Tom Smith on today’s health policy debates.

BMA deliver petition to Downing Street

An Independent article today notes that “a bitter war of words has broken out between government and family doctors over plans for polyclinics across England”. After Health Minister Ben Bradshaw yesterday accused the BMA of “misleading and mendacious” behavior, the BMA will hit back today will a show of popular support.

The BMA has collected over a million signatures in just three weeks and today presented the petition to Downing Street. The timing coincides with the annual Local Medical Committees conference, taking place today and tomorrow in central London. Laurance Buckman, the chair of the BMA’s General Practitioner’s Committee, will give the keynote speech to demonstrate he is successfully defending GPs. He told them, “if the government won’t listen to you, their doctors, then surely it will listen to the 1.2m men and women who call for a halt to the plans to promote the use of commercial companies in general practice”.

According to Healthcare Republic, Buckman’s speech ‘galvanised colleagues’ and was ‘a triumph’. In fact, they were pretty gushing about his whole performance.

‘Delegates loved him and they loved his address. He toned down his traditional garish tie…but he did not tone down his speech to match. The delegates gave him not one but two standing ovations, the second one lasting for one-and-a-half minutes’.

Laurence is pleasing the GPs, but not the CBI. Neil Bentley told the Telegraph that doctor’s leaders were demonstrating “ostrich- like denial” and said the plans would extend opening hours and increase the range of services offered to patients. “The BMA is trying to block reforms that will make the GP service more flexible and patient friendly and could transform the care on offer to millions”.

Audit Commission and Health Commission reflect on reform in the NHS

If the BMA petition was the biggest story of the afternoon, the biggest of the morning was the joint report from the Audit Commission and Healthcare Commission, examining NHS reforms since 2000.

The report is certainly hard hitting and today’s Health Service Journal says, ‘negotiations over the content has been tough’. It is pretty hard hitting so God knows what was left out.

• GPs are being paid for helping people choose hospitals, but most cannot recall being offered any choice. Furthermore, ‘there is no evidence from our fieldwork that choice policy has so far had any impact or that it has led to an improvement in the quality of care offered’.
• Foundation hospitals are not using freedom from Whitehall control to innovate and are hoarding financial surpluses
• New contracts for doctors and nurses were a ‘missed opportunity’
• Areas serviced by ISTCs do not have shorter waiting times
• Plans to move care out of hospitals and into community clinics and surgeries have made little progress.

It is interesting how differently the report was presented in different papers. The FT said market based reforms ‘have potential” but ‘remain unproved and need time to bed in’ – noting that many of the reforms are new. Others like the Guardian took a more negative tone: ‘patients no better off in competitive NHS’. Both are accurate reports, but give a very different steer to the reader.

The chair of the Audit Commission told the FT, “there are signs of recovery but progress is less than expected”. He tells ministers not to “start reaching for alternative remedies yet” adding that “the direction of travel was good”.

What is the future of commissioning?

A problem for much of policy is that the direction of travel is not very clear. Commissioning is a prime example. The Health Service Journal today suggests that we might see some radical piloting of a totally new approach, on the back of Lord Darzi’s review.

‘Sources have revealed to HSJ that pilots for integrated care schemes are strongly tipped to feature in the report out in two weeks. These could include trials of PCTs commissioning outcomes rather than services. Provider organizations would then be given funding to deliver the outcomes. They could provide the services themselves or secure them from other organizations’.

As the HSJ notes, ‘this would change PCTs commissioning role, with more emphasis on scrutinizing effective procurement of services by third parties’.

What does this mean? Is it akin to the model that Chris Ham has been arguing we adopt? It sounds similar, as though PCTs would give capitation style funding to groups of GPs who would then have to decide whether to deliver the service themselves or pay another provider to deliver it. It will produce strong incentives to save money, but how will it be taken forward?

PCTs blasted by private providers

A theme in the Audit Commission report is that managers do not fully understand the reform programme. Their lack of commissioning experience and skills is also blamed for slow progress within PCTs. The HSJ today reports complaints from private providers that despite a national vision for collaboration, this is not understood at the local level.

One says, “they are lacking in information and in any sense of commercial savvy. I’m very disappointed at the lack of joined-up thinking between the centre and PCTs. It seemed very exciting and clear to us when we listened to Mark Britnell speak, but when you go to PCT events, there’s no evidence of joined-up thinking’.

West Sussex Council wants to run the PCT

Under the ‘integrated pilots’, outlined above, the PCT would have oversight of how money was spent and scrutinize outcomes. Accountability in the system would be to them. But there is a growing mood among local authorities that they should play this role. After all, they have a direct accountability link with the public and house public health expertise.

Down in Sussex, a county council has launched an audacious bid to take over its local PCT. The HSJ reports that ‘following a meeting of West Sussex county council last Friday, councilors agreed to adopt a motion calling for the local authority to give patients a greater say in their healthcare by “taking on the functions of the West Sussex PCT with those of the county council, to bring them under local democratic control and to improve working between health and social care functions, providing health fudning is also appropriately reformed”.

The council leader will write to health secretary Alan Johnson for approval. It will be very interesting to see his reply.

The debate continues on whether the NHS should introduce co-payments

In today’s FT, Robert Shrimsley imagines an Alan Johnson letter to a patient who has asked to pay for a drug not available on the NHS, which currently would lead to a patient then being charged for their NHS treatment. Here is an extract.

You say a course of Extenda could allow you to live long enough to see you children into their teenage years. I have to tell you that our clinicians at the National Institution for Clinical Excellence feel this is not an efficient use of our money – and frankly they are the experts. In your letter, you point out that have paid for the NHS your whole life. Well then, surely, you wouldn’t want to see you taxes wasted.

I have to weigh your desire to see your children past puberty against the fact that many people cannot afford this option. Since they cannot survive, it is clearly in the public interest you shouldn’t either. In any case kids are very resilient; I’m sure they’ll get over it. Far better to lose a parent than keep a mother who carries the stigma of having betrayed the founding principles of the NHS.

I must also ask you to stop this press campaign. Please bear in mind that you will soon be dead but that we as a government will have to live with the consequences of your meddlesome and rather unfraternal campaign long after you are gone.’

Debate on whether the NHS should allow co-payments has been growing for a month, led by the Sunday Times and the think-tank Reform, who are preparing a legal challenge against the government’s stance on the issue. People on both left and right are struggling to see the logic in the government’s position. As the President of the Royal Society of Medicine said in the Sunday Times this week, there has always been a mixed economy in healthcare. Even David Blunkett, writing in the Sun yesterday, says the government’s position is indefensible. He likened it to someone being excluded from school for paying for private lessons.

Back in the FT, Robert Shrimley’s wrath is not reserved exclusively for the Government: ‘there has been near silence from the Conservatives on this issue’. ‘One imagines the Tory letter to the same patient’:

‘Every fibre of our being goes out to you. We are tempted to sympathise. Be assured that though you may find our position somewhat similar to the government’s, we care much more’.

Cameron preparing the Conservatives for radical plans on public services

There is some solace for those who wish the Conservatives to be more radical, in the form of a Fraser Nelson piece in tomorrow’s Spectator.

While Cameron’s initial strategy was to minimize the differences with Labour, the opinion polls, and a view that they will win the next election, there is now an opportunity to present bold proposals that can capture the public’s imagination. Team Cameron believe they cannot wait for Brown to combust.

Nelson notes that Cameron has already opened lines of communication with civil services. He says some interesting people are spending time with the Conservatives. The Former head of Tony Blair’s delivery unit, Sir Michael Barber ‘has been generous with his time’. ‘as has Matthew Taylor, who used to run the Number 10 policy unit. A former Blair advisor is now working full-time on the Implementation Team’. ‘The joke among the orphaned Blairites is that if half a dozen of them embed with the Tories, they could retake power – meeting Mr Blair at his Connaught Square home for weekly instructions’.