Primary care: gatekeeping or weaving?

warp_and_weftThis is a slightly revised version of an article submitted to the BMJ on 5 October 2016.

There is an interesting article in the BMJ this week[1] by Greenfield et al on ‘Rethinking primary care’s gatekeeping role’ that covers only one element of primary care, and in excluding other, more important, aspects of the role risks these others being left out of the debate entirely.

Greenfield’s premise is based on a model of health care that is currently fashionable, but which is simplistic and linear in its philosophy: ‘I’ve been diagnosed with prostate cancer, it needs treating, I need to see the right specialist as quickly as possible’. Such a symptomatic approach to medicine is clearly important, but assumes an entirely straightforward, physical spectrum of disease.

The reality of modern health care is that it is being overwhelmed by complex illness that combines multiple physical diagnoses, often chronic in nature, with social and psychological overlays. Treating my prostate without considering my diabetes, my hypertension, the impact of my illness on my job, income, and mental wellbeing is reductive and sub-optimal, not only in clinical terms, but also in terms of cost-effectiveness.

Whilst the role of general practice clearly includes gatekeeping, that function needs to be put into the context of care co-ordination and the management of complexity. In the multilayered fabric of the NHS, the warp of clearly defined clinical pathways being organised in efficient straight lines needs to be held together by the weft of primary care, weaving the intricate patterns that make up genuinely effective care. Just as the conductor of an orchestra balances the dynamics of the different sections of the orchestra to produce an harmonious melody rather than a cacophonous row, so effective primary care juggles the different (and often conflicting) drivers that influence us all, to produce coherent and effective care.

When this is done well, the whole system benefits, and researchers such as Barbara Starfield[2] have pointed out that the cost-effectiveness of health services is proportional to their degree of primary care orientation, not because of gatekeeping per se, but because of effective and appropriate holistic case management.

The risk is that an article like Greenfield’s (which doesn’t mention anything outside the linear referral model) is that it reinforces our increasingly symptomatic approach to medicine, where we treat diseases rather than people, with the inevitable result that demands and costs rise, duplication and inefficiency ensue, and everyone suffers from care that is completely at odds with the human condition.

What is required is a model that is more co-ordinated professionally and organizationally, that aligns incentives appropriately, and that carries public opinion with it. As long as the public continues to expect the linear simplicity described by Greenfield and colleagues, that is what will be provided; only when there is a better understanding of the subtlety and complexity of health care will we have any chance of rebalancing the system. Articles such as this risk moving the debate in precisely the wrong direction.

[1] BMJ 2016; 354 doi: http://dx.doi.org/10.1136/bmj.i4803 (Published 23 September 2016)

[2] Starfield B: The Contribution of Primary Care Systems to Health Outcomes within Organization for Economic Cooperation and Development (OECD) Countries, 1970–1998 Health Services Research Volume 38, Issue 3, pages 831–865, June 2003 DOI: 10.1111/1475-6773.00149

Visual ref: http://commons.wikimedia.org/wiki/File:Kette_und_Schu%C3%9F.jpg

General Practice: Jack of all trades and master of one

The NHS media profile is dominated by hospital crises, with the rock of growing demand (based on increasing need and rising expectations) meeting the hard place of static resources.

In this ‘perfect storm’, the whole welfare state colludes in damage limitation: Social Service departments expediting the transfer of hospital patients into care homes, and GPs helping deal with patients before and after admission.

There are several dissonances here: facilitating access to hospital services jars with a ‘primary care led NHS’[1]; the episodic treatment of malfunctioning body parts isn’t ‘people based;’ and the focus on institutional services is hardly ‘care closer to home’[2].

So it seems appropriate to revisit some of these concepts and see whether and how they fit into a modern healthcare system.

At the NHS front end sits primary care, based on general practice. GPs were central to the creation of the NHS: generalists running their own (for profit) businesses, often singlehandedly. They treated whom they could and referred those they couldn’t to specialists, a balance depending on individuals’ skills and interests.

Over time, circumstances and legislation have produced larger practices, becoming more systematized and providing ever more services ‘in house’. These changes have focused largely on treating diagnoses, with less attention on looking after people who happen to be ill. The triple diagnosis[3] (the physical, psychological, and social aspects of any illness) is a key attribute of holistic care, that acknowledges that sickness is determined by more than physical symptoms: dis-ease does not equate to disease. Without acknowledging the difference, healthcare systems are doomed to treating the symptoms of ever more people without addressing their broader underlying causes.

Barbara Starfield was an eminent American researcher who understood this distinction. She researched the impact of primary care on population health in many OECD countries [4]. Firstly, she described the roles of general practice, demonstrating several unique attributes in its most effective configurations:

  • first point of access to care (hence ‘primary’ care)
  • offering comprehensive services (defined by patients’ notions of illness, not clinicians’)
  • using referrals to control access to institutional care
  • coordinating patients’ journeys, wherever in the system they find themselves

Secondly, she showed a direct correlation between primary care maturity and overall healthcare efficiency. For instance, the UK and Scandinavia have deeply embedded general practice systems, and highly cost-effective health services; the USA, in contrast, has poorly developed family practice, and the world’s most expensive healthcare, whose impact on health is disproportionately poor.

However, the current UK zeitgeist is rapidly undermining all these precepts:

  • initial access to services in acute illness increasingly seems to be through A&E departments rather than primary care
  • that care focuses on physical diagnoses, a reductive definition of ‘comprehensive services’
  • the control of spending associated with holistic approaches to care is being subsumed in the drive for measurable ‘KPIs’
  • there is little coordination of care, even within the acute sector itself, let alone across the whole health and social care system

In Starfield’s typology, the NHS is losing its inherent advantages and becoming more expensive and less effective. Could this be reversed?

The short answer is ‘yes’, but concerted efforts are required in areas including policy, resources and determination. There need to be changes to hospital services and to public attitudes, spearheaded by a significant reinvention of general practice.

In a society that values medical specialization above everything else, GPs are seen as ‘jacks of all trades and masters of none’, and are gradually evolving into ‘consultants-lite,’ increasing their technical skills and reducing their emphasis on holistic care. Policy initiatives focus largely on new technology, often in the form of tablets (pharmaceutical or electronic), and the inexorable pressure to treat symptoms rather than people becomes ever more deeply embedded.

In reality, to achieve the kind of integration described by Starfield, general practice does require Specialists, but ones who specialise in the complex field of Generalism, that vague concept that encompasses empathy, psychology, pattern recognition, synthesis, and the ability to manage both people and risk, as well as excellent clinical and organisational skills. If we really want ‘joined up’ care, then GPs need to reclaim their position as the conductors of the health care orchestra; their training will need to acknowledge and include all these skills (despite the difficulties in quantifying them), and society at large will need to rethink its attitudes to these ‘soft’ skills, and celebrate them.

For if managing heart failure is complicated, then case management and whole system co-ordination are truly complex, an order of magnitude more difficult to carry out effectively. General practice at scale has the potential to offer a genuine paradigm shift, but any mooted ‘super practices’ must be based on holistic, coordinated care if they are to succeed; ersatz out-patients clinics are the last thing we need.

[1] Department of Health (1994) Developing NHS purchasing and GP fundholding: towards a primary care-led NHS. London: DH (EL(94)79)

[2] Department of Health (2007) Shifting care closer to home; London: DH

[3] Marinker M (1981) Whole person medicine in Teaching general practice (Cormack J, Marinker M. Morrell D eds); London Kluwer Medical

[4] Starfield B, Shi L, Macinko J (2005) Contribution of primary care to health systems and health; Milbank Quarterly; 83(3): 457-502

Open letter to Simon Stevens

writing-query-letterDear Simon

 

Despite the fact that most open letters probably never get read by their addressees, I thought that I would join the throng of correspondents writing to you: after all, if ‘crowd-sourcing’ can raise funds and drive international campaigns, maybe it can influence policies too…

As I’m sure you’ve recognized, the NHS is in a weird place at the moment. The cognitive dissonance we all accept as part of running a state controlled (i.e. politically sensitive) system in the 21st century has reached new extremes, with the rhetoric of localism (Clinical Commissioning Groups, local choices, patient involvement) being totally at odds with the reality of national inspection regimes, the imposition of ‘Clause 119’ and the central pressure to save costs that is currently exercising us all.

The short term ‘patch it and move on’ measures of the past few years have led to so many unintended consequences that we seem to be tying ourselves into ever tighter knots physically as well as politically. Here are just three examples, but there are many more:

Emergency departments are very busy because they’re available and GPs aren’t, so we try to discourage people from attending by….extending the range of services provided at A&E.

Lewisham Hospital is really successful, so its staff are rewarded by… their assets being threatened in order to prop up the failing South London Healthcare Trust.

CCGs are tasked with responsibility for the health of their populations, and encouraged by… having their resources cut and their nascent power diminished.

And so on and so on….

If we are ever to cut through this Gordian knot, here are just a few simple principles that might help:

  1. There should be clarity about the separation between procurement and provision of services: the Government is the commissioner, and the NHS is the provider. That boundary is where the strategic overview needs to be implemented, and where the money is exchanged. The NHS is then supposed to consider how services might best be delivered, with the CCGs intended to be pre-eminent in this process, providing what services they can through their GP networks, and subcontracting the rest to agencies such as hospitals and other specialized providers.
  1. Work with human nature rather than against it: people work best when they agree with their organisation’s overall purpose and when they can see some benefit from what they are doing. Thus, a consistent approach with obvious logic works better than a series of mixed and contradictory messages, especially when those messages are clearly disingenuous and even dishonest. NHS staff don’t have to agree with everything, as long as it is clear how decisions were made, and they can rest assured that there will be consistency and stability in their working lives.

Moreover, those benefits don’t have to be financial; people join the NHS because they want to make a positive difference to the lives of ill people, and want to be proud of what they do. Approval, appreciation, peer recognition, these are all useful and not nearly as inflationary as monetary markers, whose price has to constantly increase to retain their value.

  1. Make policy and stick to it, even if the Media pundits don’t like it: democracy is great, but where long term policies are concerned, the ballot box is a better place make judgments than the daily press. Populist government leads to uncertainty and instability, and in the end, loses the respect of the populace anyway, so the system should think in years, not weeks, when it makes policy.
  1. Society needs to acknowledge the clash between rising expectations and finite resources; efficiency is clearly a good thing, but no amount of cost improvement is going to keep pace with a population that expects everything, constantly, and for free. At some stage soon, we are going to have to grasp the nettle of putting the brakes on demand, whether by formally introducing the notion of rationing, charging, or excluding.

With these suggestions in mind, Simon, perhaps you should empower the CCGs to do what they are being asked to do? That’ll mean giving them more control of (and tighter accountability for) the mechanisms and the money; they’ll need a lot more development too, internally and in the way that they deal with the rest of the service.

Perhaps too, you should think of simplifying the fog of micromanagement and punitive regulation that has descended over the NHS? At a local NHS acute Trust for instance, the 200 pages of specific measures that have to be discussed at every Quality and Safety committee bring its members to their knees. Most clinicians have a positive intent, and are prepared to have their effectiveness measured, but to do it in such prosaic, reductive ways is not only counterproductive in the short term (the measures aren’t usually helpful) but in the long term too (they de-professionalise the workforce). A few outcome measures, measured by peers and patients, would pass the responsibility and ‘ownership’ of the service back to those who are best placed to run clinical services.

Another (albeit more difficult) objective would be to resist the pressure from the acute sector; crises are always more interesting and newsworthy than chronic and often insoluble problems, but they divert attention from what is truly important to what is often merely urgent. To achieve such an objective would be countercultural in today’s world of instant gratification, but if we don’t manage to stem this tide even a little, then the future of a sustainable service is bleak.

On a more positive note, almost everyone in the NHS (and most members of the public) are aware of these issues in some way, and would be willing to throw their weight behind policies that begin to address them. Sure, the traditional tribalism of the different parts of the service will always exercise us, but there is nothing like common purpose to bring people together, and there is plenty of that where the NHS is concerned.

It’s a daunting task, that will need stamina as well as a thick skin; but modernising health services is a worthy end, and we’ll all help where we can.

Good luck, and kind regards

Jonathan

Urgent or important? The CCG imperatives

CoveyI don’t usually have much time for self help books, and much of Stephen Covey’s ‘Seven Habits of Highly Effective People’ is fairly self-evident; it’s not exactly rocket science.

However, his famous ‘urgent/important’ matrix does come to mind when looking at the way in which the NHS operates; indeed, the matrix seems to apply to most public services. It is a pictorial diagram (see above) which essentially divides life’s tasks into four quadrants. These range from those that are not urgent and not important, and should thus be given extremely low priority, like washing the car (pretty obvious really), to those that are both urgent and important, like putting out the chip pan fire, that need to be completed as soon as possible (not too difficult to understand either).

It’s the ones in-between that are more interesting: Covey makes the point that urgency tends to trump importance, so that tasks that are urgent but unimportant are given disproportionate priority over those that are important but not urgent, which are all too often ignored. It may be so in our personal lives, where things done for the sake of appearance are all too often given priority over the things that actually need to get done, and it certainly applies to life in the NHS.

Thus for example, reporting the handling of a patient’s complaint seems to take precedence over the handling of the complaint itself, just as when we were children, keeping our rooms tidy was seen as being more important than playing the interesting games that would get them in a mess in the first place.

Much of this dissonance comes from the issue of power and agenda setting. When we were children, it was our parents who did both, and for CCGs, it seems to be almost everyone else that has the power and drives the agenda: NHS England, the area team as their local incarnation, even the local acute Trusts seem to be able to impose their priorities onto the new clinical commissioners. This has meant that many of the CCGs have been spending the last six months adhering to due process and meeting externally imposed targets –  all of which are urgent – at the expense of maturing as commissioners, and developing their working relationships – all of which are important.

The imbalance of power that leads to this distortion of priorities underpins many relationships (personal as well as in business), but is particularly pronounced in the public sector, where political pressures (often manifested in the media) are expressed as well as financial ones. It is a truism that ‘he who pays the piper calls the tune,’ but when he who pays the piper also lays down the law and feels the need to respond to populist prejudices, then the piper is bound to find it difficult to produce new tunes or even refine the old ones.

In NHS terms, we can see the consequences of this phenomenon in a number of ways; for many CCGs, the urgent daily pressure to meet an endless series of operational targets (mainly financial, but also based on clinical and administrative activity) has subsumed the important task of developing a sustainable strategic approach to the delivery of services. The constant need to tick all the short term boxes puts at risk the underlying purpose of CCGs, which is to get to grips with the commissioning agenda: rationalising the delivery of health services so that the NHS has a chance of coping with the pressures of future demand.

The external pressures are also constraining many CCGs from prioritising their own development in terms of both time and money; many have set up novel management arrangements for their senior teams, but these need developing and honing. Perhaps more importantly, CCGs all need to work with their members to change the whole nature of the relationships between individual GP practices and their CCG, so that they fulfil the promise of marrying local implementation for their individual patients with more strategic planning for entire populations.

Of course, it’s easy to criticize other people’s policies, and the reality is that political and financial imperatives have to be met. So how can the important match the urgent? From my perspective, the answer is for the Centre (NHS England and the area teams) to forge their links with the CCGs based less on micromanaged targets, and more on agreed outcomes. Once a CCG has agreed to deliver some broad, population-based outcome objectives with an appropriate budget, then it should be left to the CCG to manage its operational delivery without its ‘parents’ looking over its shoulder all the time, and telling it to ‘go and tidy your room.’

Whether as maturing teenagers or NHS agencies, the key is to feel that we are acting on what we feel is important, not what we are told by others. If the NHS perpetuates the current situation, where CCGs are all doing what others feel to be urgent, then the future of the new system will be short lived indeed; however, if CCGs are allowed to decide their own set of urgent and important priorities within a broad national framework (and budget), then the system will do what was intended: better care, more locally and efficiently delivered, on a more sustainable basis.

A version of this article first appeared in Pulse on 24 September 2013.

Square pegs in round holes: why new structures never solve functional problems

ImageWhen you sit down for a meal, do you choose your food on the basis of the cutlery and crockery in front of you, or does your food determine your choice of utensils?

For most of us, it’s the latter; for soup we need a bowl and a spoon, a steak needs a plate and a sharp knife. What we do drives how we do it, form reflects function.

So why is it almost always the other way round in the NHS? Despite the fact that we all understand the theory, we continue to look at (and change) structures, with barely a thought given to the manner in which we would like the functions to evolve.

Thus, only recently, NHS England deputy medical director Mike Bewick apparently suggested that ‘GPs should form larger provider organisations’ in order to improve access, a structural solution to a functional problem if ever there was one. Nothing was reported on what the problems with access actually comprised, suffice it to say that larger practices were deemed to be the answer.

Now I don’t know about you, but it seems to me that if I want good service in my personal life, I tend to go to small providers (restaurant, butcher, vet) rather than the faceless bureaucracy I get when I deal with a mega-provider; the only advantage that they offer is lower pricing, usually at the expense of customer service.

But that specific example is missing the overarching point; to solve the GP access problem properly, we need to understand its underlying causes; the sticking plaster of any simple structural solution simply isn’t enough. If the issues are about inappropriate demands (A&E anyone?) then putting in more ‘supply’ will merely exacerbate the problem. If it is about inflexibility in skill mix adaptation, then larger practices would be a very expensive (and equally inflexible) way of solving the problem; and so on…

So why do we seem so ready to turn to structural solutions? Firstly, structures, whether physical buildings or organizational hierarchies, are easy to conceptualise, and we all prefer things to be simple rather than complicated, even if simplicity is reductive and ultimately unhelpful.

Secondly, simple interventions are usually easier to measure than complex ones, something that is particularly important to politicians, who want to be able to point at new edifices (preferably with walls, roofs and a plaque to unveil) and say ‘I did that.’

Thirdly, structural solutions calm the insecurities we all have when life changes (as long as I know where my desk is, my job must be safe) and so help us to cope with uncertainty, even if that protection is illusory.

However, apart from the fact that structural solutions are rarely more than symptom control (using a medical analogy), they also distract us from sorting out the underlying problems. If my non-steroidal medication keeps my repetitive strain injury quiet, then I don’t have to think about changing my working practice to make real changes to the way I work, thus keeping life simple, immediate, but ultimately still broken.

The only way to start solving the underlying problems of the NHS (and of most large macro-systems, for that matter), is to take a cool, dispassionate look at what we’d like the system to produce, and then work out what is required to meet that brief. Of course, much compromise and sleight of hand will still be required, as we can never really start from a blank sheet of paper once such a large system is running.

But at least we can sort out the real diagnosis and come up with a treatment plan, rather than botching yet another short term fix merely because there are twenty other similar problems sitting in the waiting room.

The best compromise may well be to carry out such ‘whole body diagnoses’ on small but complete ‘micro-systems’ (a single practice, a CCG, even a hospital Trust), rather than looking for root and branch reform of the whole creaking organization at once. As long as the analysis and the treatments in the small unit take into account its interfaces with the larger system, then one may have a way of carrying out an holistic, meaningful analysis of the functions of an entire entity, and beginning to introduce the changes needed to improve that functionality.

Not only would the scope and size of such an approach give it a better chance of being effective, it would also allow the inclusion of two other key factors vital to the success of any change management programme: ownership and ‘buy in’ from those involved, and the start of a cultural change ‘cascade’ whereby success amongst those who are in at the start of the process appeals to the later adoptors and tempts them into the programme.

So, CCG Chairs and practice managers, are you up for having your micro-system analysed and put onto a change management regime? It’d be enlightening, cost effective, and very productive.  It’s something that I would be really keen to explore; all we need now are the pump priming funds…

This article is based on a piece published in Pulse on 27 August 2013.

Health services in the developed world: not waving but drowning

ImageLike most healthcare systems in the developed world, the British National Health Service is under constant scrutiny. However, such scrutiny is just the beginning of a much larger debate likely to exercise the whole developed world in the near future; are current health services sustainable?

Irrespective of whether funding and services are provided by the State or private sectors, a number of challenges are coalescing in such a way as to resemble a ‘perfect storm’, and all will need to be addressed if we are to avoid such a cataclysm.

These challenges have to be seen in the context of the countries involved: populations are reasonably stable, average incomes are well above subsistence levels, and population health (in terms of basic needs such as housing and nutrition) is good. Deaths from infectious diseases are low and life expectancy is high, but the negative impacts of affluence (such as obesity and diabetes) are growing. In such countries, several truisms can be highlighted:

The population demography is changing: as life expectancy in the developed world rises and birth rates slow, the demography alters, putting the emphasis of health services onto older people, who have the greatest demands; the increasing prevalence of long term conditions, co-morbidities, and rising hospital admissions all put increasing strains on health services.

Moreover, most health systems (both state and privately run) depend on the insurance principle: the ratio between those paying ‘premiums’ and those make ‘claims’, and that ratio is changing for the worse as older people pay less and claim more.

Medical technology is accelerating: medical science has become steadily more capable over the years, with a growing ability to treat ever more conditions. Some are life threatening and affect millions of people (the improvements in cancer diagnosis and treatment come to mind), some are extremely serious but affect very small numbers of people (the ‘orphan conditions’ such as Gaucher’s and Tay-Sachs Diseases), and some (the so-called ‘life style conditions’ such as baldness and erectile dysfunction) are changing our attitudes to health care so that ‘dis-ease’ of any nature is increasingly being seen as ‘disease’.

In addition, there are other influences for change that may be less direct, but are often as powerful.

Rising expectations reflect the increasing medicalisation of health problems, fuelled politically and commercially; politicians generally win elections by promising more services rather than fewer, and commercial companies survive by marketing their services to generate business. Expectations have risen in terms of what services may be available, as well as where and when they may be delivered (the so-called ‘choice agenda’). Results are expected to be virtually guaranteed, and there is a growing emphasis on improving the healthcare experience as well as its outcome.

Comparisons are drawn between the delivery of health services and commercial ones such as banks or restaurants, even though these latter are self funded (with built in brakes once they become unaffordable), whereas health services are usually funded by third parties (at least in part), making the disincentives to demand much less visible or effective.

The way in which rising expectations have been driving demand exactly mimics the developed world’s wider consumerist philosophies: economies depend on growth which requires increasing demand, driven in turn by the public’s hunger for more goods and services, delivered more quickly, more cheaply, and with greater choice. Thus, just as next year’s smartphone has to be better than this year’s, so next year’s antidepressants have to be more effective, with fewer side effects, than those available now.

However, since health care is enormously emotive, and usually largely funded by third parties, the ‘can I afford it?’ question is rarely asked, either by individuals (for whom health is beyond financial measure) or by funders, for whom the penalties of reducing expectations and disappointing their clients (electoral defeat for politicians, and lost business for insurers) outweigh most possible future problems. As a result, efforts to manage expectations downwards have been few, and have generally failed to make much progress; experiments in prioritization, such as those in Oregon, have had little impact, so the only serious control mechanism to have been generally invoked is that of increasing efficiency: getting more bangs per buck.

The reality is that, whilst there is always room to improve efficiency in large systems, the pressures are such that society will have to challenge what services are provided as well as improving how they are provided. Genuine rising need, growing expectations, and medical technology’s ability to provide more, are creating a Tsunami of rising costs; once increasing risk aversion and reduced investment are factored in, then the notion of the perfect storm begins to make sense, a disaster that can be foretold but not avoided.

So are there ways of avoiding the storm? There are, but they assume that the human propensity for short term fixes can be overcome, which may be an assumption too far. Firstly, reducing public expectations would help; understanding that healthcare resources are limited, and that some things are more important to treat than others, would be an excellent start.

How one does that is harder to prescribe; raising awareness of the real cost of services may help, even if these were not actually charged. The UK ‘GP budget holding’ experiment in the 1990s was partly intended to increase cost awareness, and the current development of Clinical Commissioning Groups is an extension of this, but the funding mechanisms mean that the there is little alignment between effort and reward.

Actual charging, on a co-payment basis, is used in countries such as France and New Zealand to demonstrate the link between usage and costs, but this would currently probably not be acceptable in the UK. Creating ‘tiers’ of services has been partially implemented countries such as Canada, where everyone is guaranteed basic services, but more ‘luxurious’ products have to paid for separately; thus for example, basic cataract surgery is free, but the fancier lens implants are not.

Service rationalisation, as mooted by David Nicholson, is inevitable if hospital economies of scale are to be realized, and the risks of low volume services are to be mitigated, but this is an efficiency gain, and not the paradigm shift that is actually required. To achieve that, the obvious variables that could be adjusted are the availability of services, or their price; changing the third variable, demand, would require our societies to bring back a more collective ‘communitarian’ response to public need, which would imply a radical adjustment of the balance between ‘me’ and ‘society,’ a utopian aspiration, but unlikely to come in our lifetimes.

This is an expanded version of a piece published in The Conversation on 20 August 2013 at http://tinyurl.com/n62gloc

The NHS in 2013: plus ça change…

Just over three years aPlus ca change 1go, ‘Clinical Medicine’ (the journal of the Royal College of Physicians) launched a series of articles in which the history of the National Health Service (NHS) was reviewed, and several eminent commentators surveyed the health- care landscape that was expected to emerge once the dust from the 2010 general election had cleared.

Thus, there were articles by the likes of Mike Farrar, chief executive of the NHS Confederation, Michael Dixon, chairman of the NHS Alliance, and Mark Britnell, from the management consultancy KPMG, as well as contributions covering subjects as diverse as system reform to improve NHS efficiency (Jennifer Dixon), the risks and challenges for a new public health system (John Middleton), the future of patient and public involvement in the NHS (Jo Ellins), the role of the National Institute of Health and Care Excellence (NICE) in assessing new technologies and value for money (Andrew Stevens et al) and the then impending commissioning reforms (Elizabeth Wade).

We are now well into the current round of reforms and, with less than two years until the next general election, it is a good time to review the events of the past three years, and speculate on future possibilities and developments.

Political context

The first thing to say is that the initial White Paper presented by the then Secretary of State, Andrew Lansley, during the summer of 2010 took most commentators by surprise. In the lead-in to the election, it had been observed that there was a basic convergence in policy and even organisational style on both sides of the political divide: the concept of the purchaser/provider split was an integral part of both Labour and Conservative policy; the independence of acute provider trusts was taken as read; and the centrality of primary care in coordinating their local health economies had been generally accepted.

Thus, it was largely assumed that, if a Conservative Government did win the election, its policies would be aimed at tweaking and refining the pre-existing direction of travel, rather than overhauling it radically and, indeed, the tenor of the manifesto of the party gave no hint of major structural changes. Such tweaking could even be interpreted as being helpful in making the NHS increasingly able to resist political change, as the policies of the main parties began to resemble each other, even if only in principle.

In the event, when the Liberal Democrat–Conservative coalition was formed and Andrew Lansley was confirmed as Secretary of State for Health, the coalition White Paper incorporated significant restructuring, and a philosophical ‘decentralisation’ that was seen as almost libertarian in its extent. The key suggestions of the document are detailed in Table 1 at the end of this piece, and now look faintly ironic, even after only three years.

A difficult gestation

As with all White Papers, the document was intended to form the basis of a Parliamentary Bill, but during its gestation, there was perhaps more debate among the various vested interest groups than was the norm; nearly all of these groups, lay as well as professional, opposed parts of it, with the most strident criticisms concerning the transfer of so much of the NHS resource to the control of general practitioners (GPs), the apparent abrogation of their responsibilities by politicians and the intention to allow the NHS to be driven so locally, with the variabilities that that implied. The fact that all the debate was being carried out under the cloud of the ‘Nicholson Challenge’ (a call for the NHS to save up to £20 billion over five years that had been issued in 2009 by Sir David Nicholson, the chief executive of the NHS as a response to the increasing austerity being rolled out across the country) added to the tensions and mutual paranoia being felt both politically and in the service itself.

In hindsight, the outstanding lesson from the launch of the White Paper was less about its content, most of which was more or less in line with the aforementioned direction of travel, than the manner in which it was introduced. The Secretary of State seemed to show a degree of political naivety in his approach to the powerful lobbies with which he had to deal and he introduced a whole raft of structural changes that were both unexpected and unwelcome, as well as perhaps unnecessary to enact the proposed reforms.

Such was the level of ‘noise’ concerning the White Paper that an official ‘pause’ was introduced, during which a Future Forum was convened, led by Professor Steve Field, the outgoing chairman of the Royal College of General Practitioners. Its official brief was to carry out a ‘listening exercise’ to consult widely and to modify the White Paper in line with its findings; to this end, the Forum comprised primary and secondary care members, nurses and Allied Health Profession (AHP) members as well as doctors, managers and representatives from other groups, including various patients associations and the voluntary sector.

The unofficial remit of the Forum was to ensure that the White Paper could be turned into a viable bill, although there were also suggestions that mechanisms were needed to counter the centrifugal force of Lansley’s ideas with some centripetal pressures to maintain parity across the service and behaviours in line with central Government policy.

The Forum met for some months (and, indeed, at the time of writing, has yet to be disbanded) and, although its activities did smooth the edges of the original proposals, some might say it changed their original intent. Enough organisational restructuring was introduced following its interventions, for instance, to obviate completely the promise concerning the ‘radical de-layering and simplification of the number of NHS bodies’. Its findings were incorporated into a revised bill, which was followed by more political wrangling in Parliament before the bill was finally turned into the 2012 Health and Social Care Act, which was fully enacted on 1 April 2013.

The 2013 Health and Social Care Act

Its final intentions and structures include the following, although it is too early to draw any conclusions about their effectiveness.

The major structural changes mainly concern the commissioning or procurement side of the NHS. The primary care trusts (PCTs) that were responsible for commissioning the vast proportion of all care for their local populations have been dissolved and many of their functions devolved into the new clinical commissioning groups (CCGs), which are each headed by a chair (usually a GP) and an accountable officer (AO); some AOs are clinical, whereas others are managerial in their backgrounds.

CCGs hold most of the budget for traditional hospital services and have the responsibility for planning and procuring these services, as well as holding them to account. In this task, they are assisted by the commissioning support units (CSUs), which are able to provide a variety of support tools, including payroll and human resources (HR), information and communications.

The CCGs have two strands of accountability within the system. The services provided within primary care (mainly general practice) are governed by the area teams, each one overseeing several CCGs. The strategic oversight of this, as well as the accountability for hospital services commissioned directly by the CCGs, sits with one of four regional bodies linked to NHS England. Clearly, each is holding responsibility for a large population and needs to develop the notion of locally developed services that are in tune with national policy while also knitting together the various funding and delivery streams that encompass primary care and hospital services to create a seamless and effective service map.

The public health function (traditionally involved in the prevention and health improvement agenda, health protection (including immunisation and screening) and generic service planning) has been split in two, with the mainstream operational services being moved to the control of the local authorities and the more strategic functions that cover larger populations, being housed in a new entity called ‘Public Health England’.

The whole system is intended to sit at some distance from its political masters, to try and insulate them from the public and media pressures that often divert policy from its intended direction. This approach was first tried during the early 1990s, under a previous Conservative government, which created the ‘NHS Executive’, housed in Leeds, in a finally futile attempt to create a similar gap between policy and service delivery.

The basic aims of all the NHS reforms of the past 30 years have been to try to bring into line behaviours and expenditure in the acute sector so that they fit with national policies and budgets. In the current round of changes, the main overt objective for this sector is simple: to ensure that all acute trusts reach the standards necessary to become foundation trusts, or if they cannot, to agree some form of strategic alliance with another organisation, so that together they might reach viability in terms of costs and quality.

However, the current changes, both planned (through the new Act) and unplanned (through crises, such as that in the mid-Staffordshire Foundation Trust) have highlighted a new, and much more significant ‘elephant in the room’, and that is the overall future of the district general hospitals (DGHs). There are several reasons why their future is now in considerable doubt.

Firstly, there is an inexorable move towards increasing specialisation, which average DGHs cannot supply; their budgets and turnover are too small, and their ability to recruit ‘premier league’ super-specialists is limited. As a result, the more ‘high-risk’ illnesses (risk being defined by cost, technical difficulty, infrastructure support, staff availability and even litigation risk) are being referred onto the tertiary ‘super-hospitals’, thus depriving the DGHs of work, income and work-related satisfaction for their high-level staff.

Secondly, there is an equally inexorable move of lower-risk illnesses out of hospitals and into the community, where their treatment might be carried out in less formal surroundings that are generally preferred by patients, by staff who can still deliver excellent care, but perhaps at a lower cost. With the shrinkage of this market too, the core business of the DGHs will become significantly smaller and will threaten their viability unless they change their form or their function dramatically.

Thirdly, there are the issues of scale; in the constant tussle between ‘small is beautiful’ and ‘bigger is better’, the size and complexity of the NHS probably mitigates against the former. Interestingly, there is a clear dissonance between the move towards super-hospitals, and the value placed on local treatment ‘closer to home’, that probably reflects the increasing polarisation of healthcare to these two extremes, which once again puts the future of the DGH in doubt. This tension is not new; as Aneurin Bevan said in April 1946, ‘I would rather be kept alive in the efficient if cold altruism of a large hospital than expire in a gush of warm sympathy in a small one.’ The difference is that the intensive interventions feasible today cannot easily be delivered in a small setting, reinforcing Bevan’s aphorism for the 21st century.

What next?

So what might we expect from the new system?

At a superficial glance, the new organisational structure might appear to be well placed to deliver what its designers wanted. It has attempted to separate the service from its political masters; it has declared a move to ‘localism’ and it will pass control of over two-thirds of the total NHS budgets to the CCGs.

However, there are significant structural issues that look likely to trip the system up. The first concerns the distinctions in funding of primary and secondary care.

Because the two streams are managed separately (hospital funding though the CCGs themselves, primary care through the area teams), there is no certainty that moving services from the acute sector to primary care will free up the resources to complete the transfer. However corporately minded GPs might be, they are unlikely to create extra work for themselves and their teams without the resources to manage this, and that process is entirely separate. As in so many previous rounds of NHS reform, the incentives in the system have not been properly aligned.

In the same way that the new system does not acknowledge the factors that motivate and drive GPs, the continuing emphasis on payment by results (PbR), which is a recipe for increasing activity and not improving results at all, is not helpful. In addition, the movement of the mainstream public health function into local authorities, although it might be appealing at a conceptual level (the drivers that influence the health of the population are largely outside the biomedical universe), the emerging reality seems to comprise mixed interest among local authorities, with some apparently not considering any of the broader determinants of health beyond repairing potholes and running sexually transmitted disease (STD) clinics.

So there are structural problems, but there are even larger and more significant issues in the processes that are now supposed to govern the NHS.

Lansley was probably unduly optimistic in his aspirations to have the NHS driven quite as locally as he intended, but in the intervening months and years that the Bill has evolved and become law, it has created a polarised dynamic between the CCGs at the local end and NHS England at the centre, with the power apparently settling increasingly at the central end. GPs and their PCT colleagues who took up the notion of CCGs are seeing their expectations and aspirations once again diluted and soured, with the result, even at this early stage, that there is already poor morale and reducing engagement.

Processes should not subsume outcomes

Clinical professionals in general, and GPs in particular, are in positions where they can make or break their local heath economy without ever doing anything wrong. Their motivation and enthusiasm are the only way that referrals and admissions might be reduced or prescribing improved and, if their zeal is missing (or worse still, lost), then the auguries for success are poor. Add to that the ‘Nicholson Challenge’ being pressed upon them and one can see the likelihood of short-term ‘fatigue’ in the new system and long-term disaster as new doctors consider their reasons for going into general practice in the first place, and begin to vote with their feet.

One final bit of soothsaying; if the new system was designed to preserve corporate memory while allowing new ideas and ways of thinking to emerge, then even that probably has not worked. As the CCGs and CSUs bed down, not only are they populated largely by staff who had worked in PCTs previously, but their growing ways of working, their modi operandi, also begin to look increasingly controlling, unimaginative and bogged down in ‘due process’. Tendering for service change, allowing experimental models of care, anything that rocks the boat of ‘doing things right’ is being frowned upon, even if it is at the cost of ‘doing the right thing’.

The road to Hell, they say, is paved with good intentions and it is easy to see how an Act designed by a committee that tries to please everyone is almost bound to fail.

In fact, the issues are remediable: if the accountability of the CCGs to NHS England was simplified into one stream based on outcomes rather than on processes, then the incentives for those in the CCGs would be more positive. The oft-cited ‘conflict of interest’ for GPs would be less relevant if they became responsible for delivering all health-care for their population, in any (appropriate) way they chose, ‘sub-contracting’ to others what they didn’t do themselves (and hence maintaining vicarious responsibility).

If the rules governing changes in the acute sector were simplified, and allowed more flexibility of function as well as structure, then some innovative and dynamic solutions to these ‘wicked issues’ would emerge. In addition, if those working in the NHS, especially at senior level, could see something positive about which they could be enthusiastic and in which they could invest their hearts and souls, then I suggest that this might be ‘another fine mess’ we could actually reverse.

Table 1. Summary of main suggestions in the White Paper Equity and excellence: liberating the NHS.

  • Shared decision-making: ‘no decision about me without me’
  • Choice of any provider, consultant-led team, GP practice and treatment
  • Hospitals need to be open about mistakes
  • Stronger voice for patients and the public
  • Focus on outcomes and quality standards. Reduced mortality and morbidity, increased safety and improved patient experience and outcomes
  • No targets without clinical justification
  • A culture that puts patient safety above all else
  • Money to follow patients across the NHS to promote quality, efficiency and choice
  • Providers to be paid according to performance based on outcomes, not just activity
  • Professionals and providers to have more autonomy and accountability
  • Greater freedoms and less political micromanagement; ministerial powers over routine decisions to be limited
  • Devolution of power and responsibility for commissioning to GPs and their practice teams working in consortia
  • More connection between local NHS services, social care and health improvement
  • An independent NHS Commissioning Board to lead on the following: achieving health outcomes, allocating and accounting for resources, quality improvement and patient involvement
  • All NHS trusts to become, or be part of, a foundation trust
  • Monitor to become an economic regulator, promoting effective and efficient provision, competition, regulating prices and safeguarding continuity of services
  • Enhanced role for the Care Quality Commission as a quality inspectorate across health and social care
  • Ring-fenced public health budgets, reflecting population health issues, with ‘premiums’ to reduce health inequalities
  • £20 billion efficiency savings by 2014,to be used to improve quality and outcomes
  • NHS management costs to be reduced by more than 45% over the next 4 years
  • Radical de-layering and simplification of a number of NHS bodies
  • Debate on health should no longer be about structures and processes, but about priorities and progress in health improvement for all
  • Implementation to be bottom up

This piece is based on an article published in Clinical Medicine in August 2013: 2013, Vol 13, No 4: 374–7