Health Policy InsightEditor's blog Monday 31 January 2011: Government responds to health select committee report on commissioning
It's going to be a busy day.
The Government has published its response to the health select committee's recent and critical report on commissioning.
The Government's response is to "welcome the Committee’s conclusion that more effective commissioning is the key to delivery of efficiency gains".
Later, some mischeivous civil servant not only drops in the outcome fox so neatly shot by the iridescent Professor John Appleby last week, s/he also fills a whole paragraph with health policy 'bullshit-bingo' jargon, including a nostalgic comeback for your old favourite and mine, 'world-class': "England’s health outcomes are lagging behind. The cost of healthcare is rising and we will need to be able to deliver more care without a corresponding rise in resources. The NHS needs to change. Without a modernising of structures and change in culture, improvements in quality and efficiency can only go so far. The Bill will reshape the health service so that it is built around patients, led by health professionals and focused on delivering world-class healthcare outcomes.".
At point 17, the response document proposes that "despite significant spending increases in the last decade, productivity has fallen" - which would more accurately be phrased, 'because of significant spending increases in the last decade, productivity has fallen'. Economics teaches us that if you increase staff numbers and wages (as happened), and accept that training medical staff is a project of years (which it is), and over-pay the private sector while faiing to meaningfully transfer risk (which we did), then productivity will in all probability drop.
Which it did.
And productivity metrics tend to struggle to capture quality gains such as reduced HCAIs (themselves having risen partly as a result of attempts to raise productivity beyond what is safe. Yep. Healthcare is complex.)
The logic behind point 18 is far from watertight: "The financial context is extremely challenging and the scale of the efficiency challenge is such that it can only be met by a system-wide programme of modernisation. Successful delivery of plans to improve quality and productivity is not something separate from making early progress with structural change – they are closely linked".
It's the TINA argument (there is no alternative). James Gubb, health lead for the think-tank Civitas, has spent over six months pointing out that restructuring the NHS has significant opportunity costs. Moreover, the argued equivalence of importance of 'plans to improve safety and quality' with 'structural change' seems odd, in the light of the generally understood design principle that form should follow function.
On evolution versus revolution: what the Coalition Agreement didn't say
The health select committee report noted that the Coalition Agreement "anticipated an evolution of existing institutions; the White Paper announced significant institutional upheaval. The Committee does not believe that this change of policy has yet been sufficiently explained given the costs and uncertainties generated by the process".
The response document blandly answers, "The changes that were not in the manifestos, particularly the abolition of PCTs, are a logical consequence of the Government’s proposals". As non-answers go, it is deliberately bland and unhelpful.
Equally, to the committee's observation that it "does not believe however that the approach adopted by the Government represents the most efficient way of delivering those objectives", the response promises that it is "building on the best". More policy in-jokes.
Plus ca change
The sharp disagreement comes on the issue of redisorganisation, where the select committee concluded, "the Committee was surprised by the change of approach between the Coalition Programme and the White Paper. The White Paper proposes a disruptive reorganisation of the institutional structure of the NHS which was subject to little prior discussion and not foreshadowed in the Coalition Programme.".
The government's response is dismissive: "There has not been a significant change of approach. The Coalition Programme set out a vision of an NHS that is free from political micromanagement, with increased patient participation and greater accountability to the patients it serves ...
"It is important to emphasise that the proposals do not involve fundamental structural changes to the organisations that provide the great majority of NHS care. They do not entail changes to acute care, community services or primary medical care services, which account for the greater part of NHS expenditure. The changes are to the organisations which commission these services. Our proposals aim to place clinicians in control of commissioning, in contrast to the muddled approach of the past where responsibility was shared between PCTs and practice-based commissioning groups.
"We intend to undertake structural modernisation only once, and the changes we are introducing now will provide a platform for greater long-term stability. An incremental approach would be wholly insufficient to achieve our shared goals of focusing on outcomes, empowering clinicians, and improving integration and developing whole system thinking across the NHS, public health and social care.".
Goodness. No fundamental structural changes in provision? Saving £4 billion a year will be very tricky!
The select committee report also suggested, "there appears to have been insufficient detail about methods and structures during the transitional phase. The failure to plan for the transition is a particular concern in the current financial context. The Nicholson Challenge was already a high-risk strategy and the White Paper increased the level of risk considerably without setting out a credible plan for mitigating that risk.".
So does the government's response say, "hmm, interesting points for us to take on board"?
Um, no.
"We disagree with the Committee’s premise that there was a surprise strategy and the finding that we have not planned for the transition or provided sufficient detail about these plans ... The benefits, costs and risks of implementing the policies proposed in the White Paper that require legislative changes have been set out in Impact Assessments that have been published alongside the Bill".
Viring cash from service transformation to redundancy
The committee report stated, "The committee notes that there has been a change in the intended use of at least some of the reserved sum of £1.7 billion. Some of the money which was originally reserved for "service transformation" is now being used to fund "management transformation". At a time when delivery of the Nicholson Challenge is going to a require a substantial commitment to service transformation, the Committee is concerned that some of the money originally set aside to support this service change is now being used to fund management change.".
Blithely, the Government response states, "The £1.7 billion is intended to be non-recurrent expenditure from recurrent resources and was introduced in the 2010/11 Operating Framework to manage risk and support change. The requirement for a 30% reduction in management costs was also introduced in the 2010/11 Operating Framework. Therefore, the one-off costs associated with the management cost reduction were always likely to form part of the non-recurrent expenditure.".
Integration or collusion?
The select committee report also states, "Real or otherwise, the perception of a potential legal challenge of commissioning decisions may be sufficient to deter GPs from engaging their secondary care colleagues in pathway redesign. We recommend that the Government addresses these concerns by clarifying the law on this issue".
The Government response is slightly odd: "Where services are to be commissioned on an Any Willing Provider basis, commissioners will need to ensure that those services (and the associated patient outcomes) are specified in a way that does not give an unfair advantage to any provider. But this does not preclude working with a range of local clinicians to design better and more integrated pathways of care. There is nothing in our proposals to prevent networks of providers developing integrated solutions, and bidding appropriately to meet the needs identified by commissioners ...
"We expect, as set out in existing DH procurement guidance, that commissioners should continue to work with a range of providers and practitioners to develop service models which are innovative, deliverable, and contribute towards improvements in quality and productivity. We intend to provide guidance, developed and tested with relevant stakeholders, on the appropriate behaviours of commissioners and providers in the procurement of services; from April 2012 the economic regulator and the NHS Commissioning Board will be responsible for ensuring the commissioners and providers are fully aware of their responsibilities, and for monitoring their behaviour to ensure they act in manner which is fair and transparent, and which does not inhibit competition".
Well, ... no, integration isn't precluded in the proposals. What is, however, very clear in the proposals is the concept that competition is good and more competition is better.
And if from April 2010 Monitor and the NHS Commissioning Board are to be running everything, then greater clarity is needed.
And we do not have it. We still do not have it.
Funding formula
The select committee report also stated, "In the light of these concerns, we recommend that the Shadow NHS Commissioning Board publishes its proposed funding formulae for consortia as a matter of urgency.".
The Government's response states, "Shadow allocations for GP consortia for 2012-13 will be published towards the end of this year. The intention is to make full details of the allocations methodology used available at this time. The NHS Commissioning Board will publish actual allocations to GP consortia for 2013-14 in late 2012".
"Towards the end of this year" is not quote redolent of "a matter of urgency" is it?
The select committee report also stated, "The Government must support consortia and existing commissioning organisations to form clear and credible plans for debt eradication and for tackling structural deficits within their local health economy. The Committee intends to further review this issue in its further work".
The Government's response is "PCTs and clusters must ensure that through planning in 2011/12 and 2012/13, all existing legacy issues are dealt with. During this period we expect developing GP consortia to work closely with PCTs to ensure that financial control and balance is maintained to prevent PCT deficits in those years".
Patient and public involvement
The Committee "does not find the current stance on patient and public engagement in commissioning persuasive. The National Health Service uses taxpayers' resources to deliver a service in which a high proportion of citizens take a close interest both as taxpayers and actual or potential patients. While the Department may be right to point out that there is no special virtue in uniformity of structure, the Committee regards the principle that there should be greater accountability by commissioners for their commissioning decisions as important".
Does the Government agree?
Mmmmm. Not really. It says, "These modernisations place increased power and responsibility to improve health services in the hands of NHS professionals who see and talk to patients every day. The Health and Social Care Bill will close a long-standing democratic gap – for far too long remote, unelected PCTs and SHAs have had control of £100 billion of health service decisions, with little involvement from the public or the people they serve.
"Councils, with their local democratic mandate, will now have a far greater influence over how the NHS is shaped, through new health and wellbeing boards in every upper-tier local authority. Health and Wellbeing Boards will have responsibility for developing the JSNA and a new joint health and wellbeing strategy (JHWS) ... We are also significantly extending the scrutiny powers available to councils. For the first time, councils will have the powers to scrutinise any NHS funded services, whoever provides them. Currently local authorities only have the power to scrutinise NHS commissioners and providers. The Bill will enable councils to require all commissioners and providers of NHS funded services to attend scrutiny meetings, provide relevant information to the local authority and be subject to requirements to consult the local authority when proposing substantial service reconfigurations.
" ... the Health and Social Care Bill places a duty on consortia to make arrangements to involve individuals to whom services are being or may be provided in planning commissioning arrangements; in developing and considering proposals for changes in the commissioning arrangements where those proposals would have a significant impact on how services are provided or the range of health services available; and in decisions affecting the operation of commissioning arrangements that would likewise have a significant impact. The Board will be able to champion effective involvement and engagement in its dialogue with consortia, through the provision of commissioning and contract guidelines and outcomes frameworks.
"One way in which the Board could promote the involvement of patients, carers and public in decisions about healthcare provision is to publish guidance for consortia on how to discharge their duties as to patient and public involvement, drawing on existing best practice. When the Board publishes this guidance, consortia must have regard to it. This guidance could cover effective ways of engaging and seeking views from members of the public, including how to engage people who do not regularly access healthcare services or who are from disadvantaged communities. This guidance could also help consortia decide in what circumstances the duty to involve patients and the public might most appropriately be met by providing information and in what circumstances a consortium should actively seek people’s views through consultation.
"Additionally, the proposed arrangements to extend scrutiny to all providers of all publicly funded healthcare will ensure that local authorities are effective in holding to account the local NHS on behalf of local people. Commissioning plans should be informed by the work of Health and Wellbeing Boards and shaped by good public engagement.
"The NHS Commissioning Board will have direct responsibility for commissioning services that it would be less appropriate for GP consortia to commission, such as primary care, specialised services and high security psychiatric services. For all areas of direct commissioning, the NHS Commissioning Board will be required to develop and demonstrate its own arrangements for patient and the public involvement and the impact of that involvement on its commissioning decisions will be published in its Annual Report.
"In response to feedback and support from the consultation for a stronger patient, carer and public voice, Liberating the NHS: Legislative framework and next steps, proposes strengthening the national and local consumer voice through the establishment of HealthWatch. Local HealthWatch organisations will have a role in service design and delivery by promoting and supporting public involvement in the commissioning, provision and scrutiny of local health and social care services. It will place greater public accountability on the commissioning process to improve the quality of health and social care services".
There's some crap in here. I've underlined the very weak 'assurances' in the text above.
They don't assure me, for one.
Or reassure me either.