’ services who run private hospitals, primary and community services.

  • http://twitter.com/leftfootfwd/status/18424620592 Left Foot Forward

    The NHS turned upside down: http://bit.ly/9p53wI

  • http://twitter.com/houseoftwits/status/18424805520 House Of Twits

    RT @leftfootfwd The NHS turned upside down: http://bit.ly/9p53wI

  • http://twitter.com/andy_s_64/status/18424900457 Andy Sutherland

    RT @leftfootfwd: The NHS turned upside down: http://bit.ly/9p53wI

  • http://twitter.com/9xzulug/status/18424908370 winston k moss

    RT @leftfootfwd: The NHS turned upside down: http://bit.ly/9p53wI

  • http://twitter.com/laurabunt/status/18426380509 Laura Bunt

    Proposed NHS “transformation” (sic.) making me think about language &how important it is to avoid jargon (note to self) http://tiny.cc/pe832

  • http://twitter.com/fkmckenzie/status/18427044302 Fi McKenzie

    RT @leftfootfwd: The NHS turned upside down: http://bit.ly/9p53wI

  • http://bestblogs.labourhome.org/2010/07/13/the-nhs-turned-upside-down/ The NHS turned upside down « The best Labour blogs

    [...] More… [...]

  • http://twitter.com/dontmindwaiting/status/18427567167 jennifer roberts

    RT @HouseofTwits: RT @leftfootfwd The NHS turned upside down: http://bit.ly/9p53wI

  • Jacquie Martin

    See this for details of the private care supplier who bankrolls Andrew Lansley

    http://www.telegraph.co.uk/news/newstopics/mps-expenses/6989408/Andrew-Lansley-bankrolled-by-private-healthcare-provider.html

    My what a coincidence!

  • StephenH

    “Standby, however, for rows during this Parliament – on the “postcode lottery” of differential service standards now likely to develop, and on health top-ups, such as for expensive drugs or faster access to services.”

    hmmm yeah this is my own interest– and isn’t it likely that posh areas are going to form consortia of the rich and healthy (with extra money for Avastin/Beta interferon) whilst poor areas band together into consortia of the sick and deprived?

    What is the funding formula when the consortia can select themselves????? please someone explain…

  • Trevor

    Stephen H – The NHS funding formula does take some account of deprivation but of course the demand from poorer areas is also much greater, based on lifestyle factors such as diet, exercise, employment, housing, education/aspiration.

    You are right to raise the risk that localised GP consortia may pusue much more of a sectional interest than primary care trusts covering a larger area, who have a strong focus on targeting health inequalities.

  • http://www.leftfootforward.org/2010/07/pcts-from-being-champions-for-patients-to-being-abolished-in-just-two-months/ PCTs: From being “champions for patients” to being abolished – in just two months | Left Foot Forward

    [...] today, Left Foot Forward looked in detail at the health secretary’s white paper, highlighting one of the most [...]

  • http://www.drfouly.org/?p=4307 The NHS turned upside down | Left Foot Forward | www.drfouly.org

    [...] original here: The NHS turned upside down | Left Foot Forward Share and [...]

  • Mr. Sensible

    I agree, Trevor.

    GPs are doctors, not managers.

    Interestingly, on the BBC website yesterday they featured the thoughts of 2 GPs, and I found the first one’s comments particularly interesting.

    Have a look:
    http://news.bbc.co.uk/1/hi/health/10600114.stm

    Trevor, in addition to all this, what impact do you think the cutting back of things like the 4-hour waiting time guarantee could have?

  • Liz McShane

    As Kirsty Wark pointed out to Andrew Lansley on Newsnight last night, medical degrees do not include business studies modules…..

  • Trevor

    Mr Sensible – the 4 hour A&E wait target was a response to regular horror stories in the 1990s about older people being made to wait many hours for a free hospital bed on trolleys in corridors. Losing targets like these will mean that minimum standards in key areas cease to exist NHS wide, without pressure from above on highly paid executives to deliver them.

    The risk is that as services become under (financial) pressure, there is no longer a system of minimum quality standards across all parts of the English NHS. (Lets not forget the Scots and Welsh are not going down the marketisation route).

  • hilary eddy

    We seem to be sitting on the sidelines as an unmandated coalition forces through something that looks suspiciously like a neocon agenda. Now the NHS is under the severest threat possible. What exactly are we supposed to do about it? I am positive that there is not a majority in the country for the vandalisation and privatisation proposed for the NHS. So what exactly, are we the people supposed to do – wring our hands, talk to ourselves and essentially do nothing?

  • Benjamin

    In a sane world, the NHS will have ongoing reform just as necessary in an ever changing world. But the problem is that both main parties – Labour and the Tories – have an agenda to privatize the NHS by stealth, and hence the endless unnecessary tinkering.

  • Trevor

    Benjamin – if “privatise” means the extent to which the private sector runs NHS services, “nationally, at most 1% of NHS-funded care is currently provided for the independent sector”, say the Nuffield Trust. Under the Coalition, this figure is likely to increase substantially.

  • http://www.leftfootforward.org/2010/07/look-left-the-week-in-fast-forward-16-07-10/ Look Left – The Week in Fast Forward | Left Foot Forward

    [...] upside down” by a leading health commentator. Our own health expert, Trevor Cheeseman, took a detailed look at the plans, the headline proposal being that £80 billion of public money is to be given to GPs [...]

  • John

    I remember the GP fundholding days.
    It was a good idea but thin on focus.
    I can see the need to challenge the philosophy and scope of the NHS!
    Lets hope this is the intention and not the mask for dismantling what is still seen as the best equitable system in the world!