Tuesday, 6 September 2011
What I did on my holidays - got married...
Friday, 8 July 2011
Didn't we do well, or did we?
This is the latest article I have sent for publication to Liberator magazine.
"John Bryant argues that while the campaign led by the Social Liberal Forum has secured some significant changes to the Health and Social Care Bill there remain some lingering doubts...
Since my last article on the fortunes of the Health and Social Care Bill after the Liberal Democrats Spring Conference in Sheffield, we have had an official pause in the Bill’s legislative journey, a listening exercise, a report from the Future Forum, and publication of amendments to the Bill.
Liberal activists have also attended the Social Liberal Forum’s first one-day conference on 18th June, which received feedback from Evan Harris, one of the key campaigners for change.
My own modest role in the campaign for change was to convince Camden’s Health Scrutiny Committee to make a submission to the listening exercise, setting out support for the 25 amendments that the Social Liberal Forum was promoting at the time. Since then there have been various claims that the vast majority of these suggested changes have emerged as formal amendments to the Bill.
So that’s all right then?
Well I think the gushing self-congratulations that have been published in recent weeks need to be tempered a little.
Not everyone in the NHS family of interests has declared its happiness with the result of the listening exercise. For the second time this year the BMA voted at its annual conference (following a critical emergency meeting in March) to support a motion calling for the Bill’s withdrawal, despite a call from its leadership not to be too critical now the Bill was to be amended.
At the SLF Conference Evan Harris was critical of the Future Forum’s report as it was littered with anecdotal references without a coherent analysis of the feedback it received from the many respondents to the listening exercise.
There was also an example of the classic bureaucrats’ answer to every problem by creating more committees. The Future Forum argues that, “there should be a strong role for clinical and professional networks in the new system and multi‐speciality clinical senates should be established to provide strategic advice to local commissioning consortia, health and wellbeing boards and the NHS Commissioning Board.”
A clinical senate may well be a useful adjunct to the more formal commissioning landscape, but something similar already exists outside of formal NHS structures. One example is “UCL Partners” which is a research body bringing together clinical leaders in Foundation Trusts in my part of North London to think through the best way of providing clinical pathways for specialist acute services. Its work in helping to shape the development of Hyper-Acute Stroke Units has led to the new “HASU” based at University College London Hospital. This is now reported to be the third best performing HASU in the UK with rapidly improving survival rates compared to the old regime.
So while such innovations as “clinical senates” may be useful I am not sure that giving them a statutory role will make their contribution even more valid than it is at present. The key to progress here is to ensure that clinical recommendations on patient pathways from such informal bodies are given effective scrutiny in public by scrutiny committees either at borough or regional level.
I am not entirely convinced by the Future Forum’s statement “We have heard many people saying that competition and integration are opposing forces. We believe this is a false dichotomy. Integrated care is vital, and competition can and should be used by commissioners as a powerful tool to drive this for patients.”
In developing an integrated care pathway for Stroke patients in North Central London the clinicians presented a case for UCLH to be the HASU, while other hospitals such the Royal Free in Hampstead would develop and expand their rehabilitation service for supporting patients in the period following the first three critical days after a stroke. Had a competitive approach been followed both UCLH and the Royal Free would have had good claims to be the HASU and a lot of time and money would have been wasted to judge between competing bids. So in my own local example working together to create a well-organised integrated care model produced the desired improving health outcomes, without competition being involved.
The Future Forum report later backtracks on the competition issue with this -
“Most importantly, the Bill should be changed to be very clear that Monitor’s primary duty is not to promote competition, but to ensure the best care for patients. As part of this, they must support the delivery of integrated care.”
Without specifying clearly how integrated care models are to be created by using competition, it begs the question that this report was surely designed to please both Conservative and Liberal Democrat members by providing a fudge between the different forces in favour of either competition or integration.
The more detailed report on Choice and Competition sets out some principles for a new Framework which are - Delivering choice; Encouraging collaboration and integration; Market making; Improving outcomes; Personalising care; Reducing health inequalities; Enabling informed citizens.
The most worrying of these for me is the principle of “Market Making”. The later section devoted to this talks about new entrants to the market, but concentrates on the creation of new social enterprises rather than admit the existence of the elephant in the room - the possibility of many more services being commissioned from the independent sector.
The Government’s formal response to the Future Forum appeared to take on board of many of the fears of Liberal Democrats, ruling out cherry-picking and competition on price. However it is noticeable that the summary on Choice and Competition also states “we will phase in the extension of Any Qualified Provider”. What the “extension” might entail could be anyone’s guess, but if you are naturally sceptical of anything the Tories put forward with regard to competition in health services I would remain alert to future interpretations of this throw away line.
One of the big worries regularly expressed by both providers and patients is that competitive tendering by clinical consortia (even on quality rather than cost grounds) could put some well-loved institutions such as Foundation Trust hospitals out of business, because without a certain level of core business they may become unviable.
So even assuming that most of the new amendments to the Bill are supported across the Coalition and are welcomed in the Lords, there is still more that Liberals should be doing.
As this Liberator was being prepared, Liberal Democrat conference representatives were being urged by SLF activists to put their names forward in support of a new motion for the Autumn conference. This was drafted by Charles West and calls for all the new NHS structures created by the Bill to have a common duty when commissioning services to “avoid the risk of a transfer of such income or case-load as to undermine the ability of existing providers to provide emergency, complex case and intensive care services, and to provide education, training and research.”
It also suggests that Monitor's duty to prevent anti-competitive behaviour, which is against the interests of patients, is matched by a duty to prevent anti-collaborative behaviour for the same purpose.
So what else should Liberals be doing? Besides supporting SLF motions at conferences Liberals can be doing some useful work at a local level too. Many principal local authorities have created shadow Health and Well-Being Boards and it is through these that Liberal Democrat councillors can argue for better integration of health and social care providers as they redefine patient pathways. They can also argue for much greater transparency of decision-making by all local providers, including Foundation Trust Boards.
Members of Scrutiny Committees could also challenge Board members of emerging clinical consortia to avoid engaging arms length organisations from the independent sector to carry out commissioning functions. PCTs were forced to shed around half their staff this year because of Andrew Lansley’s decisions to cut management costs, but the remaining postholders should be those with the expertise to understand the intricacies of health contracts. Retaining the transactional task of commissioning as an in-house function of consortia by them directly employing their own (hopefully ex-PCT) staff is something that Liberal Democrat councillors could and should be arguing for.
Liberal activists not serving on Councils should continue to make their voices heard through their local press, urging local editors to spend some time on investigating the various interests that are hovering in every community to get a slice of the NHS cake.
I ended my last article on these issues by alluding to a “reasonably managed muddle”. I am not yet convinced we will achieve anything better than this, despite the good work done by campaigners on improving the Bill. The Future Forum report attempts to look in two directions at the same time and while many of the amendments to the Bill are welcome, it is the behaviour and motivation of the key players in every locality which will need to be closely monitored over the coming months.
JOHN BRYANT
(John has been a member of the Liberator Collective as “William Tranby” for about 20 years. He is currently a Camden councillor and Chair of its Health Scrutiny Committee, and is also Vice Chair of the North Central London Joint Health Overview and Scrutiny Committee.)"
Tuesday, 26 April 2011
People already vote preferentially
Thursday, 24 March 2011
Why the Secretary of State has damaged our health
(The following article has been submitted for publication in Liberator magazine)
The Liberal Democrats Spring Conference in Sheffield was much enlivened by a first class debate on a motion entitled “Updating the NHS: Personal and Local”. The Liberal Democrat Health Minister Paul Burstow was forced to accept two amendments to avoid the humiliation of losing a vote by an overwhelming margin. Both amendments in their different ways aimed to increase the accountability of local institutions and were in line with the party’s manifesto commitment to democratise local PCT’s.
Strengthening the role of scrutiny by local Councils had been a message heard loud and clear by our Health Minister in official submissions from local authorities to the earlier White Paper and from individual councillors (like myself) at the Liverpool conference. Paul has listened to this point and the Bill now does provide greater scope for scrutiny as a separate function from that envisaged by Health and Wellbeing Boards within Councils. The motion at conference stressed this by welcoming the proposals to enable local authorities to effectively scrutinise “any provider of any taxpayer funded health services”. So far, so good.
The amendments at conference wanted to strengthen all this further by making sure that democratically elected individuals were involved in every stage, not just in scrutiny, but through “councillor-led” Health and Well Being Boards and with places on GP Commissioning Consortia too.
The debate in Sheffield also highlighted a widely shared hostility to the concept of “any willing provider”, which is possibly the most controversial concept in the Bill. There is a great concern that private operators will cherry-pick the routine operations to make money out of high volume work, leaving complex and serious conditions to be catered for in the public sector.
The last Labour Government had already promoted this private sector entryism into the health market by guaranteeing fees to private operators that were above the standard tariffs agreed for NHS hospitals. The conference was relieved when this was criticised by Paul Burstow but one has to remember that the fixed tariff system only covers around 30% of current procedures, so there is still room for the profiteers from the private sector to make money in any newly created health market.
Openness and transparency was another theme highlighted by the amendment sponsored by the Social Liberal Forum. This called for meetings of GP Consortia to be open to the public. But one has to remember in calling for changes of this sort that we have secretive GP practices now. Each practice acts as a separately traded business with no openness with regard to its business operations. While General Practice accounts need to be registered with their local PCT they are private and confidential and no one really knows how much the partners are paying themselves, and how much they are re-investing in their practice facilities, except the PCT which is not at liberty to reveal all. (There may be some principled GPs in the country who are willing to reveal their accounts but it is not the norm in my part of London.)
Paul Burstow and Nick Clegg might well feel emboldened by the clear messages from conference to seek major changes to the Bill, bearing in mind this top down reorganisation was specifically ruled out by the Coalition Agreement, but I fear the real damage to our health service has already been done by another decision of the Secretary of State which I presume had Paul Burstow’s blessing.
My local PCT in Camden was ordered by Andrew Lansley to make 54% cuts in management costs this year. That meant that by the end of the financial year about to close as I write this, 54% of the staff were to be made redundant. There would be some natural wastage and some voluntary redundancies of course. But anyone reading this with any experience of local government efficiency savings, where 10% cuts in staff in one go are just about manageable, could only describe cutting out half your staff in one go as anything but “slash and burn” on an epic scale.
There are several risks involved in doing this. Some staff with commissioning experience might jump ship and start working for the “any willing providers”, helping them to find the corners to cut. Others might be so disheartened by yet another health reorganisation that they seek employment in another field entirely or retire to look after their gardens, their expertise lost forever.
The remaining staff are required to soldier on with the specific task of helping the GP Commissioners take on their responsibilities while at the same time looking forward to losing their own jobs by 2013, which is hardly a great incentive to go the extra mile.
Health if anything is a people business. For successful commissioning we need to have the right people with the right skills carrying out the right tasks to secure good and improving health outcomes, while achieving good value for the taxpayer.
This will not be achieved in my view by a bunch of well-meaning GPs with little training, without a team of experienced commissioning staff who know and understand the intricacies of health contracts. What cannot be guaranteed by this imposed revolution from the centre is that we will end up with commissioning teams that secure both improving health outcomes for patients and good value for the taxpayer because the transfer of the right people in an orderly fashion from the PCTs to the GP consortia is not guaranteed.
It does not matter if the final Bill passed by Parliament establishes that the award of contracts will be on quality rather than cost, because if the contract specification is not written correctly the snags will emerge after the contracts are in place. Anyone with local government experience will know that out-sourcing contracts for services like refuse collection and recycling, or housing maintenance, are fraught with dangers. The so-called “best value contractor” will often be commissioned but when the operation appears not to be working the contractor nearly always has an excuse along the lines of - “what you have now requested is not in the contract but we can now do it for you, but it will cost you extra...”
Having councillors added to commissioning boards might bring some worldly wisdom to these decisions, but it is whether commissioners secure the expertise of those who can write watertight contracts which will determine whether this whole experiment will succeed or fail, and with half the available staff already lost from PCTs I think the die is already cast.
Another area which is fraught with difficulty is the way in which specialist and low volume treatments will be commissioned in the future. In recent years in London the treatment of cardiac arrests, major trauma and strokes have been significantly improved through commissioning on a regional basis. For example one of the great success stories now emerging demonstrates that creating eight Hyper-Acute Stroke Units in the capital has radically improved survival rates. The proposals were developed by Healthcare for London, an off-shoot of the strategic health authority which was answerable to the joint committee of PCTs in London and scrutinised by a pan-London Joint Health Overview and Scrutiny Committee (JHOSC) on which I served as Camden’s representative.
How will proposals for improving specialist acute services be developed in the future? It may be that the NHS Commissioning Board might create local outposts to lead on these developments, but where will the boundaries lie with GP Commissioning Consortia? And how will these developments be scrutinised? Local authorities are increasingly stretched for resources to undertake their scrutiny duties as they are now. If the Government is serious about strengthening scrutiny, and to create quality pathways for acute services, then there is more work to be done and more resources are needed.
I suppose the summary of what I am saying is that if the conference decisions lead to real improvements to the Bill then that is to be welcomed. But, as the saying goes, “if I wanted to get there I wouldn’t have started from here”. Sacking half of the PCT staff before embarking on this change to the commissioning arrangements was clearly the wrong step in the wrong direction at the wrong time.
We might be able to muddle through. The NHS has made great improvements in the past, often despite the meddling of Secretaries of State and not because of them, but does the service have the capacity to do this one more time?
And do we as Liberals in Government for the first time in 70 years want our first term legacy to be a reasonably managed muddle?