(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?