The reforms need reform
Chris Ham who was director of strategy at the Department of Health from 2001 to 2004 and one of the authors of the current programme of reform tries to writes in today’s Guardian that the current reforms need tweaking. Lets look at his arguments, shall we?
When it comes to hospitals, paying a fixed price for delivering care will drive efficiency improvements in the case of treatments where patients can choose (If the prices are set appropriately, there is transparency about what is being charged for & they are unbundled, if the burden is shared equitably i.e. an equal case-mix of patients or if this is not possible, appropriately weighted payments, both of which are not catered for. Why is that?), but that is doubtful in cases where patients have little or no choice (true). Most hospital beds are in fact occupied by patients admitted as emergencies, often as the result of an acute exacerbation of conditions such as diabetes. Many of these patients can be helped to remain at home if GPs and community nurses anticipate their needs and work closely with hospital specialists (Well, as recognised by most people, one of the consequences of the reforms has been financial instability & subsequent cutbacks by PCT’s. And not just in community services either).
The government’s reforms offer GPs incentives to avoid hospital admission. But so far most GPs have been slow to take up these opportunities. It is unrealistic to expect this initiative to be a major driver of improved performance (We are not enlightened as to why, but perhaps the incentives might be no such thing? GP’s are not fools, they are under no obligation to take up ideologically & politically motivated changes which deliver little or no clinical benefit.).
Equally questionable is whether the reforms will support the development of integrated care to reduce the use of hospital services. The continued separation between GPs and hospitals, and increasing diversity of provision to support patient choice, has brought further fragmentation, not closer integration (And yet we have the insistence on choice & the prospective introduction of the Extended Choice Network in a few weeks).
With healthcare organisations competing for a bigger share of the NHS budget, there is little incentive for them to collaborate to provide care in the community (Yes, & when you are talking about the health of a nation, what is required is an integrated healthcare strategy, not piecemeal purchases). Of greater concern still is the ability of the organisations that control NHS resources to negotiate on equal terms with NHS and private-sector providers. Primary care trusts are expected to bring about improvements in performance by becoming smart purchasers of care for their populations.
The government has strengthened the provision of care by introducing NHS foundation trusts and independent sector treatment centres (Not really, some of the acute trusts are tottering). But it has given scant attention to the development of primary care trusts. This has created a fundamental weakness in the design of the reforms, with the purchasers of care lacking the necessary expertise and resources to make the healthcare market work efficiently (This reads like justification for the introduction of the Commissioning Services Framework, allowing the PCT’s who are no good at commissioning to hand it over to other organisations who will be able to aggregate purchasing & run things efficiently i.e. provide a gatekeeper service, never mind that the health insurers who do this in the USA & are the basis for this policy are not exactly known for their efficiency). The levers and incentives do not exist to reduce variations in productivity and performance on the scale needed to fund future medical advances. (And don’t mention the transaction costs)
This article appears not to suggest any serious review of the current reforms but to argue the case for their extension into the areas being identified as weaknesses.
There is a review in the Guardian which gives more background.
I don’t know, I side with Allyson Pollock myself. For one, she has actual medical experience in public health & knows the system from the inside. And she has the right approach.
One of her basic tests …… “does it work?”. Kept firmly grounded in the reality of the health service by weekly attendance at UCLH Trust management board meetings, she says: “Our work is case-study based and highly empirical. It is all about evaluating what is going on on the ground from a public-health perspective: its impact on patients, staff and the wider population, and its relationship to the bigger picture.”
Further reading
Prof Colin Leys’ Paul Noone lecture